Beginning of the end of the Republic’s solvency. Soon come the first steps to a reformed regime – or a new regime.

Summary:  Home truths about America’s health care system.  It cannot long continue in its present form, and no substantial reforms appear likely until a crisis.  At the end are links to other posts about this issue.


From a joint statement by the Social Security and Medicare Boards of Trustees, March 2009

The drawdown of Social Security and HI Trust Fund reserves and the general revenue transfers into SMI will result in mounting pressure on the Federal budget. In fact, pressure is already evident. For the third consecutive year, a “Medicare funding warning” is being triggered, signaling that non-dedicated sources of revenues—primarily general revenues—will soon account for more than 45 percent of Medicare’s outlays. A Presidential proposal will be needed in response to the latest warning.

The financial challenges facing Social Security and especially Medicare need to be addressed soon. If action is taken sooner rather than later, more options will be available, with more time to phase in changes and for those affected to plan for changes.

Translation from the government’s phony description

  • Cash flow for the Hospital Insurance (HI) Trust Fund went negative in 2004 (it was negative during much of the 1990’s, but was fixed by eliminating the cap on wages).
  • Cash flow for social security is estimated to turn negative in 2016.  It’s already near zero (see this table from the 2009 SS report; compare income and costs).

For decades the taxes for Medicare and social security exceeded expenditures on those programs.  The government spent this money.

Now the boomers are aging.  Expenditures for our social retirement programs has become an inexorable rise.  Their cash flows are no longer funding the rest of the government, but turning into drains.  This is the end of an era.  For more on this see “The biggest bailout yet“, Fortune, 17 August 2009).

The size of the age wave is too great for any feasible tax increases to cover it.

What does this mean?

The doomsters predict bankruptcy.  They are probably wrong (they are always probably wrong).  Benefits must be cut.  Benefits must be cut.  Doing so will be one of the greatest challenges in US history, like nothing seen since the early 19th century battles over slavery.

Speculating, that’s the patter we are most likely to see.  A series of crises, each met by a “great compromise” solution.  Each proving inadequate, until eventually a durable solution evolves.  The sooner we reach that point, the less pain and damage to the Republic.

Indications and Implications

This will test the structure of our political regime.  It’s not in good shape, and fixing it should be one of our top priorities.   Hillbilly logic might prove lethal — as in “can’t fix the roof when it’s raining; don’t need fixing when it’s not.”

Unfortunately the current political debate suggests that this will be a long, slow, difficult process of adjustment for the American people.  Neither party shows much interest in grappling with the problem — because the American people refuse to look at the facts.  For decades the Democrats won elections by demonizing Republican attempts to reform our social retirement systems before it was too late.  Now Republicans return the favor.

This dynamic already dominates the political debate.  One of Obama’s key advisers wrote about the looming problem of heath care costs (Dr. Ezekial Emanuel, brother of Chief of Staff Rahm Emanuel), and discussed possible solutions.  Which Republicans, like ex-Gov Palin, demonize as “death panels.”  Our politicos cannot be wiser than us, the voters.

Principles for allocation of scarce medical interventions“, Govind Persad, Alan Wertheimer, and Ezekiel J Emanuel, The Lancet, 31 January 2009 — Abstract:

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate 8 simple allocation principles that can be classified into 4 categories:

  1. treating people equally,
  2. favouring the worst-off,
  3. maximising total benefits, and
  4. promoting and rewarding social usefulness.

No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate 3 systems:

  1. the United Network for Organ Sharing points systems,
  2. quality-adjusted life-years, and
  3. disability-adjusted life-years.

We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

This is a start at grappling with a serious problem, that about one-quarter of Medicare outlays are during the last year of life — and much of this neither substantially increases the patient’s life nor improves their quality of life.  (From the US Department of Health and Human Services).  As the boomers age we will no longer be able to afford such expenditures.

The Republicans, like ex-Gov Palin, demonize this research as advocating “death panels.”

Our politicos cannot be wiser than us, the voters.

