health care

What a Subway Breast-Implant Ad Can Teach Us About U.S. Health Care

The idea that people won't be able to afford medical treatment without Obamacare is simply wrong.

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RICHARD B. LEVINE/Newscom

For sheer accumulation of elite institutional prestige, it's hard to top Atul Gawande. He is a professor at both Harvard Medical School and the Harvard School of Public Health and a regular contributor to the New Yorker magazine, where I've enjoyed reading and learning from some of his brilliant and fair-minded past work.

Gawande greeted the news of Donald Trump's election and its impact on heath-care policy with this gem: "eliminating Obamacare isn't going to stop the unnerving rise in families' health-care costs; it will worsen it. There are only two ways to assure people that if they get cancer or diabetes (or pregnant) they can afford the care they need: a single-payer system or a heavily regulated private one, with the kind of mandates, exchanges, and subsidies that Obama signed into law."

A few days later I was in the New York subway and saw a poster advertising plastic surgery. "Breast augmentation," the poster blared: $3,900. "Free consultation, 100% financing available—includes all fees."

On the health care financing question, I think the New York subway ad is closer to the truth of the matter than the New Yorker magazine.

If there's anything American capitalism is really good at, after all—for better or worse—it's figuring out ways for consumers to pay for things that they otherwise couldn't afford, and may not even need. That new iPhone? Pay for it over two years in connection with your cellphone service contract. A new house? How about a 30-year mortgage, or even an interest-only adjustable rate mortgage? A new car? Lease it for three years. College tuition? Try a section 529 tax-deferred savings account, student loans, and financial aid.

Leave cancer or diabetes aside for the moment. With all due respect to Professor Gawande, Harvard, and the New Yorker, it's just hard for me to believe that in the absence of Obamacare, the expense of pregnancy will suddenly become out of reach to ordinary Americans. Somehow, hundreds of millions of Americans managed to become pregnant in the more than two centuries that the republic existed before 2010, when the Patient Protection and Affordable Care Act was passed. If the law is repealed, we'll find a way to reproduce again afterward.

If anything, pregnancy and childbirth are fine examples of the way that government involvement, regulations, and subsidies increase the cost of medical care rather than decreasing it. When someone else is paying, all of a sudden any personal financial incentive a patient might have had to see a cheaper nurse-midwife for routine prenatal care rather than a more highly paid obstetrician/gynecologist disappears. Likewise, if the government requires insurance companies to pay for a two-night hospital stay, why go home sooner?

Much of the expense of modern pregnancy care—fetal echocardiograms, repeated sonograms, various other tests—relates to a policy agenda of preventing the birth of disabled individuals. That may or may not be a policy agenda worth furthering by making everyone's pregnancy more expensive, but if that is the tradeoff, let's at least be transparent about it, rather than pretending that it's the pregnancy, rather than the disability-birth-prevention, that is the expensive part.

The most expensive part of health care is usually a doctor's time. The supply of trained physicians is artificially constrained by limits on how many medical students, residents, and fellows are accepted each year in American medical institutions. Even highly competent and experienced foreign-trained practitioners often are required to repeat their training if they want to immigrate here and practice in America. If Americans were paying directly for their own health care, you might see political pressure build to increase the supply of physicians (and drive down the wages). Or perhaps "medical tourism" would increase, with pregnant patients choosing to schedule their labor or delivery at less-luxurious hospitals overseas, where doctors and hospital staff earn less money.

Even the billing might become more efficient if government and insurers were cut out of the picture. My local orthodontist, for example, has managed to figure out how to bill for braces in ten or twelve payments charged directly to my credit card. With other doctors, where, unlike at the orthodontist, an insurance company is involved, I seem to get at least four different bills or statements for each visit — a copay, a statement of benefits from the insurance company, a bill from the doctor, and then another bill from a lab or hospital or an imaging center.

Sure, health care differs in important ways from other parts of the economy. As even Donald Trump concedes, we don't want people dying in the streets because they can't afford health care. But health care is similar in important ways to other parts of the economy, too, in the sense that if people want something badly enough, the market will find a way to provide it.

The idea that without ObamaCare, people won't be able to afford pregnancy is an idea that is itself symptomatic of the syndrome known as elite post-election panic. There's no cure yet known for it, but one hopes for everyone's sake that it will get better with that time-honored medical technique known as "watchful waiting."

