Insurance

Paying For Health Care the Hard Way

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This is going to hurt you a lot more than it hurts me.

Here's the opening to a misguided but not-altogether-bad New York Times piece on why ObamaCare is unlikely to bring down health care costs:

Dr. Robert Colton, an internist in Boca Raton, Fla., has a problem, and he knows it. His patients come in wanting, sometimes demanding, tests and treatments that are unnecessary, just adding to the nation's huge health care bill. He even has patients, he says, who come in and report that their chief complaint is, "I need an M.R.I."

And what does Dr. Colton do?

"I do the damn test," he said. "There is no incentive for me, Rob Colton, to reduce overutilization. If the person wants it, what are you going to do, say no?"

And the new health care legislation, he says, is not going to make a bit of difference.

The piece goes on, making some reasonably good points about problems with the way care is doled out and paid for. But I think the author gives away the game in the second sentence, which ends with words "adding to the nation's huge health care bill." The nation's. Not the patient's. There's a huge difference between the two, and therein lies the problem.

Third-party payment systems, whether they work through private insurers or the government, result in massive overutilization of care because consumers aren't price conscious. When somebody else is paying, there's no incentive to find out what a procedure costs, or if it's really necessary. And the more the third party pays for, the bigger the problem. The result is that consumers end up thinking of health insurance as medical prepayment rather than as a hedge against major expenses. 

That makes medical care a collective expense, and thus a collective problem. ObamaCare, by reinforcing our clunky third-party payment system, only locks the country further into that problem. And that's why we have health wonks mulling the virtues of government-managed rationing:

One way to make those links is to do what some other countries do — say that there will be no payments for care that is not deemed the most cost-effective. But politicians shy away from such measures, Dr. Luce said. "That is not likely to happen soon, particularly at a national level," he said.

It would mean rationing, said Dr. Robert D. Truog a professor of medical ethics, anesthesia, and pediatrics at Harvard Medical School. "That's the word nobody wants to use. It's just a firecracker. Nobody wants to touch it."

The result is a crazy system in which, he points out, a government-appointed task force on screening mammography was explicitly forbidden to consider the costs of offering mammograms to women for whom the benefit is very small.

"The point is that as long as a health care system has anything less than an infinite budget, there is a need to decide which types of health care will be funded and which will not," Dr. Truog said.

Truog is right that limited resources inevitably place limits on care. But aside from the basic technocratic appeal of centralized efficiency rules, why should those limits be set centrally, by bureaucrats rather than by individuals and their doctors? 

As former Reason editor Virginia Postrel recently pointed out in The Atlantic, when government sets out rules determining which treatments are cost-effective and which aren't, the result is a politicized medical system that frequently ignores the varied responses individuals have to care. I'm all for deciding "which types of health care will be funded and which will not"; I'm just skeptical that the government is the entity best positioned to make those decisions. 

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  1. More proof, as if it were needed, that every working professional in this country should be forced to wait tables in an average restaurant for one month.

    Basic customer service skills acquired from handling the ovebearing assholes whom you depend upon for tips would solve the “I need an MRI” problem.

    1. Dr. Colton is not representative of the medical field at large in his perspective; most clinicians I work with would not just hand out MRIs to everyone who asks.

      But again, Boca Raton is hardly a representative part of the country with a high median income and relatively large number of retirees.

      1. What percentage of the population of Boca Raton are lawyers?

        1. It’s posh South Florida, so off the top of my head, I’d have to guess 30-40%. Tops.

    2. I suspect that the fear of a lawsuit was fresh in his mind as well. Defensive medicine is a very real phenomenon.

      1. Yes, but it’s not likely to be either easy to measure or go away quickly with malpractice reform. Once you’ve been trained to practice it, and have done so over your whole career, it’s hard to stop. It’s also hard to define what is defensive medicine vs. placating the patient vs. lazy-let-the-lab-make-the-diagnosis medicine.

    3. More proof, as if it were needed, that every working professional in this country should be forced to wait tables in an average restaurant for one month.

      I have known people who made $80,000 per year waiting on tables.

      I suspect those jobs may be hard to come by.

  2. Where was the New York Times with this piece before the vote?

    1. This bill, for all of its flaws, corporatism and failures, and despite the fact that it was virtually written five years ago by conservatives, is still “better” than nothing.

  3. Truog is right that limited resources inevitably place limits on care. But aside from the basic technocratic appeal of centralized efficiency rules, why should those limits be set centrally, by bureaucrats rather than by individuals and their doctors?

    Because there’s great comfort in the abdication of the responsibilities of adulthood. And what has the boomer generation trumpeted more than perpetual adolescence as the ideal way to order one’s affairs?

    1. I really like what you wrote here. Well done.

  4. Truog is right that limited resources inevitably place limits on care. But aside from the basic technocratic appeal of centralized efficiency rules, why should those limits be set centrally, by bureaucrats rather than by individuals and their doctors?

    Because that’s just short-hand for saying that rich people will be able to walk into the doctor’s office and order an MRI for every headache, and the poor won’t get them even if they need them desperately?

    I know your position is more sophisticated than that, but you’re going to need to do a better job of presenting it if you want to rebut those kinds of responses.

    1. Because that’s just short-hand for saying that rich people will be able to walk into the doctor’s office and order an MRI for every headache, and the poor won’t get them even if they need them desperately?

      We could impose price controls on therapeutic health care, punishable by execution, and let doctors and patients sort things out under these restrictions.

      1. Hyperbole will get you know where. Whether you restrict access to care by fiat or financing, the result is that either way we have to control health care expenditures. There are injustices that are created with either mechanism; a fact that both sides, who seem only to notice the problems in opposing solutions, need to recognize.

    2. Not exactly. The poor will have to make a more conscious choice about whether getting an MRI is really something they need.