Other posts on the FM website about American health care

  1. The American public is organizing and getting involved! Are we happy now?, 12 August 2009
  2. Important:  Beginning of the end of the Republic’s solvency. Soon come the first steps to a reformed regime – or a new regime., 14 August 2009
  3. Hidden truths about American health care, 19 January 2010
  4. About the political significance of the conservatives’ health care propaganda, 23 March 2010
  5. The core truth about our health care system, 3 April 2010

For more information

To read other articles about these things, see the FM reference page on the right side menu bar.  Of esp interest these days:

  1. Good news about America, a collection of articles!
  2. About America – how can we reform it?
  3. About the Financial crisis – what’s happening? how will this end?.
  4. About The End of the Post-WWII Geopolitical Regime.

Posts about the government’s finances:

  1. Forecasts – Why wait? Read tomorrow’s news … today! (part 3), 17 July 2006
  2. The post-WWII geopolitical regime is dying, 21 November 2007
  3. We have been warned. Death of the post-WWII geopolitical regime, 28 November 2007
  4. The most important story in this week’s newspapers, 22 May 2008 — How solvent is the US government? They report the facts to us every year.
  5. The most important news of the month. Perhaps the year., 25 September 2008 — Warnings from our foreign creditors.

Here are previous posts in the FM series about the Constitution.

  1. Forecast: Death of the American Constitution, 4 July 2006
  2. The Constitution: wonderful, if we can keep it, 15 February 2008
  3. Congress shows us how our new government works, 14 April 2008
  4. See the last glimmers of the Constitution’s life…, 27 June 2008
  5. Remembering what we have lost… thoughts while looking at the embers of the Constitution, 29 June 2008
  6. A report card for the Republic: are we still capable of self-government?, 3 July 2008
  7. Another step away from our Constitutional system, with applause, 19 September 2008
  8. What comes after the Consitution? Can we see the outlines of the “Mark 3″ version?, 10 November 2008
  9. Are Americans still willing to bear the burden of self-government?, 27 March 2009
  10. “Lights, Camera, Democracy” by Lewis Lapham, 24 May 2009
  11. “The Constitution that I interpret and apply is not living, but dead.” – Supreme Court Justice Scalia, 9 June 2009



64 thoughts on “Beginning of the end of the Republic’s solvency. Soon come the first steps to a reformed regime – or a new regime.”

  1. FM: “However, [rationing] need not lead to poorer care!

    That is certainly true if you happen not to be on the receiving end of rationed care. Otherwise, the assertion is absurd. I should add that “rationing” is not simply “limiting,” but implies the withholding of care that is likely to improve the patient’s condition. Incidently, limitations imposed on goods and services by market forces are not rationing in the sense that limitations imposed by gov’t bureaucracy rules are rationing.
    Fabius Maximus replies: More evidence of the irrationality of this debate!

    “the assertion is absurd.”

    Since I gave a specific example of how care could be limited without affecting either lifespan or quality of life, your denial seems odd. It’s even more so given the fact that other nations have equalivalent health care results and pay far less.

    “limitations imposed on goods and services by market forces are not rationing”

    Another comment by someone apparently not aware that the government already finances most medical care for the elderly (Medicare, Medicaid, VA, Tricare).

  2. FM: “Thanks for posting links to these excellent articles. However they both support my statement that the US system produces outcomes that are similar to the better european systems, but at a far greater cost. Note Perry’s conclusion, in the Nov 2007 article … These differences between outcomes (usually < one year) are all small, and well within their error bars (i.e., not statistically significant).

    Also, you don’t see the point of this post. It’s not a discussion of alternative health care systems. It’s about our government’s eroding solvency. The conclusion is that radical change in the government’s mix of income and expenditures is needed, and that the debate so far consists largely of exaggerations and lies by both sides.

    As for the comment on eroding solvency, see my post #31 on Medicare and Medicaid – not only do they have huge detrimental impacts on the health care market, but they are also driving us into involvency. Don't you think that the goverment should "fix" those programs prior to trying to "fix" the rest of health care? If they can't "fix" them they should get the hell out of the health care business. I don't care if they tax me to subsidize the purchase of insurance for other people. In fact I'd be happy to have that happen if they'd also kill of medicare and medicaid and open up the health care insurance market. Not only does that return the decision making power to the individuals (even if there's a wealth transfer there), but it also keeps the market open to put realistic funding into innovation – A HUGE FAILURE IN THE EUROPEAN SYSTEMS.