NEXT: Who Wins From New York's Ban on Airbnb? The Dirtiest Hotel In America

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  1. “The idea that people won’t be able to afford medical treatment without Obamacare is simply wrong”

    Give them time

    1. This article would be a lot more exciting if you took the word “ad” out of the title.

      1. nom nom

  2. what do they think people did before Obamacare? Orphans were dying in the streets, right?

    We know that’s wrong because we Libertarians take care of our orphans ….

    1. It hasn’t been that long since we had a merely fucked-up system, as opposed to a colossally fucked-up system.

    2. Exactly. They die in our factories, digging coal by hand, after we’ve extracted their blood and vital organs from them.

      1. Dammit. s/b ‘They die in our factories,…’

  3. As even Donald Trump concedes, we don’t want people dying in the streets because they can’t afford health care.

    I do. That’s obviously why I opposed Obamacare in the first place.

    1. I thought it was because you didn’t like Jews, the biggest recipients of Obamacare.

        1. Dybbuk schmybbuk, i said more ham!

    2. What I wish is that U.S. policy makers were as honest as you are. Why can’t right-wingers just tell everyone they want more desparately poor citizens to die quickly? At least you are brave– not a coward like these Republicans.

      1. As opposed to those on the left who just want to create as many desperately poor citizens as possible?

        Anyone can make a straw man.

      2. Give it time, you don’t implement socialism overnight.

      3. Everybody knows that the poor are better off dying slowly waiting in NHS lines, right comrade?

        1. Not just the poor dying in lines, but the rich too. That’s how you know it is working.

          – Bernie Sanders.

          1. But not the party chiefs, because they’re important!

          2. But not the party chiefs, because they’re important!

      4. I thought it was the leftists that wanted to eliminate the excess population.

      5. As opposed to rationing care, so people of all economic classes get to die in the streets. The socialist definition of progress.

      6. Why can’t right-wingers just tell everyone they want more desparately poor citizens to die quickly?

        Because it’s a goddamned lie, you mendacious little twat.

        -jcr

    3. As even Donald Trump concedes, we don’t want people dying in the streets because they can’t afford health care.

      That was charitable of the writer, wasn’t it? Even the fount of all evil doesn’t want people dying in the streets.

  4. For some reason it’s better to be required to make large monthly payments for insurance you may never need for your whole life than to have monthly payments after the fact for a medical procedure that you did actually need.

    I don’t know what this reason is, but lots of people seem quite convinced.

    1. Ask a prog why a person who is a cash billionaire should have to buy health insurance. Blank stares.

      It’s obviously about cronyist compulsion.

    2. It’s about impossible to do this, but it would be really great to see what pricing for healthcare and medication would be in a free-market economy.

      1. That’s pretty much what the article demonstrates. I should be able to get lots of other surgeries for $3900.

        1. Poor people don’t have $3900. So $3900 is too much. Therefore some sort of price control is in order.

          1. Maybe poor people don’t need breast augmentation?

        2. I think lasik is under $1k.

          1. A local place is offering it for $149 per month. Didnt see total.

            Does Rand Paul do lasik surgery? Could I get my eyes fixed by my senator? Would I want to?

          2. When I looked into it a few years ago it was still going to be something like $3k for both eyes.

          3. I had it done just this past Thursday. It was $4,040.00 for both eyes and medicated drops. It also included next day follow-up, 1 week follow-up, 1 month, 3 month, and 1 year. That was with a 15% discount for 100% payment up front.

            1. I had it done this past spring. My optometrist referred me for some kind of discount program, so I paid $2k. That was for both eyes, and covered everything, including follow-ups. I likewise went with the 100% down and nothing a month payment plan. So far, my only regret is that I didn’t do this a few years sooner.

        3. You can, in places where healthcare is allowed to operate in a more free market-like sort of way.

      2. I’ve asked several doctors what ordinary annual physicals would cost absent insurance, and the answer was usually around half if I paid cash. I guess it would be even less w/o Obamacare enhancing the bureaucracy.

      3. Look at veterinary medicine.

        I had one of my mares in for treatment of a squamous cell tumor on her eye, a few years back. Unfortunately the eye couldn’t be saved, but she got the eye and tumor removed and follow-up radiation therapy for just over $2000 at the top Equine Opthamology hospital in the country.