      MRIs, incidentally, aren’t budget busting apocalypses. We’re talking $1,500-$3,000. Not small change, but consider the cost of a used car, for comparison. This is the kind of thing that could perhaps be paid off over a couple of years.

      Also, there are other mechanisms to provide care for poor people, besides fucking up the entire insurance market by forcing insurance companies to pay for treatment for every sick person that walks in the door.

      1. Indeed. So lets talk about something else. A gallbladder surgery for $10,000. A cardiac catheterization when you’re having an acute MI for $15,000. The NICU bill for a premature infant at $650,000.

        Of course there are other mechanism to pay for the poor. Medicaid. Charity. Pro bono care. Ultimately, though, if you argue for an pure market economic solution, there are going to be 65 year old men with heart attacks who need catheterization and can’t afford it, while 89 year old men who can pay are getting them with only marginal benefit. And with a single payer system, you’re likely to get the reverse, where someone seeking care with only a marginal benefit can’t get it even if they can afford it. A single-payer system will be distorted by politically sexy diseases getting more attention, while a free market system will pay more attention to diseases of the affluent. No matter which side you support, there will always be injustices involved; stop pretending like there’s any goddamn utopia out there at the moment.

  5. Because that’s just short-hand for saying that rich people will be able to walk into the doctor’s office and order an MRI for every headache,

    Assuming they pay for it, what’s the problem with that?

    and the poor won’t get them even if they need them desperately?

    Which begs the question: why won’t the poor be able to get them?

    If its a question of limited supply, you need to ask why supply is limited. For example, in many places, the government has to approve major new medical investments (like MRIs) to prevent “oversupply”, which in the wacky world of government economics, leads to overcharging.

    1. Really, RC? Why do you think poor people don’t drive new Lexuses?

      It must be that the government is artificially limiting supply! Yes, that’s it.

      1. Actually, Im pretty sure most Lexus drivers ARE poor, measured by net worth.

      2. Just because someone drives a Lexus, that doesn’t mean it’s paid for…and it doesn’t mean he has anything but good credit.

      3. Just because government doesn’t limit the supply of luxury cars, doesn’t mean that it also doesn’t limit the supply of medical care.

        I’m wondering, in the pre-ObamaCare world that is ending, can anyone show me a poor person who was denied an MRI because they couldn’t pay for it? Links, please.

        1. It depends on what you mean by “need.” When I worked in a free clinic, I certainly saw people who needed gallbladder surgery, knee MRIs, joint replacements, etc. They weren’t dying of their medical conditions, although they suffered signficant disability and pain, and if they’d been insured, would have recieved treatment.

          Now, if you come into an emergency room with a stroke, you’re likely to get a CT scan and MRI, no matter your economic circumstances.

    2. If its a question of limited supply, you need to ask why supply is limited.

      Because we don’t live in a Star Trek post-scarcity economy.

      For example, in many places, the government has to approve major new medical investments (like MRIs) to prevent “oversupply”, which in the wacky world of government economics, leads to overcharging.

      Ironically enough, in a sense, we are oversupplied with MRIs. We certainly have more per-capita than any other first world country. However, for technical reasons, the machines are going to continue to be multi-million dollar investments well into the future.

      The problem with MRI costs, and medical costs in general, however, are mainly that medicine requires lots of highly specialized labor. You can try to trim costs by decreasing utilization of physicians, for example, relative to physician assistants or nurses, but fields with high skilled labor requirements are not going to show the same improvments in efficiency as the parts of the economy more amenable to mechanization.

      1. I claim BS on this. Medical care that is not covered by insurance or government programs goes down in costs even while utilization, technological quality and provider supply increases. Think of Lasik or Plastic Surgery. You need to do better than this.

        1. Oh, there are niches in medicine which have decreased in cost, but attributing this completely to the free market is a little biased. Lasik is a rare niche of practice that is easily mechanized and plastics procedures brief and usually technically simple, so both have decreased in price. With incentives, other small surgeries like hernia repairs (which are done by PAs in Canada) could become cheaper. But until you can invent a robot that does most of the work of a colectomy, or has the broad ranging skills and acumen of an ICU nurse or ER physician, you’re not going to dent most medical expenditures. Even for the technically simple stuff, like wiping an old mans ass, you need human labor, and human labor gets more, not less, expensive with time. That’s why most middle class people don’t have domestics today, whereas it was quite common with my mother’s generation.

          1. Except that it’s hard to know exactly what might decrease in price and by how much until there’s more transparency and competition. In retrospect Lasik looks easily mechanized, but would it have looked that way 40 years ago?

      2. medicine requires lots of highly specialized labor

        True, but sometimes those “requirements” are legal and not medical. Up until the late ’40s, pharmacists could prescribe drugs. Other laws prevent nurses from doing things that don’t really require doctors. Etc.

        1. Indeed. I think you could generate some cost savings by utilizing less highly trained practitioners (don’t count on pharmacists to prescribe; they make about as much as your family doc if not more). This will reap some initial benefit, but the reality is that medical practice is complex and only getting more so, and expertise comes with a price.

  6. We had a recent Nobel Prize winning economist here in Indiana whose work tells us that top-down mandates and one-size-fits-all schemes are bound to fail. While she didn’t address health care, her work would seem to apply.

    But who cares about pesky things like reality when the glory of the proletariat American people is at stake?

  7. But I think the author gives away the game in the second sentence, which ends with words “adding to the nation’s huge health care bill.” The nation’s. Not the patient’s.

    There is no difference, you fascist! Health care is a right! Hands off my ovaries! Impeach Bush!

  8. The horror of modern America!

    Does anyone here realize that a rich person can walk into any car dealership and buy a Porsche whenever they want one? And that a poor person wouldn’t get a Porsche no matter how much they needed one?