    As for the cost differences it comes down to : INNOVATION, INNOVATION, INNOVATION, {snip, we get the idea}

    WE are willing to fund it and they aren't. Just as we paid for Europe's defense needs the past 60 years we are also funding their healthcare innovation. Take us away and who will fund the research? Perhaps you should start by figuring out how to get them to pay their fair share.
    Fabius Maximus replies: I am not proposing solutions (are you having difficulty reading?). This post notes the nature of the problem, obviously not widely understood by the number of comments saying “all’s great.” Analysis of the various solutions is beyond the scope of this post.

    “As for the cost differences it comes down to : INNOVATION”

    Do you have any evidence for this, or is it a religious thing with you?

  3. Health care spending does NOT need to be cut, and probably will not be. That’s just what rich, old, less healthy people (like Ted Kennedy) SHOULD spend their money on. And boomers will.

    Government spending Other People’s Money as health (or other) benefits — yes, that should NOT RISE, per person. Which will feel like a cut, but possibly could be politically sold as a ‘freeze’. Any gov’t system will include Death Panels, as exist today in Canada and the UK, tho not called as such. No gov’t system will have the tax collected money to spend as much on every old man as the Kennedies are spending on Teddy — and whatever title is given to such a system, it will act as a Death Panel.

    My optimal proposed alternative–forced savings (to replace SS), forced health health insurance, but then spending your own money/ insurance.
    Fabius Maximus replies: Experts from dozens of agencies, companies and NGO’s warn that the spending is unsustainable, but some American retain delusional levels of confidence. Nice of Tom to provide us with an examples.

    Tom, like many folks posting on this, seems unaware that a large fraction (probably a large majority) of medical spending on the elderly is already by the government — through Medicare, Medicaid, and the VA.

  4. A big problem with these ‘vast amounts of money are spent on the last year of life’ equations is that you never know going in what the last year of life is going to be. My mother is one of many examples – at age 78 she got colon cancer. It was a close thing, but now she is as fully recovered as one can be and could easily live another 20 years (our family history is good for long life).

    If you make the call to deny care based on the percentages, you wipe out the percentage that would pull through and return to health.
    Fabius Maximus replies: In fact there are proven guidelines used in other nations.

  5. Who knew the FM forum would turn into a Town Hall screaming match? Wowza.
    Fabius Maximus replies: It’s not even unusual. Too bad I don’t see ads.

  6. FM: “The language police strike again! How sad that we see only your virutal presence, depriving us of the opportunity to mock you in person. It’s a free country; get used to it.”

    Thank you, you just made my day. The number of comments on this topic indicates that Americans are and have been thinking on this issue for a long time. Too bad that has not turned into any meaningful reform to date.

    We have a public-private hybrid system now. The projected deficits tell us it isn’t working. Clearly some kind of reform is needed. However, given our propensities to not want to pay for things – after all part of our founding impetus was to not pay our fair share of taxes – and, place a high value on life, (e.g., the Terri Schiavo affair) I am not convinced that any of the plans currently suggested will do anything to address that.
    Fabius Maximus replies: Agreed. Of course, eventually we will be forced to make changes.

  7. As a Brit , the existence of our NHS means I have one less thing to worry about . I deal with pet health insurance claims and imagine human equiv are similar , wriggly as eels in a jar without a lid , when it comes to paying up . The problems of the NHS are not due to it being the NHS , but to the same factors that plague the education system , the law courts , the armed services , the maintainers of rivers , social services , etc .
    Which Are ( and could be fixed )
    1.The Compensation culture .
    2.Unreasonable expectations of life .
    3.Ignorant politicians /bureocrats screwing things up for the people at the coal face who know what they are doing , and how to do it.
    4.Not honouring the idealists . Many people who choose to get their hands dirty in public services, are not motivated only by riches ,but ‘ hunger and thirst ‘ to do something worthwhile .
    5. The bureocrats who have control of the money , find the need for endlessly more bureocrats .

