[Winstonm]

Anyone who seriously believes the Military-Industrial Complex would sit idly by and allow Congress and the President to cut defense spending has been living with the fantasies of Harry Potter as reality far too long.

The American Empire will continue on the path to ruin until it is only a historical afterthought.

[blackshoe]

Thank you, Winston, for your vote of (no) confidence.

[phil_20686]

Winstonm, on 2010-November-14, 22:00, said:

Anyone who seriously believes the Military-Industrial Complex would sit idly by and allow Congress and the President to cut defense spending has been living with the fantasies of Harry Potter as reality far too long.

The American Empire will continue on the path to ruin until it is only a historical afterthought.

LOL

[kenberg]

Winstonm, on 2010-November-14, 22:00, said:

Anyone who seriously believes the Military-Industrial Complex would sit idly by and allow Congress and the President to cut defense spending has been living with the fantasies of Harry Potter as reality far too long.

The American Empire will continue on the path to ruin until it is only a historical afterthought.

Hey, you, get off of my cloud! I'm the local pessimist.

There are, of course, grounds for pessimism. One example would be the notion that people who make less than a quarter mil a year are just too financially strapped to be expected to pay anything more in taxes. After all, the kids do need their i-phones and their summer trips to Europe. Otoh, it was in 1951 that my seventh grade teacher expressed the view that empires come and go, the U.S. has had a good run, now it was coming to an end. There were Commies everywhere, we had no chance. Something like that.

We need to co-opt the Tea Party: Yeah, got it, we need to deal with the deficit. Unlike Republicans, we even worry about the deficit when our guy won. So less talk about Mama Grizzlies, more action. For example, instead of yelping about death panels, some real thought about what we can afford and what we cannot afford for end-of-life medical care would be welcome. I think quite a few seniors would take a view something like "I know I will die someday, I don't expect the government to stop that, but while my health holds I would like to be able to hold on to the house, get around to visit the grandkids, and eat regularly. So act sensibly with medical care but go easy on the Social Security cuts."



It's true that human nature seems to require a heart attack before the need for a revised diet sets in, but maybe we can overcome that this time.

[y66]

kenberg, on 2010-November-15, 07:51, said:

Hey, you, get off of my cloud! I'm the local pessimist.

...

It's true that human nature seems to require a heart attack before the need for a revised diet sets in, but maybe we can overcome that this time.

Please define pessimism.

[PassedOut]

Peter Orszag contends that the Bowles-Simpson plan to adjust Social Security, while not perfect, should not be rejected out of hand by the democrats: Safer Social Security

Quote

The main flaw in the proposed Social Security plan is that it relies too little on revenue increases and too much on future benefit reductions. A reasonable objective would be a 50-50 balance between changes in benefits and changes in revenues. But the way to bring reform into better proportion is to adjust the components of this proposal, not to fundamentally remodel it.

Finally, even though Social Security is not a major contributor to our long-term deficits, reforming it could help the federal government establish much-needed credibility on solving out-year fiscal problems — which in turn could improve the political prospects for providing additional short-term stimulus for the economy. All of which suggests that Democrats in Congress should support the basic construct of the Bowles-Simpson proposal, while arguing for some changes to improve it. That has not, however, been their reaction thus far.

It is therefore crucial that the Obama administration recognize the opportunity and respond to it more positively. The White House has been handed a highly progressive reform plan for Social Security that could attract Republican support as well.

Compared with health care costs, Social Security only needs minor tweaks to fix. It makes sense to fix it right now before the tea partiers try to dismantle it.

[Gerardo]

Winstonm, on 2010-November-14, 22:00, said:

Anyone who seriously believes the Military-Industrial Complex would sit idly by and allow Congress and the President to cut defense spending has been living with the fantasies of Harry Potter as reality far too long.

The American Empire will continue on the path to ruin until it is only a historical afterthought.

phil_20686, on 2010-November-15, 05:43, said:

LOL

Rome was not built in a day (nor fell in a day either).