    And this same nightmare is repeated at restaurants and grocery stores and Best Buys all over this great land? I mean, not one person ever on Medicaid has gotten an MRI. I mean poor people are on Medicaid, right?

    1. Nobody ever needs a Porsche.

      And seeing a libertarian cite Medicaid as an example of why government intervention in health care isn’t needed is one of those buttery-popcorn begging moments.

      1. That’s why health care is different. You don’t die from not getting a Porsche. Sometimes, you do die if you don’t get a million dollar operation.

        1. After you’ve wrecked healthcare, what’s next? What’s the next area of the economy is going to be “different” and “an exception to the free market”?

        2. No, that’s not why it’s different; in fact, it’s not different at all. You just happen to think it’s a right.

          1. Something like that.

            The alternative is that poor people should die if they can’t afford the care they need.

            Even on minimum wage, one can probably afford food and shelter. Very lousy food and shelter, but enough one doesn’t die.

            Health care is different.

            Even at higher income levels, health care is different in that you can’t budget for it if you can’t get insurance (pre-existing conditions, for instance). Food, shelter, transportation, etc., all have steady, budgetable costs. Health care might be a million dollars tommorow or you die.

            1. Food, shelter, transportation, etc., all have steady, budgetable costs. Health care might be a million dollars tommorow or you die.

              So why do people need auto insurance if transportation has steady, budgetable costs?

            2. That presumes that the high costs of healthcare are the natural state, when in fact they are exacerbated by government policy at every level. When you restrict supply directly through licensing monopolies, certificates of need, etc and indirectly through byzantine regulations, and subsidize demand in a million different ways, you should not be surprised that prices go through the roof.

            3. Not likely. The thing with these million dollar estimates is that, given that 70+% of the population has no fucking clue what medicine costs out-of-pocket, they come up with these bizarrely inflated estimates.

              Everyone should try paying out of pocket for a few years so they realize that many things you don’t *need* insurance for. And in fact it is far cheaper not to use insurance for them.

              Now, if you are in the ICU for a few months, yes, your bills might rack up into the hundreds of thousands. But that’s what insurance *is* for. The kind of insurance that you can get for $50/month.

              1. I was recently in the ICU for less than 24 hours. The bill was $26,000, not counting two doctor bills ($1500) and the ambulance ($1500). The hospital decided I made so little last year that I qualified as a charity case, so I didn’t have to pay. The others I paid out of pocket. The ambulance was probably so expensive because in SF, some drunks and homeless use them like free taxis.

                I don’t know of any health insurance for $50 a month, though.

                1. I pay $50/month on a high deductible plan in Arizona.

                  Granted I havn’t visited the ICU lately, so you’re probably right about costs there.

                  Spending actual time in a hospital bed seems to be what gets you the huge bills.

        3. Sometimes, you do die if you don’t get a million dollar operation.

          So why do operations cost a million dollars or more?

        4. And under government health care, the government sets a number–it may be a million, it may be a gazillion–and just decides that it will let people die rather than get that X dollar operation. The next step will be to make it illegal for people to buy that operation with their own money, because it would be “unfair” for rich people to be allowed to live when people dependent on government health care must die.

          1. The next step will be to make it illegal for people to buy that operation with their own money, because it would be “unfair” for rich people to be allowed to live when people dependent on government health care must die.

            Has any government actually done this?

            1. Canada.

            2. Pretty much, yes. “Under current rules, hospitals may withdraw treatment from patients who want to use their own money to buy drugs not available on the health service.” (http://www.telegraph.co.uk/health/3367813/Patients-will-be-allowed-to-pay-privately-for-top-up-cancer-drugs.html) Note that that was a couple years ago and the article is about them changing the rules, but the point is that at least at one point, yes, they did decide to not “allow” you to buy your own treatment.

        5. Write this in your own blood if need be.

          What Sugarfree described using Porsche because it is an item we take for granted that a rich person can afford as was his point is universally true in every exchange the highest bidder wins the bid. Without that dynamic in place you would have shortages and inefficiencies that not make life unbearable for every one, not just the rich.

          Your altruism with other people’s money does not change the underlying laws of economics one iota.

          1. scratch that last ‘not’, notzees.

      2. The fact that Medicaid exists, which I oppose as well, means that the cries about “the poor” are not what the current bout of HCR is about.

        The truly poor are already covered, right? To let the proponents of HCR get away with saying it’s all about the poor is one of the more bullshitty aspects of all of this.

        The current reform is about getting people who are productive to pay for the medical care of the non-poor segment of society that doesn’t want to spend their disposable income on healthcare.

        1. The truly poor are already covered, right? To let the proponents of HCR get away with saying it’s all about the poor is one of the more bullshitty aspects of all of this.

          Indeed. Most of the yelling comes from yuppies and the middle class who see their insurance as too expensive. But if you want to deal with them, you need to be able to defuse their “but the poor…” argument.

          That being said, Medicaid is shit.

      3. No one needs an MRI. They are handy, but people survived for millenia without them.

        1. Uh, robc, even Methuselah didn’t survive for one millenium, let alone millenia. I take it you mean “the human race didn’t go extinct without MRIs”, and that is indeed correct, but it’s not a terribly individualist viewpoint. Many humans died or lived out lives as cripples due to lack of MRIs.

          Also, I guess you have to drop the whole “Canadians have to wait 6 months for an MRI” argument if they’re so unimportant.

          1. I said they were handy didnt I?

            I am willing to pay for something that handy. Im not willing to pay for it for you though. There are plenty of people Im willing to pay for an MRI for, but they have to ask personally, and you arent one of them.

      4. And seeing a libertarian cite Medicaid as an example of why government intervention in health care isn’t needed is one of those buttery-popcorn begging moments.

        When Americans become aware of the fact that Medicare has a much higher rate of refusal for service even adjusted for age compared to private insurers, this is going to leave the left in yet another pickle.