    3. You can’t bill someone who died under your knife…

      1. I hadn’t actually considered this before as regards billing. Do insurance companies pay up if their customer is dead?

  5. This was the best Reason article on free market healthcare.

    https://reason.com/reasontv/201…..doctors-fi

    1. Interesting. They should do a follow-up piece, though it’s tough to operate on a quasi-market basis when all around you is socialist crap.

  6. I have to keep my mouth shut at home about this. Two members of my family (one on my wife’s side, one on my side) had painful, expensive, chronic problems that they just lived with prior to getting subsidies for insurance and getting the “pre-existing condition” block removed.

    My mother-in-law immediately bought her cheap insurance and got two knee replacements (she couldn’t go up or down stairs before), and my cousin got a spinal surgery he needed for a disk that had disintegrated. So both of them basically accuse me of wanting them to remain in pain until they qualified for Medicare any time I bring up my opposition to the ACA.

    1. We didn’t have a health care problem we had an insurance problem and it should have been treated as such.

      1. Exactly, but I would also add… we have a litigation problem compounding the insurance problem.

        1. ^^ this!

          Here in the PRK I would seriously estimate that the costs of all goods and services are at least triple what they should be otherwise due to fear of litigation.

    2. And if there had been a true free market in healthcare like there is for other necessities of life such as food, clothing and shelter, they would not have had to wait for Obamacare to relieve their pain.

    3. But how does your family feel about your breast implants?

    4. So both of them basically accuse me of wanting them to remain in pain until they qualified for Medicare

      This is the fundamental problem. There are millions of sad stories out there. Any attempt to talk about rational approaches to reforming the medical system results in accusations of cruel indifference to the all those sad stories.

    5. getting the “pre-existing condition” block removed

      Even the pre-existing condition block has a pretty straightforward market solution. Sell insurance to parents planning to have kids before they even conceive that will cover any potential chronic conditions. Parents would pay a premium for the peace of mind but then their kid would be covered. No reason the same thing couldn’t be done later in life but before any chronic issues emerge.

      1. We would have been better off allowing them on Medicare albeit with monthly payments due then what they ended up doing.

      2. Whole health insurance, like whole life insurance. Although someone once explained it couldn’t be made affordable. I dunno, the $’s coming from somewhere no matter what.

        1. Although someone once explained it couldn’t be made affordable

          I’d like to know the assumptions they are making going into that analysis. Anecdotally it seems like the vast majority of people don’t incur major medical expenses until near the end of life. Granted, end-of-life care could totally ruin it, but maybe that should be covered differently? After all, insurance makes the most sense for protecting against low-probability but high-cost events. Getting old isn’t low probability.

        2. “Although someone once explained it couldn’t be made affordable. I dunno, the $’s coming from somewhere no matter what.”

          The general proggie population mindset in a nutshell.

      3. So, Obamacare then. Just force everyone to buy insurance.

      4. Insurance companies wouldn’t sell such a policy. The risks are too uncertain. The only kind of policies I know that cover someone for long periods are life insurance and title insurance. Those kind of risks can be measured pretty well. And if anything people’s life expectancies will go up, which would benefit the writers of life insurance policies. But average healthcare costs are a total crapshoot in the medium term, never mind the long term.

    6. So both of them basically accuse me of wanting them to remain in pain until they qualified for Medicare any time I bring up my opposition to the ACA.

      Don’t you? I mean, it’s your Mother-in-law!

    7. Where do they think the money is coming from? It’s not Obama’s pocket change that funded their treatments.

      1. Never mind, I’m sure they think it’s coming from the Scrooge McDuck vaults every insurance company stashes its gluttonous profits into.

  7. “Even the billing might become more efficient if government and insurers were cut out of the picture.”

    This is 100% true. Doctors have to charge insurance companies more just to get a reasonable sum for the hour (or so) they spend with the patient. When I worked for a neurologist, we billed new patients insurance $250 and only received about $90 back for the doctor (this was in 2003). The amount of paperwork back and forth is ridiculous, with complex diagnosis codes and every insurance company rejecting every claim the first time just for the hell of it, just to see if we would eat the cost. I ended up having to attach the visit summary to every medicare claim I submitted. The whole process is madness.