    Particular problems for the Health Service , are :
    Not allowed to assist suicide , which I think should be allowed ( the quoted guidelines would be relevant )
    Not daring to wait and see , or do nothing ( because of the compensation culture )- so every
    minor grouch has to get treatment .

    Means Testing : this rewards the feckless and penalises the hardworking .This causes great bitterness in the hard working , and great joy in the lazy .(unlike Aesop’s the Ant and the Grasshopper ?) If Gates ” has anything about him ” he will not draw his pension .
    More Children Pay The Pension Bill . No , No ,this does not work . When the More Children get old they need More More
    Children to support them . Then your country gets Full , like mine . The roads are gridlock . You cannot sit on a train . The meadows are built over . The rain has nowhere to soak in , or the rivers are drunk dry . Hospitals and schools are bursting , everything gets out of hand and there has to be a Police State to keep control. Eventually , we starve .

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  9. Nobody expects their auto insurance to pay for gas, oil changes, and normal maintenance. Yet somehow we have fallen into this idea that “insurance” is for every medical expense that comes our way.

    I advised my nephew, who is just starting out, to get catastrophic coverage with a high deductible, and pay cash for ordinary services (most providers give a 25-33% discount for cash payers. And make sure not to skimp on preventative care. His costs are dramatically lower than those of his contemporaries, and he is buying insurance for what it’s meant for–a loss that he can’t afford.

    The primary problem, which has been well documented, is that beneficiaries have become disconnected from the true costs. As long as someone else pays, not my problem mon. Single payer will not fix this, it will exacerbate it. Moreover it will kill any remaining competition that can contain costs.
    Fabius Maximus replies: Interesting observation. I’d like to see some expert comment on this.

  10. Japan has a public-private system, with everyone paying 30% at the (probably) privately-owned specialist’s clinic and the government (and/or employer) picking up the other 70%. It’s in the red and debate is going on about making the eldelry pay more, as they use more.

    Apparently the government caps many prices, so the latest and greatest gear and tech come slowly. Some people must order meds from abroad because they are either not domestically approved or not covered by the national plan. Dentists often have patients come for scaling as four separate visits: upper left jaw, upper right, lower left, and lower right. This is because they get more of that 70% for 4 visits than for 1; it also is one suggestion of why government involvement in heathcare leads to cost overrun.

    Occasionally in Japan one meets a foreigner with a problem that the local specialist “solves” by telling them to “learn to live with it.” In such cases, those with money go to Thailand (preferably) and get it done with better gear, arguably better skill, and by doctors much more likely to speak English. Toss in better rooms, food, and climate. The Canadians don’t go back to Canada for the treatment after making enquiries; most likely the Germans don’t go back to Germany (if for no other reason, the airfare is horrid to Europe from Japan).

    I’ve heard similar stories in the US about people flying to Mexico for medical and dental work because it was cheaper with the same gear (and sometimes better skill) than what could be had locally.

    As for the British fellow puzzled about Americans and government, my worthless opinion is that the Constitution set up a bare framework, a workable minimal structure to ensure life, liberty, national defense, legal contracts, the pursuit of happiness, etc. Codify the minimal government to make possible the maximum. Naturally government at all levels began to grasp further (politician push and voter pull), but for a long time, one could simply run away to a territory or place so remote that one was left alone; that is the role Europe’s cities played with serfs and others, I thnk, at one point. There is a desire to be left alone and interact with government only when truly needed; however, many also want the government to provide all. Thus you get anti-government militias who are all on the dole and statists who demand equality in the form of government deciding 50% of media content be “left” and 50% be “right,” whatever that means. I don’t want to pay for it; I want someone else to. Surely the more of one’s paycheck that is taken by the government, the more people become upset. It’s perhaps a bit like life under Stalin: you knew the government was stealing from you and giving you little, if anything, in return (assuming you weren’t exiled or summarily shot), but what could you do about it? Nothing, and so despair or impotent anger sets in.

  11. FM, this has been yet another outstanding piece of work for several reasons.

    Although I’m pretty cynical about America’s future in general, I had high hopes that your readers (a smart, experienced, and well-read group of people, far better than you’d get from sampling any average pool of American voters) would have interesting feedback, counter sources of information, and perhaps one or two bright new ideas.