        Since they have demanded large scale change in private insurer coverage does it not behoove them to also demand reform of Medicare along similar lines? How will they do this without running up the deficit or pay for it without a fuckton of other peoples money (or, what they should refer to as SOP)?

    2. I mean, not one person ever on Medicaid has gotten an MRI.

      Not if it could be avoided. Medicaid doesn’t reimburse enough to meet costs.

      1. And this will suddenly change under ObamaCare?

        So instead of the poor not getting enough MRIs it will be instead 40 “uninsured”?

        Leftist decry the insufficiency of Medicaid but can’t understand that it’s the same thing as the single-payer system they all drool for.

        1. Medicaid is largely ignored, neither decryed nor hyped; it gets only a fraction of the attention that Social Security does. I thin this betrays something of the actual interests of the loudest segments in the healthcare debate.

          My personal opinion is that we have the worst of all possible worlds right now. Either a single payer or completely free market system would be better than this shit. When it comes to a completely free market system, though, I just don’t see any way to get there from here. The die was cast years ago with Social Security.

          1. There’s nothing really left that’s not fairly draconian. Unless the notion of insurance and pre-paid healtchcare fund are legally torn asunder, we are stuck.

            Single-payer will be a fucking nightmare. Choney like to huff and puff about daring us to not look at healthcare in Britain and Canada, but that’s bullshit. The US is more like Canada and Britain then anywhere else, and healthcare horrors from both countries ought to give us pause.

            1. True, we might end up like Canada or Britain, but even that’s better than what’s at the end of this road. And it’s possible that we could end up like France or even Switzerland. Given that we’re never going to be able to tell our old sick codgers to just kick off, I think it’s unlikely we’d end up like Japan.

          2. Actually, the almost unlimited money in the system caused by the 3rd party tax deduction does lead to a lot of innovation. Having the relatively poorer young subsidize the health care of us relatively wealthy aging boomers isn’t all bad.

          3. Social Security is a progentitor of the fiscal disaster we now delusionaly court like a pregnant, cankled prom queen. The funny thing about social security is that in theory, a large portion of the middle class and all of the rich should never have been forced into such a scheme for “their own benefit”. If you can save money now to live off of later, there is no reason that money should be funneled through the governmental Brita water filter and then back to you years down the road as diluted backwash. The cynical (and accurate) view is that, regardless of how much we wish that money was just thrown into a lock box waiting for us to turn grey, the government will use it as toilet paper to clean the corn out of its bureaucratic ass. Finally, this scheme has derailed, but it will be some time before the train crashes into a municipal building, burning the toads who forced us to ride on it. It reminds me of the Monorail episode of the Simpsons.

  9. Something tells me the overwhelming majority of people who say “I need an MRI” couldn’t actually tell you what it is. They probably think it’s a magical healing device like they had on Star Trek.

    1. “They probably think it’s a magical healing device like they had on Star Trek”

      I want one NOW!

    2. Tell them to wrap themselves with a coupla hundred turns of antenna wire and hook the ends to their television sets.

    3. If that’s the case, Dr House’s trick for handling hypochondriacs — giving them lemon candies in prescription medicine containers — could be adapted to meet the psychological needs of MRI obsessives.

      1. I actually knew a pediatrician in Canada (before universal Medicare) who used to give out colored sugar water or sugar pills to his patients.

        It wasn’t for the benefit of the patients, so much as to calm down the overanxious mothers.

        An MRI is an awfully expensive placebo, of course.

        1. You don’t need a real MRI. Just a big plastic tube with some speakers around it. Call it a “virtual MRI” and tell them that everything looked OK.

        2. I wonder if this pediatrician figured out he could make a lot of money this way and ending up founding Mannatech.

  10. And that a poor person wouldn’t get a Porsche no matter how much they needed one?

    Why do you hate and ridicule the poor?

    You fiend.

  11. I too “need an MRI”. Doctor said so.

    But my deductible is high, and wouldn’t you know it, an MRI thru my plan costs around the same as my deductible.

    So I’m calling specialty clinics, looking for a lower cash-only price. While a few actually can tell me what the cash price is, when I ask most of them “how much does it cost?” their response is along the lines of “Huh? You’d have to ask your insurance provider”. It is almost impossible to compare prices.

    It’s not just that the web of 3rd party payers drives costs up, it’s that medical providers don’t even know the price to charge for their own services. It is nuts.

    1. Check with your largest state university with a medical school. They probably deal with the vast majority of the Medicaid/care patients in your state, so they are usually eager for people that will pay cash.

    2. That reminds me of a time when I called an opthamologist’s office, to whom I had been referred, to find out what laser surgery on a retina would cost. You’d have thought I was asking for the pin number to their credit cards or something. Actually hostile.

      1. I’ll third this. Trying to get an estimate from the medical provider is often like pulling teeth. The attitude is: “I’m sure your insurance will cover most of it, so what are you worrying about?”

    3. I went online and looked up the cost of MRIs in my own area.
      it varies depending on the type of thing you are scanning for, but the price range starts at $1,500 and goes up to a few grand.

  12. I believe one mister Paul Krugman has dispelled this myth. He just said on Sunday in a dialogue with Samuelson that markets don’t work with health care, like electronics. And people can’t pay for their own medical expenses. The debate is over.

    I’ll provide an example to dispell this myth. Recently, my mooching, perpetually in school little sis had me over for dinner. Now, she is considerably younger than me, and has never so much as bought me a PBR draft beer. No problem. Nevertheless, I was shocked she was cooking us dinner. I expected cereal or some sort of noodle dish. Much to my surprise, we had ny strips, chicken kabobs, roasted garlic smashed potatoes fresh veg with balsamic, and a delightful “organic” salad. Wow, sis, what’s up with this? Fucking food stamps. “A lot of my friends are getting them.” That’s fucking terrific. 3rd party. Free. Now she can become an artist and get free health care! I, of course, had to provide the “adult” beverages.