    1. And a year and change ago they went from ICD-9 to ICD-10 for no good reason I can discern.

      1. Because everyone else was doing it. That’s basically how standards work.

  8. To the best of my recollection, my wife’s bilateral knee replacement was in excess of $60K ten years ago. This is not something you finance when you are nearing or past retirement.

    So why the fuck do we need to talk about elective tit enlargement?

    The real issue is whether or not this fictional thing called “society” is responsible to cough up six figures to replace the knees of an elderly person who no longer has private health insurance.

    Why doesn’t “society” just say “sorry dude, start a go-fund-me for a new wheelchair”.

    And remember, $100K is chickenshit money when we start talking about cancer treatment.

    1. He mentions breast augmentation because cosmetic surgery, as well as other procedures such as LASIK, have largely flown under the radar of regulators, allowing them to retain some semblance of a free market. The price of these procedures have gone down, even though healthcare costs in general have gone up.

      1. When people see the money coming straight out of their own pocket, they tend ask questions. “Do I really need this?” “Where can I get the best deal?” That sort of thing. When providers have to compete, they find a way to improve services, lower costs, or both. Best of all, customers can choose for themselves whether to go for the lowest-cost, no-frills option, or to pay more to be pampered. One size doesn’t always fit all, and in a free market, it doesn’t have to.

    2. $60K will get you the BMW of golf carts.

    3. At my company’s annual “here’s how much we’re jacking up your health care contribution” meetings, they always manage to bring up the one or two folks (not by name) who basically ate up 99% of the company’s health care costs that year. “One case was x million dollars” and so forth. It is madness.

      1. This is like the 80/20 rule:

        https://en.wikipedia.org/wiki/Pareto_principle

        Nassim Taleb also talks about it with his ideas on “extremeistan.” Some lucky bastards will be perfectly healthy over the course of their lifetimes. Some people will be the largest cost, taking up most of the cost.

        http://fortune.com/2015/07/18/deanna-fei-book-aol/

    4. In reality everyone should be saving a lot more money over their lives to cover this stuff. But people aren’t. If you don’t save enough to cover the costs, you incur a deficit. There’s no way around that. Taxes basically are forced saving.

      Thats what people are asking for when they ask for public healthcare: for the government to make them save up for future health costs because they refuse to do it on their own. But government usually adds a redistributive spin to it. This of course is a problem because it discourages people who are smart enough to save voluntarily from saving, which aggravates the central problem: we’re not saving enough to cover future costs.

      Also, why on earth is the average retirement age still 62? Probably 52 for government employees.

    5. Because it doesn’t REALLY cost $60K.

      It costs $60K bewcause of this–

      When I worked for a neurologist, we billed new patients insurance $250 and only received about $90 back for the doctor (this was in 2003). The amount of paperwork back and forth is ridiculous, with complex diagnosis codes and every insurance company rejecting every claim the first time just for the hell of it, just to see if we would eat the cost.

      How much is the REAL cost?

      Probably less than lasik–the surgery is so commonplace.

      1. Nah, it’d be more, because the implants used in the replacement process aren’t cheap. The cost would certainly come down (or would come down some places, and not others), but it wouldn’t get that cheap.

  9. What happens if someone defaults on their payments for implants? Do they send some sort of repo man?

    “Never broke into a bra. Never hot-wired a bra.”

    1. I know a girl who took out a loan to get breast implants with her parents as co-signers.

      It’s like they WANT her to be a stripper.

  10. OT: Abortion. Not really sure what Kasich is going to do. This is going to be another pretty loud argument over the next 10 days.

    http://www.foxnews.com/politic…..-desk.html

  11. The idea that without ObamaCare, people won’t be able to afford pregnancy is an idea that is itself symptomatic of the syndrome known as elite post-election panic. There’s no cure yet known for it, but one hopes for everyone’s sake that it will get better with that time-honored medical technique known as “watchful waiting.”

    Also, not covered by Obamacare.

  12. Sure, health care differs in important ways from other parts of the economy.

    No it doesn’t. It’s a set of goods and services, all of which are scarce and are best managed by price signals on a free market. It only feels like it differs in important ways.

    We don’t want people dying in the streets because they can’t afford health care.

    So? We also don’t want people dying in the streets because they can’t afford food, and yet we allow a relatively free market in food to everyone’s benefit.

