A recommendation for your list of blogs to follow: the blog of Bernard Finel. About Politics. National Security. Crime and justice. Social commentary. Incisive writing and insightful analysis. Much of his material runs along similar lines to that on this site.
Two recent posts ask (or imply) interesting questions that have been answered (partially) here.
(1) Health Care
The Other Key Health Care Fact, 16 September 2009 — Excerpt:
As I’ve mentioned before (The Missing Trillion Dollars: The Challenge for Opponents of Health Care Reform), the first key fact to know about the health care debate is that we as a nation spend about $1 TRILLION per year more than we would if we spent at the same rate as other industrialized nations, and we don’t have anything like $1 trillion worth of better health care to show for it.
… The second key fact, is this one: A Number Is Worth a Thousand Words, Ezra Klein:
If health-care costs grow as fast as they have over the past five years, the average premium for a family policy in 2019 will be $24,180. If they grow as fast as they have over the past 10 years, premiums in 2019 will average $30,803. No one quite knows when, or how, the system will crumble. But make no mistake. At this rate of increase, it will, eventually, crumble.
Crumble is a powerful word. The people of that future day might not see it as such. The simple — and IMO most likely solution — is severe rationing. See 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 for details.
(2) The Af-Pak War
Why Not Be Honest and Ask For the 150,000 Now?, 15 September 2009 — Excerpt:
Does anyone doubt that we’ll see continued requests for more forces until we reach at least 150,000 ISAF troops? That plus at least 250k Afghan security forces gives you the bare minimum to do a pop-centric COIN campaign. And I think we all know that is the case. So, what does is say when instead of just asking for the right number, Mullen, et al., are engaged in a salami slicing exercise? How is this anything other than a conspiracy to mute debate by hiding the real costs of the conflict?
For an answer see How many troops would it, 15 September 2009.
About Finel
From his bio at the America Security Project website. Finel also blogs at his own website.
Dr. Bernard I. Finel is a Senior Fellow at the American Security Project (ASP) where he directs research on counter-terrorism and defense policy He is the lead author of ASP’s annual report, “Are We Winning? Measuring Progress in the Struggle against Violent Jihadism.”
Prior to joining ASP, Dr. Finel was a professor of military strategy and operations at the U.S. National War College from 2004 to 2006. From 1994 to 2004, he held various positions at Georgetown University, most notably as Executive Director of the Security Studies Program and Center for Peace and Security Studies from 2001 to 2004. He was also on the visiting faculty of the School of Foreign Service and a member of the core faculty of the M.A. Program in Security Studies.
Dr. Finel has published widely on international politics and security. He is co-author and co-editor of two books. Power and Conflict in the Age of Transparency (2000) was one of the first volumes to systematically examine the influence of increasing international transparency on international security. Ultimate Security: Combating Weapons of Mass Destruction (2003) highlighted the challenges to the non-proliferation regime and stressed the ineffectiveness of the U.S. government’s response to the issue. His research has been published in the journals Security Studies, International Security, Aerospace Power Journal, International Studies Quarterly, National Security Studies Quarterly, and World Affairs.
Dr. Finel is a frequent media commentator on international developments. Dr. Finel received his B.A. in International Relations from Tufts University and holds an M.A. and a Ph.D. in Government from Georgetown University.
Afterword
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Please share your comments by posting below. Per the FM site’s Comment Policy, please make them brief (250 word max), civil and relevant to this post. Or email me at fabmaximus at hotmail dot com (note the spam-protected spelling). Also, please state the author and site of links you post in the comments, so that people see the source of your information without having to click through.
Other posts on the FM website about Bernard Finel
- Second salvo in the Afghanistan Strategy Debate — Bernard Finel, 9 August 2009
- We must stay in Afghanistan to prevent atomic war!, 24 August 2009
- Valuable, powerful articles about our war in Afghanistan, 27 August 2009
- Another attempt to justify our Af-Pak war, and show the path to victory, 31 August 2009
- The advocates for the Af-pak war demonstrate their bankruptcy. Will the American public notice?, 1 September 2009
- Today’s volleys in the domestic battle about Afghanistan, 2 September 2009
I am not clear on one fact about the health care debate: are either drug R&D or capital equipment costs included in the number?
“How is this anything other than a conspiracy to mute debate by hiding the real costs of the conflict?”
T’is worse than a crime; it’s a blunder.
Mullen, Obama, and various chest thumpers are in denial and have no clear or competent grasp of what they are getting into.
“The simple — and IMO most likely solution — is severe rationing.”
The term “rationing” suggests a level of organization and deliberate policy that would be much higher than what would be likely to happen.