    1. Hearing the phrase smashed potatoes usually sends me into a killing rage. IT’S MASHED FUCKFACES GAAAAARRRRR

      1. Non-carbon-based salads are delightful too. Be a little more open-minded, maybe.

      2. Praise Galt for people who hate the term “smashed potatoes”. What are you, a little kid? Did you whip these potatoes against a wall, Jai Alai style? Grow up.

        1. I MASH them. With a potato MASHER. You’re worse than Hitler, you horsecock-braising faggot.

          1. I whisk mine then use a large spoon because they start off as flakes.

            For some odd reason I never have liked non-instant mashed potatoes.

          2. It doesn’t drive me into a blood rage. A distinction between whipped (mashed smooth and air added in), mashed (mashed smooth, but left dense) and smashed (only partially mashed and usually with the implication that herbs/cheese/bacon/aromatics has been added) is useful.

            You know that a baked potato and a twice-baked potato are actually two different things, right?

            1. You’re talking about three variations of mashed potatoes. All are mashed potatoes, and only obnoxious foodies like yourself try to impress themselves and each other by insisting on the distinction.

              Anyway, shouldn’t you be laying off the starches, you walking corpse?

              1. So there’s no difference between a Mettalica, Tyrant, and Cannibal Corpse because they are just three varieties of metal, right? And only obnoxious music fans like yourself try to impress themselves and each other by insisting on the distinction.

                1. Fundamentally, yes. By the way, I’m gonna come to your house, gouge out your eyeballs, and skullfuck you.

                  Also, is Tyrant even a band?

                    1. Tasmania? They have electricity there?

                    2. Errol Flynn was from Tasmania. Thanks, Trivial Pursuit!

                    3. Why, yes, they do have electricity in Tasmania.

                      They even had it back in olden times when I lived there.

                      I actually went to one of the schools Errol Flynn was expelled from. But that’s not hard he went to, and was expelled from nearly every school in town.

                    4. On the other hand, indoor plumbing was less common. 🙂

        2. And what the fuck is up with “praise Galt”, anyway?

          1. It’s for people not sensible enough to recognize the Glorious Splendor of the Omnibenevolent Pasta.

      3. I like ’em almost as much as sketty.

      4. Yins don’ like smashed potatoes an’ ‘at?

        1. It’d be patatahs.

          1. Oh, say now – I like tatahs. ‘Specially big, soft, fluffy ones.

          2. Oh, say now – I like tatahs. ‘Specially big, soft, fluffy ones. 😉

            1. No, not pa-ta-tas, it’s more like pah-tay-tuhs.

              1. Some say pa-ta-tas and some say pah-tay-tuhs. 🙂

    2. Has Barack been filling her gas tank, too?

        1. Depends. Since the mouth is the way you fuel the body, it could mean face-fucking.

          1. I was specifically referring to “gas tank” and thinking of the rectum but you actually can be right with that line of thinking too considering that belches are gas and come out the mouth.

            So we both win. Yay!

            1. And the gas from semen rotting in the stomach is often much more rancid than even a hard-boiled egg fart.

              I really, really hated my college roommate.

              1. Was your roomie female? That would actually make it worse.

                1. I don’t know what it was.

    3. I have never before heard the term “smashed potatoes.” Is that a northeastern thing?

      1. It is an ASSHOLE thing.

      2. I never had until now. I don’t know how people get the potatoes drunk.

      3. It’s the food equivalent of LOLspeak.

      4. It’s an idiotic Nouveau American Cuisine thing. Similar to McDonald’s chicken nuggets “infused” with butthole meat.

  13. Peter, you just don’t get it. The Times is agitating for death panels.

  14. Much to my surprise, we had ny strips, chicken kabobs, roasted garlic smashed potatoes fresh veg with balsamic, and a delightful “organic” salad.

    1. What- no whirled peas?

      *shakes fist at squirrels*

  15. Nobody ever needs a Porsche.

    That’s just wrong.

  16. Where are these doctors that give the patient whatever he asks for. My docs never order enough diagnostic tests or sufficient pain medication. I wind up going back two and three times over weeks to finally get treated for what should have been diagnosed on day one. I’ve never had an MRI.

    1. I have the same problem. I have a friend that got pain medication when he broke his little toe. I’ve torn my rotator cuff & cracked my sternum. Two different doctors & both of them wouldn’t give me pain meds. They told me ibuprofen would take care of it.

  17. As long as your health insurance is actually a pre-paid body maintenance plan, this shit is going to be a problem.

    How often would people need new tires if auto insurance was treated the same? How many auto shops would turn them away because they really don’t?

    Sometimes you need a new differential, sometimes you need an MRI. Insurance shouldn’t be paying for either but the laws say the MRI has to be covered.

    1. Comparing auto and health insurance is like comparing apples and orangutans. Auto insurance does not, repeat, does not…did you get that, DOES NOT…cover mechanical breakdowns. If your engine seizes up because you didn’t get the oil changed for three years, your insurance doesn’t have to buy you a new one. That’s why auto insurance doesn’t cover oil changes.

      But health insurance is totally different — if anything goes wrong with your body, the health insurer is going to have to pay to fix it. Therefore it makes sense for them to cover preventative medicine such as yearly physicals.

      The analogue of autor insurance for one’s body would be accident insurance (eg, AFLAC). As you might know, AFLAC doesn’t cover yearly physical examinations.

      1. Also note that auto insurers do cover some preventative maintenance — windshield chip repair is covered by glass policies — not to mention the discounts (which are effectively payments) offered for defensive driving courses and the like.