    Instead I’m slightly appalled that your readers have been responding at a frantic pace (which is good) but mostly to explain to you that:
    1. You’re wrong because all of the research and analysis you describe has missed an obvious magic wand that will cure all of the problems (not true although very tempting to believe)
    2. The other systems are inherently flawed (perhaps true but they seem to be less flawed than our current, rapidly sinking system, perhaps a change would do us good)
    3. Your language is offensive because it is too blunt (without the use of clear, non-sugar-coated language there can be no debate because everybody thinks they are getting what they want, this is Obama’s greatest sin)

    The frequency of your responses and your clarity and patience are all extremely impressive and I commend you for donating large amounts of your personal time in doing so. But it appears to me that your efforts are in vain. Near as I can tell, you have only converted the choir and the rest are perfectly willing to continue in their beliefs in spite of the evidence you’ve presented.

    This is further evidence that the American society’s OODA loop is massively broken and CANNOT be fixed within the framework of the current Republic, a fact that I deeply regret.

    It may well be time for a post speculating on the details of the next form of government. With luck, that will shock some common sense into enough people to carry the ship of state forward a little while longer.

  12. Post 34 “FM – You’re missing one gigantic point about Germany and France – for the last 60 years, they have had almost all of their national defense needs covered by the American taxpayer. They also have significantly higher taxes than the United States. ”

    Excuse me but how is this relevant? If Germany or France owed their better results in healthcare to higher levels of expenditure, then you could argue that they could afford these levels of expenditure by spending less on defense. But the FACT is that France and Germany spend LESS, so higher taxes and American protection are irrelevant.

  13. All comparisons with European health care are red herrings. Who is flocking to live there? People who come from places with no care of any kind. We have a similar problem as we encouraged “cheap” labor which of course is anything but as we are finally learning. We know that our national health care is bankrupting the country. Medicare may have been “great” for a while, but it is bankrupting us. Maybe it can be “reformed” but why give the same scoundrels bankrupting us more authority? Lunacy. We have 50 states. Let them experiment and let them use more and more of existing federal tax authority to pay for it. And we need to compel the Congress into Tort Reform. But all of this is of little importance compared with our failed economic model, our vast indebtedness, our need to create a national energy policy that will diversify and demonopolize. And there is a real federal role to be played. A common nuclear design needs to be selected and a national inspection corps modeled on Rickover’s nuclear navy to be wholly in charge of all design and construction approvals and maintenance. This is something of value the Feds might do, even enfeebled.

  14. I thought that what #51 stated was simply common sense. I did the same thing as my job doesn’t provide coverage. It was plenty affordable. Granted I didn’t have any kids.

    When you insure a nice painting, do you expect that insurance to cover a new frame? To cover the lights and fixtures used to illuminate it? Bi annual restorations? Of course not. You buy it to protect against catastrophic events.

    I am not an expert but I can offer an anecdote. Take it for what it is worth. My grandparents were at the bottom of the social order… black, poor, both parents worked hard, four kids. Yet somehow they were able to afford major medical insurance for everyone (the job certainly didn’t provide anything). If you needed glasses you paid for them out of your own pocket. When you got sick you paid 7bux for a house call (notice people bitching about a $10 co pay today). If you got really sick you went to the hospital. That was covered.

    If we really need to have full coverage for everyone let’s have major medical only. For the poverty stricken the government can pay the premium and put a matching amount in an HSA account until the balance is 3x the annual out of pocket maximum.
    Fabius Maximus replies: This misses the point. The problem is not a lack of possible solutions. We have dozens, perhaps hundreds, of those. The wide range of adequately functioning solutions in other nations shows that there are many possible ways to organize a society’s health care machinery.

    Our political regime — our leaders, us, and the overall public policy apparatus — is not able to decide upon and implement any one of these.

    This is a commonplace in debates about the need to reform America. This site has hundreds of comments saying “why don’t we do X, a simple and effective solution”. The issue is not the lack of “X”, but the reason why we don’t do “X”.

  15. Comment #51: “The primary problem, which has been well documented, is that beneficiaries have become disconnected from the true costs. As long as someone else pays, not my problem mon. Single payer will not fix this, it will exacerbate it. Moreover it will kill any remaining competition that can contain costs.