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Fabius Maximus replies: I disagree. Medicare and Medicaid are centralized systems that could easly ration health care even more than they do so today. For others (mostly under age 65), health care rationing is not imperative — and provided adequately by market forces.
Duncan,
You’re right, without some kind of centralized control, “rationing” in the strict sense is impossible. More likely is that we will see “rationing” by price, declining coverage for the same premiums or higher premiums for the same coverage, the same way the market “rations” consumption of Rolls-Royces.
Not sure if it’s been linked to here yet, but this piece in the September issue of the Atlantic provides a good breakdown of the various “market failures” in the health care industry, going much farther than I have been able to in my primitive analysis. His tentative recommendations are interesting too.
“the same way the market “rations” consumption of Rolls-Royces.”
More likely how the market rationed the consumption of gasoline by Rolls-Royces during the 1970 oil boycotts. I believe we are heading toward what John Stewart refers to as a “clusterf**k.”
The flip side of all this bad news is how good it will feel when we stop pounding our heads against a brick wall. My cat got sick last week; diarrhea. Our vet came to the house (with an assistant), drew blood, got a stool sample, one of 17 visits that day. She’ll perform a battery of tests, very broad scope, and advise therapy. Four hundred bucks total cost.
She has no liability to manage, no record keeping nightmare, no office staff, indeed, no office. She rents time in facilities as needed for surgery, testing, and etc. All this competence, service, and technology, delivered at reasonable cost in a very high COL part of California.
When (and if) we get out of the war for fun and profit mode, it will be just as refreshing. The great thing about being FUBAR is it’s easy to do much, much better. Hope my cat isn’t NRTS, pronounced nertsed, (not repairable this station).
Goodness me , your veterinary would be facing … problems … in UK and is surely on thin ice in California . No liability insurance , public or professional ? She should be sweating cobs . No record keeping ? And she sleeps at night ? No staff ? She is on duty 24/7 AND answering the ruddy phone herself ? Even when operating ? Cashes up , and cleans inside the car , and meets the drug delivery man in a highway carpark ? Rents other’s equipment , premises , staff – Supervises their quality control , staff training , post surgical care ? Pays taxes ?
Re: 6
“No liability to manage” does not mean “No insurance”
“No record keeping nightmare” does not imply “No record keeping”
I have no knowledge of her staff structure, nor any need to know. My needs are met, and very well, that’s my point. Found her by referral, from other very happy clients. She will prescribe any needed drugs, which I will buy at a “people” pharmacy, but at one tenth the price cause they’re “animal” grade drugs.
You’re not convincing me the “people” program is entirely superior or necessary at ten’s to hundred’s times more cost.
“The system will crumble” does not mean “severe rationing.” We already have “severe rationing.” 22% of all Blue Shield claims in California are denied. Around a quarter of all insured with severe medical conditions requiring more than a quarter million dollars of treatment undergo recission by their insurance companies — meaniing that when they get sick, their insurance companies terminate their insurance.
“Crumble” more likely means something else. Mass riots, mobs firebombing hospitals, national guard troops called out to protect hospitals, martial law. That’s what “crumble” means. Severe rationing is already in effect.
Of course, “crumble” might also take the form of a nationwide H5n1 pandemic. In that case, because of the complete inadequacy of our health care system, society might break down completely. People could wind up getting bricked up inside their houses when they get sick. Mountains of corpses could wind up getting burned in nightly bonfires.
Either way, “severe rationing” has been here for quite a while courtesy of recission and insurance companies denying claims and denying treatments. That’s not the next step of the health care crisis in America. The next step is much, much worse.
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Fabius Maximus replies: IMO this is all greatly overstated, far beyond the any reasonable analysis. Just moving to an system like Europe’s would reduce costs by very roughly 1/3, making all those dire predictions unlikely.
Limiting treatment in the case of obviously terminal illness will save vast amounts. Limiting treatment to elderly (knee replacements for 70 year old folks) and self-inflicted (liver replacements to drunks) might also play a role. Folks elsewhere live with lower standards, without rioting or plagues. So will we.
Both FM’s claims in this case are provably false. The issue isn’t the absolute cost of medical care but its rate of increase. Moving to a single-payer system like Europe’s would reduce costs somewhat, but there is no evidence that a single-payer system in the U.S. would reduce the rate of increase of American medical costs.
Most people don’t grasp the tremendous power of exponential functions. If your medical costs increase at the current rate, 10% to 12% per year, that means you have a doubling time of roughly 7 years. So in about 7 years you’ll pay twice as much for health insurance. Let’s say you cut health care costs by 1/3: the amount you pay goes down to 67% of current costs, but doubles in 7 years. In another 7 years it doubles again. In another 7 years it doubles again. Do the math. Doubling and redoubling, up and up and up, very soon no one can afford health care No one — except the top 5% of the population.