        1. And thus it is a lot like health insurance.

          In a free market, there are lots of different types of health insurance policies – the AFLAC accident policies, catastrophic policies (which are most like auto insurance, with some obvious differences as you pointed out) and then low deductible policies which are generally stupid, IMO.

          And, of course, HSAs, which, in a not-quite-free market with tax implications, are the best of all. Combining a catastrophic policy with pre-tax spending on maintenance and prevention and basic minor costs.

      2. Yes, but the body maintanence expenses are non-emergency. Hence not the kind of thing you can’t shop around for or haggle for.

        Auto insurance covers accidents. Sudden large expenses that could not be prevented.

        Which is to that that health insurance *should* look a lot more like auto insurance since you don’t *need* health insurance to shop for your yearly physical.

        The argument that you can’t haggle over the price in the emergency room doesn’t apply when you’re talking about preventive care, it only applies to the kind of emergency expenses that are most analagous to accident insurance on autos.

        1. You’re missing the point. The problem isn’t that people have to shop around for physicals, it’s that they don’t want to get them at all if they have to pay for them. And if they don’t get a yearly physical, their chances of developing a condition that grows from a small, easily and cheaply corrected problem to a life-threatening one skyrockets. And that translates into bigger insurance payouts, unless you want insurance companies to be able to refuse to pay for heart surgery because you were 30 days late getting your annual exam five years ago.

          Auto insurance covers accidents. Sudden large expenses that could not be prevented.

          It goes without saying that the vast majority of auto accidents could have been prevented.

          1. Well, in that case, heath insurance companies ought to have a financial interest in paying for yearly physicals. Perhaps as a condition for lower rates. Don’t get a physical each year and your rates jump.

            I think the auto insurance analogy is still apt. An auto insurance company will charge you less if you’ve taken devensive driving, or if you have a good driving record. Under the right circumstances they might even charge less if you got your brakes checked and had regular maintenance on your car.

            Of courset he analogy isn’t perfectly exact. No analogy ever is. But the main point of it is not that health and auto insurance do work the same, but that health insurance *should* work more like auto insurance.

            1. They’re fundamentally different objects. With auto insurance, if the insurance doesn’t cover something and you can’t afford to pay for it out of pocket, then you suck up and deal if it’s cosmetic, or go without a car for a while if it makes the car undrivable. With health insurance, you either let your condition get worse or you die.

    2. Once I was getting a “free” oil change at an auto dealership, and the service tech came up to me and told me that my front tires were running out of tread, and offered me exorbitantly priced new tires. Since the rear tires were in good shaped, I asked him to just rotate the tires instead, for whatever fee they charge for that, and he refused saying he could not do that “in good conscience” because it would still be an unsafe condition.

      1. Cool story bro!

        I was getting my oil changed at Valvoline last December and they said my battery was getting low (it was) and offered to replace it for some crazy price. Instead, I drove to Wal-Mart bought a battery and replaced it myself.

        I have no idea the point of either of our stories.

        1. If my auto insurance paid for battery replacement, I would have let Valvoline handle it at the crazy price instead of doing the work myself.

          1. If auto insurance paid for battery replacement, they would almost certainly tell you at which shops you could have the replacement done, too.

            1. True, but they wouldnt say “buy it at Wal-Mart and install yourself”. At least not as long as government mandates existed.

        2. I was responding to J sub D’s implication that auto repair shops never refuse to perform a service. My example shows that in some cases they’ll refuse to do a less expensive service in the hopes you’ll let them do a more expensive one.

          Of course in that case I just told them to forget doing either, went across the street to Goodyear, had them rotate the tires, and then drove 2000 miles in the winter on them with no problems, until spring came and I had a job and a local tire store had a sale. The guy at Goodyear tried to push me into getting new tires too, but at least he didn’t flat out refuse to rotate them.

          1. In every profession, scammers exist. I noticed that the goodyear had no problem doing the tire rotation even though they thought you needed new tires too. Which is Jsub’s point. Notice he didnt say that none would turn it down, he asked a question. And even your response implies the answer is very, very few.

          2. I’m going to go out on a limb and say that I probably *would* have got my tires replaced under those circumstances. Maybe not at the same shop. But I tend to be skeptical that an auto mechanic is going to flat out refuse to provide a service unless he really thinks that you have a safety issue. Anyway, I’m way too cautious about getting into car accidents to let something like that slide for a few months.

  18. Dr. Luce said, “That [rationing] is not likely to happen soon, particularly at a national level.”

    It’ll happen as soon as we admit that, as a nation, we are out of money. Or when other nations finally stop purchasing our debt. So yes, it will take a while, but that fateful day is approaching rapidly.

  19. You’d have thought I was asking for the pin number to their credit cards or something. Actually hostile.

    They’re offended. Only an ape-faced merchant would know the price of what he sells, or do business with random losers off the street. Most medical businesses will gladly, and many angrily, dodge your ready cash just to avoid being seen touching it.

    So the one good thing about Obamacare is fuck them. However they get screwed, they asked for it. Begged and paid for it, actually. Woot.

  20. If the person wants it, what are you going to do, say no?

    Now *that’s* a great pick-up line.

  21. The law does not impose price controls on health care services.

  22. THE PURPOSE OF INSURANCE IS TO PAY FOR LARGE UNEXPECTED EXPENSES THAT YOU CANNOT BUDGET FOR OR CASH FLOW.

    Sorry to yell, but the point needed to be made.

    1. This needs to be posted at the top of every healthcare thread.

    2. No, the purpose of insurance (well, health care insurance anyway) is to redistribute income from the healthy and the rich (who may or may not be the same) to the sickly and the poor (who may or may not be the same). We call it “insurance” for the same reason we call social security “insurance”: to trick people into thinking it has something to do with insurance as defined by robc.