It fell one day, though.

[Gerben42]

Quote

Compared with health care costs, Social Security only needs minor tweaks to fix. It makes sense to fix it right now before the tea partiers try to dismantle it.

As an outsider, it seems the biggest challenge of the US health care system is to get the cost down to European level. There must be something wrong when the two major concerns about travelling to the USA are:

* Getting in trouble with immigration because they were over-active in connecting dots that weren't related.
* Ensuring medical coverage while visiting because costs will by far exceed the European equivalent.

As an outsider, I cannot imagine what exactly makes health care so much more expensive in the US compared to other countries. Are wages for medical doctors much higher than in Europe? Is it the excessive damages paid in case of a medical mishap? Perhaps someone can explain. What are the solutions proposed for this?

[mike777]

Gerben42, on 2010-November-15, 15:36, said:

As an outsider, it seems the biggest challenge of the US health care system is to get the cost down to European level. There must be something wrong when the two major concerns about travelling to the USA are:

* Getting in trouble with immigration because they were over-active in connecting dots that weren't related.
* Ensuring medical coverage while visiting because costs will by far exceed the European equivalent.

As an outsider, I cannot imagine what exactly makes health care so much more expensive in the US compared to other countries. Are wages for medical doctors much higher than in Europe? Is it the excessive damages paid in case of a medical mishap? Perhaps someone can explain. What are the solutions proposed for this?

For starters what is the median gross revenue that doctors generate in Europe?
In general what is the gross expenses, personal and business wise?

Just a few of the larger expenses doctors have here:
1) Paying for a large staff, plus their medical care plus taxes for them etc...
2) Large expense for medical equipment, lab etc.
3) Mortgage on medical buiding
4) Mortgage on home, cars, kids education, etc.
5) Tution bills from education for themselves
6) Medical malpractive insurance, property insurance, life insurance, other kinds of insurance.
7) Income taxes...other taxes....such as property tax...etc.
--------------

Side note I was just thinking about this issue last night watching a show made in the UK on BBCAmerica.

In the show women go to a male doctor who never has a female nurse in the room.On the show the doctor raped women in the examination room. The only staff seemed to be a temp answering phones across the building. We thought this was rather wierd and wondered if this is the norm in terms of staff?

---


Also in the usa about 50% of all medical costs are incurred in the last 6 months of ones life.

[kenberg]

Gerben asks a good question which has of course occurred to me and probably to most people. I do not know the answer.

Much of what we do, in medicine and elsewhere, really seems to be botched up. It's easy enough to see some errors, harder to see how to pin down which are the most destructive and hard to see what the fix is. Doctors do make pretty good salaries, but I seriously doubt that is much of a problem. Since our current view is that anyone making less than $250,000 is too poor to help solve the deficit problem, let's stipulate $350,00. Some make more, some less. On a 40 hour work week that's $175 an hour, The costs for treatment run far in excess of that rate. Cutting his salary down by 100K won't fix the problem.

[mike777]

kenberg, on 2010-November-15, 17:00, said:

Gerben asks a good question which has of course occurred to me and probably to most people. I do not know the answer.

Much of what we do, in medicine and elsewhere, really seems to be botched up. It's easy enough to see some errors, harder to see how to pin down which are the most destructive and hard to see what the fix is. Doctors do make pretty good salaries, but I seriously doubt that is much of a problem. Since our current view is that anyone making less than $250,000 is too poor to help solve the deficit problem, let's stipulate $350,00. Some make more, some less. On a 40 hour work week that's $175 an hour, The costs for treatment run far in excess of that rate. Cutting his salary down by 100K won't fix the problem.

Also note many doctors do not have any salary. I think people forget this that many people have incomes but have a zero salary.

Now there are many kinds of incomes.....defining taxable income may take a 1000 pages or more.

One needs to look at expenses, if just one expense say medical malpractice is 260k a year I may need a gross income of a million or more, not uncommon.