So what happens when hospitals get reserved for treating only the elite pols and their corporate buddies? What happens when you bring your dying child down to the hospital but you get turned away, while the limousines of corporate CEOs and Washington politicians pull up outside the hospital for face-lifts and liposuction while your’e told your kid has to die because “we don’t have the medical resources to deal with that problem”?
Dying people tend not to be tremendously concerned with consequences. If a person is dying in agony of cancer because they can’t get insurance, why wouldn’t they load up a van with fuel oil and fertilizer and drive it into the hospital that turned them down for health care because they had no coverage? If your child just died screaming in pain because the local hospital was too busy performing tummy tucks for celebrities and congressmen, why wouldn’t you load up your station wagon with cans of fuel oil and fire-bomb it?
The claim that “limiting treatment in the case of obviously terminal illness will save vast amounts” is a myth that has been bunked numerous times. Like dianetics or ufology, it keeps coming back.
Numerous studies have been performed and they uniformly debunk FM’s assertion:
Also see “Health Care At An Advanced Age: Myths and Misconceptions.“, Gene D. Cohen (MD, PhD, George Washington U), Annals of Internal Medicine, 15 July 1994.
Also see “Medicare Beneficiaries’ Costs Of Care In The Last Year Of Life“, Christopher Hogan et al, Health Affairs, July/August 2001.
Assume you could reduce the costs of the last year of illness in a patient’s life by 50%: that would save only 13% of all Medicare outlays, which the study shows to be not meaningfully greater than the costs of privately insured medical care. A 13% saving is not “tremendous,” it’s minor — comparable to the increase in the cost of medical care in one year. In other words, if instead of caring for all old people with terminal illnesses we shot them in the head behind the hospital instead, this would only save the equivalent of two years’ increase in the cost of medical care.
That’s not saving “vast amounts of money,” so FM’s claim is clearly and provably false. Studies prove it, the statistics demonstrate it.
The actual driver of medical costs in America remains the fact that doctors go into business, opening clinics to do medical tests and blood workups and pooling their cash to buy CAT scanners and then charging exorbitant fees to hospitals to do the scans. See this for proof: “The Cost Conundrum – What a Texas town can teach us about health care.“, Atul Gawande, The New Yorker, 1 July 2009.
Until and unless America gets capitalism and business out of medicine, medical costs will continue to skyrocket endlessly. Since America is devoted to laissez faire capitalism with the monomaniacal adoration seldom witnessed outside the love of child molesters for childrens’ playgrounds, it’s easy to deduce that America’s medical costs will continue to skyrocket until essentially the entire population gets shut out of any kind of medical care. At that point, with no jobs and no welfare and no medical care, why will the population care whether they die when they suicide-bomb hospitals? What’s left to look forward to? 20 more years of living under a bridge and eating garbage out of dumpsters?
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Fabius Maximus replies: I still do not understand the basis for your severe, even distopian, forecasts. Other nations have mixed public-private systems, but do not face this outcome. So it is not inherent in a mixed public-private system, but is peculiar to our dysfunctional system.
(1) “A 13% saving is not “tremendous,” it’s minor”
IMO saving 13% from a single change that does not meaningfully affect outcomes is “vast.” I did not say or imply that this would save the system by itself, but illustrates that making reasonable reforms could make a difference.
(2) “If your medical costs increase at the current rate, 10% to 12% per year”
Can you provide some evidence for that? I know little about this subject, but 10%/year seems high.
(3) “Both FM’s claims in this case are provably false. The issue isn’t the absolute cost of medical care but its rate of increase.”
Where do I make this claim? Health care is discussed only twice on this site, here and here — both times focused on the problem of health care costs increasing as the boomers retire.
(4) “If a person is dying in agony of cancer because they can’t get insurance, why wouldn’t they load up a van with fuel oil and fertilizer and drive it into the hospital that turned them down for health care because they had no coverage?”
First, adequate pain treatment means that people should not be “dying in agony.” Second, where in the world do you see this happening? It’s argument by citing your nightmares as evidence. It’s become a popular rhetorical trick in America, one of the major props for the Af-Pak war. If it works we truly are morons.
(5) Thanks for the 2 excellent citations! These discussions would be far more useful if others followed your example here. However, neither refute my point. The first says that little was saved “because a significant proportion of the anticipated savings were due to fixed costs.” That’s a commonplace from an operational change. Realizing the savings requires reallocating the freed-up resources. It’s a 2 step process.
Your 2nd citation re-enforces my point, and says it is a long-standing problem.