    FM reply: “Interesting observation. I’d like to see some expert comment on this.

    I would submit that this response from FM is a symptom of the illness of US society as well. FM is a highly intelligent, logical, rational, thinking being. His kneejerk response when presented with an obvious logical and economic truism is to await the judgement of someone else who will tell him whether or not to believe it. Someone who almost certainly had to display allegiance to the status quo in order to become certified as an expert and is thus financially interested in the maintenance of the status quo. Is it any wonder then that reform of the status quo is so difficult?
    Fabius Maximus replies: As someone with a bit of knowledge about both economic theory and the behavior of large systems, I strongly disagree. While the relationship is valid, the magnitude of the effect is not. As stated it has no numbers, and hence little meaning. Let’s get specific.

    “Single payer will not fix this, it will exacerbate it.”

    That’s a testable proposition. Has it proven to be true in the nations with single-payer systems? Come on, Pode, give a precise answer! You sound like an intelligent, logical, rational being. You shouldn’t need experts to gives us some numbers.

  16. The US health care debate has found its way to Foreign Policy: “The Most Outrageous U.S. Lies About Global Healthcare“, 18 August 2009.

    You can find some (small) inaccuracies, e.g. I would not cite the WHO ranking as it based on a useless mixture of hard facts and opinions and has a much lower quality than many studies that solely based on hard metrics, but this does not really change the situation.
    Fabius Maximus replies: About time. The misrepresentations and outright lies about other nations’ health care systems — many of which are broadly equal to ours at far less cost, providing far wider coverage — make us look like fools. The emphasis on the UK NHS, ignoring the far superior euro-systems, suggests that we are fools.

  17. The presence of third party subsidies increases consumption of the subsidized good/service. If the subsidy is supplied by a private firm, then the magnitude of the subsidy is constrained by that firm’s profit/loss constraints and its competition. A private single payer gains a monopoly, and so the competition constraint is removed. A government single payer is unconcerned with profit/loss, so there is no cost constraint whatsoever. A system with no mechanism to constrain costs cannot possibly do so.
    The existing single payer systems achieve their apparent cost control not by making the services cheaper, but by rationing access to the service as required by the laws of economics. The issue is not whether there will be rationing, there is always rationing for scarce goods by definition. The issue is whether that rationing is done via price so that I retain decision making ability over my own care or whether rationing is done by government. I’ve taken issue with you elsewhere about how responsive government is, I think you can guess my feelings on the subject of having to petition it for medicine.
    Fabius Maximus replies: This is sophomoric analysis in the essence of the word, like your comment #57 mocking experts in technical field like health care. It is a high-level theoretical argument, ignoring all the messy complexity that determine real-world outcomes.

    It’s an esp absurd argument since there are so many examples of national health care systems, run over decades — even generations. Those provide real world experience on which we can reform our system. But using that requires actual expertise, more than the Econ 101 theories you prefer to rely on.

  18. @ Pode

    OK, from a German perspective: We have a mixture of various health insurance companies, some are social/public ones, some are private. The interesting thing is, that the private ones, who could in principle cherry pick their customers do not better than the social insurance companies, which usually have a higher percentage of problematic customers.

    For my mother it means that her payments for her private health plan, which covers only 50% of her health care costs, increases more than her retirement payments per year (in absolute euros).

    My suspision is, that in health care systems the mechanismens of free market do not work and, therefore, some of your conclusions are wrong.

  19. LOL @ the advocate of one size fits all care plans upbraiding me for failing to consider messy complexity.

    As for your vaunted real world experience/expertise, where are the double blind scientific studies that follow a control group fed exactly the same diet, exposed to exactly the same pollution environment, and getting exactly the same levels of exercise? Can you concede the possibility that cultural tendencies re diet, environment, and exercise might have a greater effect than the type of health insurance used? If so, does it not follow that unless those variables are controlled for (actually controlled by not allowing them to vary, not handwaved away with comparative BS), all data on national health care systems is at least somewhat suspect? Furthermore, is there any reason at all to suspect that national level statistics in health care are accurate when national economic data and climate data are known to be manipulated for political ends? In light of this, which of us is truly being sophmoric in their attitude towards numbers? Saying the numbers we have are the best available is no excuse for using them if they are clearly inadequate. Far better to reject their inappropriate use and instead reason from first principles. Which, BTW, are usually taught in 101 courses :)
    Fabius Maximus replies: Your opening line is false; please don’t make stuff up. There is nothing in any of my posts advocating any specific health care system, let alone a “one size fits all plan.” Not even close.