[nigel_k]

If a country has a 'single payer' system then doctors are on a fixed income. Maybe not each individual doctor, but all doctors as a group will be. This means that supply will not automatically increase to meet demand. Also, since costs are not paid directly by the recipient of care, there is no way for price to exert downward pressure on demand. Hence demand will exceed supply and the result will inevitably be rationing.

Where I live this rationing takes the form of waiting lists. It is quite possible to go to your local GP with chest pain, be referred to a specialist, spend months waiting for a specialist appointment, then be recommended for an angioplasty for example, wait some more months and then die before ever seeing the inside of a hospital. Unsurprisingly, the government can save a lot of money with a system like that. Meanwhile, if your dog gets sick, he can have surgery within a week but you have to pay for it.

[kenberg]

I hope we do not get bogged down in these 1100 pages. I may not know where to find the answer to high medical costs, but I am confident the answer is not in 1100 pages of discussion about salary and income.

[kenberg]

y66, on 2010-November-15, 08:54, said:

Please define pessimism.

Toward the end of her life, Kathryn Hepburn said "I think I was born at just the right time and I am dying not a moment too soon."

Or, from E.E. Cummings "Progress is a comfortable disease".

But, of course, I don't really agree. I still like the world and I plan to hang around for a while. My wife insists.

This thread is really useful so I don't want to wander off into philosophy. Back to the deficit.

[mike777]

nigel_k, on 2010-November-15, 17:39, said:

If a country has a 'single payer' system then doctors are on a fixed income. Maybe not each individual doctor, but all doctors as a group will be. This means that supply will not automatically increase to meet demand. Also, since costs are not paid directly by the recipient of care, there is no way for price to exert downward pressure on demand. Hence demand will exceed supply and the result will inevitably be rationing.

Where I live this rationing takes the form of waiting lists. It is quite possible to go to your local GP with chest pain, be referred to a specialist, spend months waiting for a specialist appointment, then be recommended for an angioplasty for example, wait some more months and then die before ever seeing the inside of a hospital. Unsurprisingly, the government can save a lot of money with a system like that. Meanwhile, if your dog gets sick, he can have surgery within a week but you have to pay for it.

Again if docs are on a fixed income who pays all of their expenses. See the list above. Who pays the staff, who is the boss of the staff, who hires and fires etc? Who makes the decisions in running the office if the doc is not the boss and is just hired help? Who pays the mortgage, tuition, property tax, disablility insurance. pension...etc etc?

Again my point is there are dozens and dozens of expenses besides "just seeing a patient".

[mike777]

kenberg, on 2010-November-15, 17:43, said:

I hope we do not get bogged down in these 1100 pages. I may not know where to find the answer to high medical costs, but I am confident the answer is not in 1100 pages of discussion about salary and income.

Discussing income of course means you must discuss expenses...how much are they, who pays for them, what expenses do you want to incur...etc etc...big discussion.
Or you can just let a govt panel decide.

[y66]

re: Gerben's question, Atul Gawande looked at differences in the costs of medical care between two Texas cities with similar demographics, El Paso and McAllen, and described his findings here in May 2009 or so.

In a follow up interview with Ezra Klein, he identifies 3 specific, common sense examples of types of changes that can significantly cut costs. So maybe part of the reason costs are lower in other countries is that people there use more common sense.

Do you think much that we're hearing in the political conversation is responsive to the issues you pointed out?

Part of the difficulty is that it's very hard. But you can learn from good hospitals. They do peer review, for instance, and that changes what doctors do in their offices. They blunt the financial incentives in various ways that we haven't studied at all. It's kind of ridiculous that there haven't been very many people putting feet on the ground and studying what the positive deviants are doing. There are hundreds of examples out there. They're not just the Mayo Clinic and not just Grand Junction. Go to Portland, Oregon; Temple, Texas; Pensacola, Florida. These are places that are doing something differently.