    3. Yes sir.

      Until we actually start discussing insurance in these terms and quit assuming that the only way to pay for healthcare is through an insurance company money launderer, we’ll never have true reform. We’ll just have “reform” instead. Everything else is unserious.

    4. Don’tbe ridiculous. Insurance is for every time my ex-girlfriend gets a cold. How else could the “free market health insurance market” keep premiums falling?

      Luckily, with the mandates imposed on the one-size-fits-all policies, when my buddy (who happens to be a trust fund kid), that’s drinking himself to death, goes to rehab, he’ll use his insurance to pay for it. He’s a proud liberal. This too should help drive down the cost of premiums. Don’t get me wrong, I am all for my friend’s right to drink himself into rehab (I’d rather he tone it back a bit – doubtful), but I just don’t want to have to pay for it.

  23. But I think the author gives away the game in the second sentence, which ends with words “adding to the nation’s huge health care bill.” The nation’s. Not the patient’s. There’s a huge difference between the two, and therein lies the problem.

    Okay, it seems the coast is clear (no Chad, Tony or shrike…), so let me tell you all about collectivists (leftists, huge numbers of Democrats, communitarians, etc.) while they’re not around to be offended.

    The collectivist has accepted as a premise that his problem is also your problem, that your problem is also his problem, and that all of our problems are actually all of our problems. (Leave it for later to figure out whether it’s nature or nurture that makes them this way.) The collectivist doesn’t want you to pay for (or insure) your own medical care, and him to pay for (or insure) his own. That’s too simplistic, too atavistic, too selfish, and too plain old individualistic. For the collectivist, every time another person is born on this planet, it just increases our collective burden, and our collective responsibility. So, the collectivist perceives this real “problem” with “our” medical care costs rising uncontrollably. The real problem, sadly, is in their own minds (and possibly brains/DNA – again, we can have that debate).

    Not sure what we can do to help these folks with their disorder. Anyone have any suggestions?

    1. The “cure” for Hoof-and-mouth disease is always an option.

    2. For the collectivist, every time another person is born on this planet, it just increases our collective burden, and our collective responsibility.

      I hate to interrupt your caricature of collectivists, but we also see each new person entering the world as someone who can contribute to the common good, in the great circle of human life.

      1. A new slave is born every second.

      2. Got it. To a collectivist, you are either a tax payer to be yoked to the cart of the common good, or a tax consumer to be placed in the cart for a free ride.

        1. Most people are going to be both contributors and beneficiaries — or if you insist on casting it in negative terms as InsulinShock up there does, “slaves” and “free riders”.

          I might add that to a radical capitalist, you are either a “winner” who has a lot of value to trade in the market, or a “loser” who doesn’t and deserves to starve to death. Yeah, you guys always say charity will rescue the losers, but that’s not part of your system; you’re depending on a residual collectivist impulse of charity to justify your radical individualist system.

          1. So we all agree that we have contributors(slaves) and beneficiaries(free riders). Now we all no that times are preet tough now and we have to figure out some way to make them better. I advocate we get the slaves to contribute a little more and we put some of the beneficiaries out of their misery(mercy killing)…this will all be for the good of the collective.

            Sacrifices are required by both groups so who could oppose?

      3. No doubt you do (more anon).

        First, I’ll state that capitalists and rational egoists embrace new individuals coming into the world because we know that we can trade value for value with them, to mutual benefit.

        I notice that you self-caricature (in my view) by using the term “contribute” to the “common good.” Sort of frightening, in a “reminiscent of the kolkhoz” kind of way.

        1. I’ll state that capitalists and rational egoists embrace new individuals coming into the world because we know that we can trade value for value with them, to mutual benefit.

          Unless they happen to be the aforementioned “losers” who have little of value to trade. Then you embrace their right to choose which gutter to lay down and starve to death in.

          1. Lucky for them, everyone is free to improve his own lot in life. Nobody is born a carpenter or electrical engineer.

            1. Truly it is the fault of the kid born with one arm that he is not a carpenter, and the girl with down’s syndrome that she is not an electrical engineer.

              That’s not even bringing up the kids who are born in the ghetto and have no opportunity for the necessary education until they’re too old to start.

              1. Forrest – shut the fuck up

                1. You shut the fuck up, you AIDS-junkie cripple, Lt Dan SIR!

              2. I’ve never heard of a kid being born without parents, who would presumably care for the kid or give them to an adoption agency.

                As for the kids in the ghetto, all the government in the world hasn’t done a damn thing to improve their life, now has it? In fact, they can thank the War on Drugs for many of their present ills. Education in Harlem was better in the 1900s than it is today.

                1. Again, you assume that collectivism will continue to contaminate your individualism in order to make your system sound like anything other than a law-of-the-jungle horror story. Interesting that you assume that only the pleasant things about collectivism will survive into your system.

                  1. Get back to me when you can understand the difference between coercion and voluntary cooperation, which is in no way incompatible with individualism.

              3. It is clearly not the fault of the down syndrome kid that he is born that way, but it is a burden on the whole community now in these tough times.

                Of course the selfish individualist breeder parents will insist that they should be able to keep their down syndrome kid but it is hardly fair to the community. The selfish parents should make a sacrifice for the good of the community and put their down syndrome kid out of their misery…what possible benefit can come from the down syndrome parents using so many resources on their selfish hobby?

                For the good of the collective perhaps we should weed the garden and that way we can hope that some of the less marginal beneficiaries can improve their lot in life and become contributors.

      4. Indeed. We will add their distinctiveness to our own. Resistance is futile.

      5. “I hate to interrupt your caricature, but you should be making the ears bigger.”

  24. If people are going to justifying this because poor people have been denied medically necessary care, I’m going to need to some showing that poor people have been denied medically necessary care.

    I haven’t seen that yet. Nor will I, because it simply doesn’t happen in any meaningful way.

    This isn’t about health, people. Please stop pretending that it is.