    1. To wit, more people die from complications due to obesity than malnutrition or starvation.

      1. So your saying the fix for obesity is food shortages caused by government management?

    2. Never mind the fact that Obamacare didn’t do dick about making health care affordable. It didn’t even make health insurance affordable. And, as we all know (well accept amsoc, but he’s an idiot), the two are not the same.

    3. And then we solve the problem of some people not being able to afford food (or at least assuming that some people can’t afford food) by providing them direct financial assistance. But with healthcare we instead provide everyone over a certain age with a huge subsidy, regardless of whether or not they can afford healthcare and then we make it totally inefficient with our delivery systems of that subsidy.

  13. Sure, health care differs in important ways from other parts of the economy

    I hear this a lot and see scant evidence for it, outside of true emergency treatment. Which, I believe, is a very small fraction of overall healthcare usage and spending, and any rate can be handled under real insurance.

    The other reason cited for why healthcare is different is asymmetric information between consumers and providers, which exists in lots of other areas of the economy and would exist to an even worse extent if government were trying to micromanage things.

    IOW, citation needed.

    1. I was just about to bring up this exact point, and I’m getting a little pissed that reason seems to be increasingly engaging in this sort of nonsense lately.

      Health care differs from the rest of the economy? In important ways? Really? Okay, please prove it and show your work.

      1. Health care is different from consumer goods and services in that if you don’t get it, you die or become disabled. I can shop around for a new car, and if I can’t find a good deal I can wait in most cases. I love JCrew’s clothes, but cheaper T-shirts and blouses aren’t going to affect me one way or another. Medical care, however, is not the same. My husband is an insulin-dependent diabetic. His drugs cost us out of pocket something north of $2,000 per year and the insurance company pays, I think, about $10,000. His glucometer and other paraphernalia aren’t covered at all. Of course, without the drugs, he would die, slowly and painfully. Postulating that a theoretical free market would produce wonder drugs for pennies per dose is great, but no such market exists yet, and the process of changing from what we have to what you all want would be very complex and likely quite painful.

        Emergency medicine is even worse. In 2014 my son had appendicitis. The total bill was $48,000, of which I was responsible for $4,000. How, exactly, does one negotiate for cheaper rates on emergency surgery? What kind of horror of a person wouldn’t get the surgery for her son?

        1. Insurance against low-probability but high-cost events (like emergency surgery for appendicitis) makes a ton of sense and would absolutely be available in a free-er market for healthcare and health insurance. Emergency care of that type is also a small percentage of overall healthcare consumption. Most of what we consume in the way of healthcare is absolutely amenable to shopping around. One can also insure against diseases like diabetes.

          No one here will claim to have all the answers about what a free-er market in healthcare would look like. That’s the reality of decentralized systems.

          What I do know is that we need food, water, clothing, and shelter to live – go without any of those for more than a few days and you’ll start to die, slowly and painfully. We need education, transportation, and communications technology to have a decent standard of living in the modern world. All of these things are provided in quantity and quality that are unprecedented in human history and are within reach of pretty much every American, thanks to relatively free markets.

          1. What I do know is that we need food, water, clothing, and shelter to live – go without any of those for more than a few days and you’ll start to die, slowly and painfully. We need education, transportation, and communications technology to have a decent standard of living in the modern world. All of these things are provided in quantity and quality that are unprecedented in human history and are within reach of pretty much every American, thanks to relatively free market.”

            I agree completely on this. I simply wanted to note that health care provision is a lot more complicated.

            1. Because it has been made so by excessive government regulation and control of the market. You bring up the costs of your husband’s treatment for diabetes. Granted it is expensive, but it could also be much cheaper if the prices weren’t artificially inflated by government subsidizing the treatment costs. If you know you’re getting at least x dollars from source G, you’ll charge everyone x dollars even though you can provide the good for much cheaper. So what if you lose some business, because you’re guaranteed to get the business from G.

              Additionally, depending on your husband’s type of diabetes, it could be controlled by a low carb diet, for example. Which is what was used prior to the extraction and synthesis of insulin for treatment.

        2. “the process of changing from what we have to [a free market in healthcare] would be very complex and likely quite painful.”

          Yes, probably. But many necessary changes to the organization of society are temporarily painful.

          A heroin junkie kicking the habit goes through extreme pain, but this doesn’t mean that the solution is to keep shooting up forever.