    I do advocate studying other nation’s health care systems. Those that work poorly (e.g., the UK’s NHS), and the more successful mixed public-private plans in Europe.

    “where are the double blind scientific studies that follow a control group fed exactly the same diet, exposed to exactly the same pollution environment, and getting exactly the same levels of exercise?”

    I have no idea what this means, in a discussion of national health care systems. I suspect it’s just chaff.

  20. It means that the national health care systems are run in different nations, on groups of people with different diets, different pollution exposures, and different exercise regimes. If you’re going to compare health care systems based on effectiveness, for the comparision to have any scientific value you have to control for those differences. To spell it out plainly, would the French system still produce the best care in the world if the French lived on Big Macs? How much of the French system’s success is due to the fact that it’s treating French people and not Americans?
    Of course, this line of thinking must be incomprehensible irrelevant chaff, because it threatens the ability of experts to argue from authority and forces them to address my sophmoric high level argument on the merits. Which I notice you have yet to do.
    Fabius Maximus replies: This is false. There is a vast literature comparing different national health care systems. On life expectency at birth for people of similar socioeconomic levels and ethnicity. Comparing outcomes for similar health problems (not all differ by the factors you mention, any more than broken bones do). There are many ways to do this. None perfect, as usual in science.

    These are boring discussions, but commonplace. People who know little about technical subjects, exulting in their ignorance and despising experts. No more here, please. Go to a website focused on health issues and explain to experts how little they know.

  21. Strong recommendation to read: “5 Myths About Health Care Around the World“, T.R. Reid, op-edin Washington Post, 23 August 2009 — List of the 5 myths:

    1. It’s all socialized medicine out there.
    2. Overseas, care is rationed through limited choices or long lines.
    3. Foreign health-care systems are inefficient, bloated bureaucracies.
    4. Cost controls stifle innovation.
    5. Health insurance has to be cruel.

    Money paragraph:

    Some countries, such as Britain, New Zealand and Cuba, do provide health care in government hospitals, with the government paying the bills. Others — for instance, Canada and Taiwan — rely on private-sector providers, paid for by government-run insurance. But many wealthy countries — including Germany, the Netherlands, Japan and Switzerland — provide universal coverage using private doctors, private hospitals and private insurance plans.

    In some ways, health care is less “socialized” overseas than in the United States. Almost all Americans sign up for government insurance (Medicare) at age 65. In Germany, Switzerland and the Netherlands, seniors stick with private insurance plans for life. Meanwhile, the U.S. Department of Veterans Affairs is one of the planet’s purest examples of government-run health care.

    About the author (from the his Wikipedia entry): “T.R. Reid is an American foreign correspondent for The Washington Post and author of ten books, most recently The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care.”

  22. The healthcare market is strange, very strange indeed. Some years ago, as a younger man, when money was tight, I needed a failrly routine surgical procedure done, and decided to do some shopping around based on price. Imagine my surprise when I found that not one of the physicians with whom I spoke could tell me the cost of the procedure, not one was willing even to get within +/- 30% of the figure. I was referred to their business offices in most cases. One can understand anesthesiologists being unable to quote a price, due to varying amounts of drugs, gases, compex instrument and machine use, and the time under anesthesia, but surprisingly neither could the surgeon quote an approximate price. Ultimately, I threw up my hands and choose a provider, after having first cleared the procedure with my insurer – having no idea what my out-of-pocket expense would be, or thr total cost of the operation. In short, the system as currently structured does not allow accurate price information to be transmitted between client and provider. Is it any wonder that medical care is so expensive under such a regimen? There is little incentive for efficiency in the current system, and since “someone else” is paying for your care, no reward for economizing on your care, finding the best product at the least price.

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