    1. some showing

      Two years after a 12-year-old Maryland boy died from an untreated tooth infection, low-income kids continue to face barriers to dental care despite state and federal efforts to improve access, government investigators said Wednesday.

      “The bottom line: Children’s access to Medicaid dental services has been improving but remains low,” said Katherine Iritani, health care acting director at the Government Accountability Office.

      1. Could, could you get me a glass of water, Forrest?

        I know it is against your rules, but have some compassion, for once.

      2. Setting the aside the now-apparently-forgotten principle of “If you can’t afford to have kids, don’t have kids,” where does it say that this kid was “denied” dental treatment? What would have prevented the parent (want to bet there was only one?) from taking the kid to the dentist and dealing with the bill later? And what sort of parent lets their kid suffer dental pain rather than getting help, regardless of the cost?

      3. Perhaps people shouldn’t have children, if they can afford medical care for them. Has that ever occurred to you?

        1. Ah, PapayahSF beat me to it.

        2. can’t (damn it)

        3. Perhaps people shouldn’t have children, if they can afford medical care for them. Has that ever occurred to you?

          Perhaps if people are poor, they should just get rich. Problem solved.

          Let’s focus on reality for now, though. Rich or poor, people will fuck and have kids. Acting morally superior does absolutely nothing to fix anything.

          1. Perhaps if people weren’t sneered at for pointing this out, fewer people who can’t afford kids wouldn’t have them? Social pressure and all that.

      4. I wonder what Canadians do about dental care.

        Hint: they don’t get it from the government.

  25. “The nation’s. Not the patient’s. There’s a huge difference between the two, and therein lies the problem.”
    Well, I pay a co-pay, and for high priced tests (like my cardica tests) it is a considerable nut.
    But remember, the doctor is the one proscribing it. I am skeptical of these tests, but I don’t want to get in a pissing match with my cardiologist.

  26. Auto insurance does not, repeat, does not…did you get that, DOES NOT…cover mechanical breakdowns.

    What do you think a “warranty” is?

    1. Is it when your parents pay for your operation?

    2. I think it’s not auto insurance as the term is commonly understood.

      And if you don’t get the oil changed on time, every time, your warranty isn’t going to cover a blown engine. Those things require proof of maintenance.

      1. Maybe we ought to require “proof of maintenance” on health policies.

        Forget the sin taxes, just say, “been drinking, pay up or forget about getting that liver transplant.”

        And yes, a warranty is an insurance policy. Some – extended maintenance policies for used cars – are explicitly sold that way.

        1. Sorry, mam, you were 10 days late getting your annual mammogram at age 44. So your insurance doesn’t cover this $15,000 mastectomy.

          Will that be cash or Visa? If you want another option, Robc Self-Medical recommends a steak knife, mirror, and a box of bandaids to people in your situation.

          1. Could you get me some water?

            1. After I had to sit through your incredibly bad movie for 3 hours, you’re lucky I don’t piss in your mouth.

  27. The rarely noted point about National Universal healthcare is that it exists not for the benefit of the poor but so that the “middle-class” and well-to-do will never have to spend any of their savings or sell any of their assets to pay doctors’ or hospital bills.

  28. You have seen Scotch Hamilton and Forrest on numerous threads today.

    Do you believe their contribution has added ‘Jack + shit’, or have they not wasted your time with stale arguments you may have once believed yourself before you got a good grasp on how the world actually works?

    1. Whew! For a moment there I was afraid you were going to hit us up for a donation.

  29. Do these threads benefit from a ‘diversity of opinion that furthers our discussion’, or does answering the same damn asinine baseless rationales the left throws out there in the place of a reasoned counter argument keep us in a rut?

    1. Well, for a site called “reason”…

    2. If you’re going to quash any comments that don’t include truly insightful thinking rather than just repeating talking points or vacuous backtalk, most of these threads are going to be empty. You might even lose a couple of my comments!

    3. The comment section wouldn’t be nearly as entertaining without Chad, Tony, et al. And Forest. What the hell happened to Crayon? Actually, what the hell happened to the Old Mexican? Chony comments aren’t the same without an OM beatdown.

  30. I tried to get Forrest to STFU, but he’s on PCP and running full tard ahead

    1. I would recommend sending his mother condolences for her loss in person. She is really cute and may need some ‘comforting’.

  31. Truly it is the fault of the kid born with one arm that he is not a carpenter, and the girl with down’s syndrome that she is not an electrical engineer.

    This might be relevant if we were discussing the merit of programs or aid for the handicaped. Something that would bring out a vaiety of different viewpoints.

    But we’re not. We’re discussing a middle-class entitlement.

    1. There are plenty of middle-class people with Down’s Syndrome. Some of them even post here!

      1. Yes, but we wish you wouldn’t.

  32. Say goodnight, Forrest.

  33. “It would mean rationing, said Dr. Robert D. Truog”

    Duh. And much more. The upcoming “soda tax” – soon to be pioneered by our friends in Albany – is just the beginning. Socializing health care gives them the excuse to punish pretty much any currently unfashionable behavior they wish. Be afraid.

  34. Every blog gives a unique set of information. It would be useful for us to collaborate with the kind of info we want.

  35. and enemies of regressive taxes. The Puritan strain in the American psyche is as durable as ever, I see. I’m saddened, but undaunted. I long ago learned how to brew my own beer, and I suppose I could learn to grow tobacco in my backyard too, if it comes to that, or make friends with my local smuggler. Some forms of social engineering are unpleasant, and some are intolerable. Surely, even among liberals, we can agree to disagree about which is which.

  36. What youre saying is completely true. I know that everybody must say the same thing, but I just think that you put it in a way that everyone can understand. I also love the images you put in here. They fit so well with what youre trying to say. Im sure youll reach so many people with what youve got to say.

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