          Likewise, the American people are kept in a state of addiction to our hodge-podge of socialist and cronyist healthcare delivery. But the fact remains – we are on an unsustainable course. We have to break the cycle of compounding government regulation and let healthcare markets function so that people will be able to afford life-saving and life-improving medical care without having to resort to government force for funding.

    2. I think the problem is that there are differences with buying health care that make it more complicated than other goods and services, but those differences do not change the fact that a free market still works best. Many people, including Reason contributors, simply jump to the conclusion that because 1. it’s a lot more complicated with healthcare and 2. some life-saving medical treatments are not affordable for some people, the free market must be jettisoned.

  14. *Adds the New Yorker to the list of Fake News? sites*

    1. Considering some of the Onion-grade clickbait I’ve been getting from them lately, I might do that as well.

  15. Gawande’s book on mortality and end-of-life care is quite good. Unfortunately, you should always assume that anyone writing about health policy is an idiot until they can prove otherwise, and he doesn’t really do that here.

  16. certificate of need laws can also fuck the hell right off.

    1. I was in a bar with some colleagues during the final debate and the topic of conversation remained on politics. Someone told me that we tried a free market health care system and it didn’t work. I then explained to the Brit sitting next to me why this was obviously not true and cited certificate of need laws. He was appalled (though I suspect equally appalling things exist in the British system that he isn’t aware of).

      1. Back when I got into hospital law, my first project was to help hospitals comply with a brand new CON law in Wisconsin. I thought it was ridiculous, and worked on getting it repealed instead. It was repealed, but the tax on hospitals to fund the bureaucracy is still on the books, as far as I know.

      2. – Certificate of Need laws
        – Almost half of spending on healthcare is from government sources
        – Illegal to buy insurance from other states
        – AMA (a private organization) exercising huge amounts of control via the forceful instrument of government

        >US healthcare
        >free market

        nope.exe

        1. Add to this list: onerous state requirements for the provision of health insurance that differ greatly between states.

        2. Don’t forget this part of the article:

          The supply of trained physicians is artificially constrained by limits on how many medical students, residents, and fellows are accepted each year in American medical institutions. Even highly competent and experienced foreign-trained practitioners often are required to repeat their training if they want to immigrate here and practice in America. If Americans were paying directly for their own health care, you might see political pressure build to increase the supply of physicians (and drive down the wages).

          I always wondered why there were so few people becoming doctors… I used to think all the regulation and legal shit scared too many potential physicians away, but now it looks like the medical schools are just as bad as OPEC in controlling output.

  17. There are only two ways to assure people that if they get cancer or diabetes (or pregnant) they can afford the care they need: a single-payer system or a heavily regulated private one

    Or, we can recall that just under half of the hospitals and associated integrated delivery networks are charitable nonprofits who have long histories of providing care without regard to ability to pay.

    1. Don’t be silly. That can’t possibly be true.

      Government is good because everyone is actually bad, and bad people won’t do good things without the ever present threat of imprisonment or death at the hands of zealous law enforcement officer.

      Charity is a fiction told by evil Republicans.

    2. The problem with your assertion is that treatment for diabetes, heart disease, and many kinds of cancer aren’t provided in hospitals but in private clinics or doctor’s offices.

      1. Karen24|12.12.16 @ 7:44PM|#
        “The problem with your assertion is that treatment for diabetes, heart disease, and many kinds of cancer aren’t provided in hospitals but in private clinics or doctor’s offices.”

        OK, so?

        1. So the business model for a non-profit hospital doesn’t really scale down to individual doctor’s offices. It can work for clinics, but generally only with government money to cover the difference between the charity’s funds and the services need.

          1. but generally only with government money to cover the difference between the charity’s funds and the services need.

            Your assumption of government funds being required is overblown.

            Private non-profits like the Ford Foundation and the Tides Foundation, United Way, etc. are sitting on billions of dollars that can be used to fill the gap. Furthermore, if people were taxed less to cover the U.S. entitlement behemoth, they’d have more money to contribute to charity.

  18. Like it or not, government involvement in healthcare isn’t going away anytime soon. With that in mind, what can we do? We need to bring market forces to bear on as many aspects of healthcare as possible, but we must also make sure people aren’t “dying in the streets”. So how about a nonprofit government option that covers only life-threatening conditions?