But getting there requires a change in local medical cultures and rebuilding local medical systems. All medicine is local just as all politics is local. But let's create a cadre of researchers who go into these communities and figure out what's going on and spread the word.

The Washington debate -- there are smart reasons to think about including a public option in the mix, but we have not been thinking hard enough about how we control costs and make a better system. I think it's achievable in about 10 to15 years, and maybe even faster. I can tell you three things that will transform McAllen overnight. But CBO doesn't score them.

So what are the three?

First, they spend more than $3,500 per Medicare beneficiary on home visits. El Paso is around $800. McAllen is spending more than half what many communities spend on their entire health care expenditures. The doctors there have to disinvest from these home health agencies and come to agreement on when those visits are worth using.

At the end of life, McAllen spends $22 per person on hospice but more than $3,000 on ambulance rides. In a place like Portland it will be more than $400 on hospice and around $500 on ambulances. Increasing use of hospice, offering that as an option and working as a community on how to manage end of life, would be a smart move.

Work on basic cardiac prevention like getting people statin drugs. Most studies have shown you'll lower the cardiovascular disease rate by 25 percent and lower the number of procedures ordered. This was done in by Kaiser of Northern California, and they became the first community I've ever heard of where heart disease stopped being the leading cause of death.

If you took those three things and worked on them for a year, you could go from $15,000 per person per year to less than $10,000.

In a discussion of his August 2010 story about end-of-life care, he observed

The fundamental issue I found, however, was not the percentage of people at the margin who really do want to spend their last days on a ventilator with a feed tube and dialysis machine, or getting knocked down by a fourth round of chemotherapy with a miniscule chance of helping. Perhaps there ARE more of these folks in America than elsewhere. But the crucial problem is that for most people, this is misery. They don’t want this when they really get down to thinking and talking through it. The failure of our system is that we are not good at helping people sort out what is most important to them when they are dying and then helping them achieve it.

Based on recent family experience I'd say that's not just a failure of the system. Individuals and families are not exactly doing a great job of sorting this stuff out either.

[kenberg]

In my college days I read Dylan Thomas, as college students will do. "Rage, Rage against the dying of the light". Well, actually it doesn't help much.

[phil_20686]

kenberg, on 2010-November-15, 17:52, said:

Toward the end of her life, Kathryn Hepburn said "I think I was born at just the right time and I am dying not a moment too soon."

Or, from E.E. Cummings "Progress is a comfortable disease".

But, of course, I don't really agree. I still like the world and I plan to hang around for a while. My wife insists.

Despite increases in the Cost of Living, it remains popular.

[helene_t]

Those physicians' incomes you site, Ken, sound quite substantial. The US is a rich country and has high income disparity so to some extent it is to be expected. But also:
1) The costs of training physicians are to some extent booked on the gvt's education budget over here. In the US, prospective physicians pay a larger part of the costs themselves, which justifies higher salaries.
2) Malpractice lawsuits also justify higher salaries so they can pay their insurance fees.
3) I have heard the argument (is it true?) that the American Medical Association actively keeps supply low to make sure the prices are high.

2) and 3) should be easy to get rid of, and 1) isn't really a problem, just something that must be taken into account when comparing US to European health budgets.

But the demand for health services is is just bound top be larger in the US than in Europe due to higher obesity rates and higher incomes, so getting the costs down to European levels is not realistic I think.

Getting rid of the malpractice lawsuits will reduce the number of pointless examinations. But someone needs to be given real incitements to keep costs low, and that is difficult. Getting rid of the tax deductions for health insurance would make patients demand cheaper insurances, but it remains difficult to design insurance plans that cover necessary expenses without covering pointless expenses.

And giving care providers an incitement to reduce costs is not really compatible with a market-based system, I am afraid. The UK system relies on caregivers to prioritize their resources on the basis of patients' needs. Whether it works for UK is debatable, but in any case I suppose nobody in the US want something like that.

y66's quote of the study of the two Texan towns is important, I think, as it hints at a (partial) solution based on American experiences.