    You want to go to the doctor twelve times a year? Fine, but you’ll be paying for it, and you’d best be shopping for good prices. No more socializing your costs. No using your insurance to get your back popped and get a shoulder massage. Want a flu shot? Cool, go to Walgreens and pay $20-30 for one. Having a lot of sex? Good for you, but buy your own birth control.

    Maybe a “major medical” plan could be affordable if everything under the sun wasn’t covered, you know? It sounds like a good start to me.

    1. It already exists. It’s called Medicaid.

      1. Seriously, we have been having a debate about instituting a program that already exists and has existed for 50 years. It’s like “common-sense gun control”. We’re already there, mission fucking accomplished.

      2. Isn’t that only for the elderly and very poor? And they take money from everyone who works to pay for it, right? I was thinking about some kind of voluntary option to replace traditional medical insurance.

        1. The elderly get Medicare, which despite its similar name is actually a very different beast (whereas Medicaid is heavily rationed, Medicare is basically a goddamn free-for-all at taxpayer expense).

          But yeah it does seem that I missed your point entirely. Apologies for that.

    2. Also, EMTALA prevents any ER from turning away patients due to lack of ability to pay.

    3. Wonder what an auto tire would cost if Allstate had to pay every time your kid had a blow out because he operated the Civic off road in Moab?

      1. There was a science fiction writer who wrote a short story (actually a fairly long one) about if car insurance was like health insurance.

        A fairly old time writer, it was in one of the Baen collections. I guess written in the ’60s. I want to say Christoper Anvil.

        Anyway, basically costs skyrocketed, just like with health insurance.

    4. Ok, so now that I’ve actually read what you wrote rather than just ranting based upon what my poor job of skimming picked up…

      I don’t think it’s a bad idea, but I don’t see how it wouldn’t turn into a money suck from the general fund due to sympathy votes. If it were feasible, it would have been done already outside of government. Although, I guess the government could set up an organization that doesn’t have to adhere to all the BS regulations of HMO, HIPAA, etc. But I doubt it would be set up that way, and it would be better if they just rolled back those regulations so that people could form organizations outside of government to do it.

      1. I’ll be the first to admit that I don’t know much about those regulations. I was trying to apply “libertarian-leaning common sense” to come up with something that might be politically feasible.

        Our insurance went up again this year, 12.5% this time, enough to nullify our cost-of-living raise. 😐

        1. I don’t think you’ve got a bad idea there per se but the interaction of regulations with healthcare has been one of the primary drivers of costs. It is the biggest reason why the ACA has not made healthcare affordable, never mind the socializing aspects of it. It floors me sometimes that people seem fundamentally unable to grasp the notion that rules cost money.

          1. I’m speaking about the ACA writers/promoters in that last sentence.

        2. My insurance premiums and deductibles have skyrocketed, too; moreover, I decided to switch from an HMO to a more expensive PPO plan (and both options were already more expensive than the equivalents last year) because the HMO no longer covered 100% of emergency care (and that’s on top of having a copayment and needing to meet the deductible first). What is the point of health insurance if it doesn’t even cover emergency care?

    5. A voucher system, combined with significant deregulation of both the insurance and healthcare industries.

    6. Thanks to Aflac, I read “major medical” and get that high-pitched cartoon voice in my head. Fuck you Aflac.

  19. The problem is that you can’t really have a free market when it comes to medicine.

    You’d have to stop licensing doctors and nurses. You’d have to let anyone have whatever drug they wanted. And you’d probably have to do away with patents.

    While that might sound good, it’s never going to happen.

    And if it does, it runs into problems. Doctors already over prescribe anti-biotics, which bred antibiotic resistant bacteria. Imagine if anyone could use them?

    And what about vaccinations? There are good reasons to force them, but they are definitely against the free market.

    1. Why would a drug company want its product to become useless? Why would a hospital want to hire doctors or nurses without any assessment of their credentials? Would you go to a completely unrecognized doctor, if you had the money to afford a licensed professional with a public reputation?

      The government cannot provide anything that the market isn’t able to provide, since the government doesn’t produce anything; it only threatens people and shuffles money around. Licensing of medical workers and restricted prescription of certain medications don’t require the government to do anything except protect property rights, the same as for any other people/industry.

      The difference with letting the market develop and implement solutions is that people who were unable or unwilling to accept the government’s standards remain free to accept other standards.

    2. Doctors already over prescribe anti-biotics, which bred antibiotic resistant bacteria. Imagine if anyone could use them?

      We’ve been in an arms race with germs since the beginning of life on this planet. The timescales have shortened with the advent of antibiotics but it never has and never will stand still. Is there benefit to trying to delay the onset of bacterial resistance to drugs? Sure. And when they inevitably adapt we’ll have to develop new, better drugs. I see no particular reason for panic.

    3. I don’t disagree that it won’t happen but your self-fulfilling idiocy is more of the reason(s) why;

      Doctors already over prescribe anti-biotics, which bred antibiotic resistant bacteria. Imagine if anyone could use them?

      Believe it or not, there are large parts of the world where getting ahold of antibiotics is not at all difficult. Even in this country, veterinarians aren’t entirely unchecked, but are fairly free to prescribe antibiotics as they see fit. Not surprisingly shooting and dosing yourself full of antibiotics to (not) fight off a viral infection is not very effective and lots of people who live rather close to the land are exceedingly well trained to recognize varying sorts of infections in an effort not to waste time, effort, money, and even human lives on ineffective treatments.

      When you run and/or remove your own stitches, you generally know how to keep it sanitary. If you don’t or know or are unable to, you’re fairly familiar with the pain and burning that results from infection. It’s the people who’ve always had stitches put in for them and get pre-dosed with antibiotics to prevent infection who just assume everybody does, or would continue to do, things the exact same way.

    4. And what about vaccinations? There are good reasons to force them, but they are definitely against the free market.

      Unless they’re forced and/or shielded/subsidized, they aren’t against the free market. There’s an overabundance of tetanus vaccine because people have largely opted to stop taking it. Originally, you ran a rusty nail or barbed wire into your skin, contracted tetanus, and died. Once the vaccine was developed, you didn’t go get it for no reason or for every scrape and cut but, if you were handling rusty metal and punctured yourself you’d choose, freely, to get the vaccine rather than suffer a tetanus infection/poisoning. Now that people don’t work with barbed wire and rusty nails as often, they don’t get the vaccine as often and, concomitantly, don’t suffer fatal tetanus infections as often.

  20. Why can’t we go to a system where the first let’s say $50,000 for an illness is the responsibility of the patient with the rest covered by the government. Individuals would be free to take on any amount of the risk of that $50,000 he sees fit. An insurance policy with a $10,000 deductible and a cap of $50,000 would be extremely inexpensive. Someone with access to the right data and actuarial experience could give us a better number but I would guess under $50/ month. Those who go without insurance and incur medical bills they cannot pay would have to rely on private charity via voluntary reductions in bills by providers or other charitable organizations.

    Abuse of the system would be limited to those who desire an illness that costs more than $50,000 to treat. I’m guessing that is a small number of people.

    My guess on the cost of insurance is based on my experience of a family of 5 with a $10,000 deductible and $1million cap (pre-Obamacare) that cost me $158/month.

    1. Now that same policy costs me $450/month thanks to our wonderful new healthcare law that removed the $1 million cap and forced me to pay for pregnancy coverage even though we can no longer procreate.

  21. All of my adult life, politicians have been screwing around with ‘the health care system’. I know that, in theory, each round of meddling completely supercedes the previous mess, but I can’t help feeling that what we have is, in effect, a mess of bandages, one on top of another, and no real idea what the wound underneath looks like.

    I do know that the countries most like us in culture (Britain, Australia, Canada) have tried single payer and that it doesn’t work well. I know this because, among other clues, the British cartoonist Giles, who was a socialist in the 1930’s, was making fun of the National Health’s shortcomings as early as the 1950’s.

  22. The most expensive part of health care is usually the government enabled rent seeking that requires us to purchase a doctor’s time.

    FTFY

    The medical mafia can go fuck themselves with a rusty pipe.

  23. Cosmetic surgery, unlike most heath care, is optional.

    1. Okaaay-would you also agree that food and shelter are not optional Mr. Toad? yet the government doesn’t issue us “free” tents and food rations-or maybe you would prefer that too?

  24. For sheer accumulation of elite institutional prestige, it’s hard to top Atul Gawande. He is a professor at both Harvard Medical School and the Harvard School of Public Health and a regular contributor to the New Yorker magazine,

    Gee, if you wanted to set him up as an authority, why did you say so many terrible things about him?

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