Monday, April 30, 2012

Blog comment of the day

So we learn the following from the British press:


A majority of doctors support measures to deny treatment to smokers and the obese, according to a survey that has sparked a row over the NHS's growing use of "lifestyle rationing".

Some 54% of doctors who took part said the NHS should have the right to withhold non-emergency treatment from patients who do not lose weight or stop smoking. Some medics believe unhealthy behaviour can make procedures less likely to work, and that the service is not obliged to devote scarce resources to them.


In response, over at Hot Air, a commenter said this:


Well count me among the anti-fat and anti-smoking bigots. You choose to poison yourself (while also advocating that significantly less harmful stuff like weed should be illegal) then I could really care less about you. Get off the damn couch, turn off the damn TV, put down the greasy pork leg and do some friggin cardio already. And really, I blame the people who let fat men get laid. If women would stop sleeping with fat men, this obesity epidemic would be solved.
libfreeordie on April 29, 2012 at 10:19 PM



Do you agree?

26 comments:

W.B. Picklesworth said...

The problem here is the framework of public funding of health care. If that's the way it works, then one man's fastfood and smoking denies another person treatment for something that is entirely outside of his control (per the scarcity of resources.) If this is the only way that health care is available, then people are set against each other, fighting for what scraps they can get with whatever justification they can find.

A system that isn't based on limited common resources (artificial scarcity) doesn't have this problem. In fact, I would think that high demand for medical goods and services would cause prices to decline over time, no?

It seems to me the question that we should be asking is, "Why are we trying solutions that impose scarcity?"

Anonymous said...

I just find it ironic that the poster's ID "livfreeordie" exactly describes the oxymoron of nationalized health care. You cannot live "free" because if you do, you will be allowed to die. Freedom says it should be MY choice to smoke or sit on the couch or whatever, and that then /I/ will be responsible for the costs to my health and my health care. Giving the government control over your health care gives them total control over your life. Not good, IMHO.

J. Ewing

Bike Bubba said...

What about allowing companies to condition their health insurance rates upon whether or not one smokes or is outrageously obese? Maybe even give a discount for those who get an annual checkup and take action on it?

Reality here is that nothing talks like money out of pocket, really.

Mr. D said...

What about allowing companies to condition their health insurance rates upon whether or not one smokes or is outrageously obese? Maybe even give a discount for those who get an annual checkup and take action on it?

Good plan, but we're talking about the NHS in this instance. Which brings up the question I always ask when anyone starts bruiting about the advantages of single-payer healthcare -- what happens to you if the single payer refuses to pay?

Brian said...

Of course it sucks to be a healthy, hale person who makes good life decisions, and still have to spring for an alcoholic's cirrhosis, a smoker's lung cancer, or a fat person's Rascal.

But the thing is...you do anyway, regardless of what kind of health care "system" we put in place. Private insurance and single payer both work by the same principle: pool the risk. The net effect is that the healthy subsidize the unhealthy. Most of the time, that means the young are subsidizing the dying. Moral hazard is built into the system, regardless of who is managing it.

One way around that is to completely unregulate private insurance. That probably sounds really appealing...until you realize that in such a scenario, there basically exists no incentive to insure anyone who's had any kind of health complication, anyone over about 40 years of age, or anyone with a functional uterus.

(I mean, it may not be quite that dire in practice, but there would almost certainly be a race to the bottom. Companies willing to offer broader coverage would have to charge more, leaving the healthy to flee to cheaper plans with narrower coverage, taking the low-risk low-cost customers out of the larger risk pool, making those plans even more expensive, etc., etc...)

So I don't know. Maybe the problem is a third-party payment, period. If everyone paid for everything out of pocket, the market would certainly be less distorted. But I just don't see a lot of people getting on board with that.

Especially as long as we let old people vote on it.

Bike Bubba said...

Brian, with regard to your argument, health insurance in this country was developed without a lot of regulation. So your argument is contradicted by the very genesis of the industry.

I would agree that all Hell would break loose if we suddenly were to deregulate things, but given the costs we're incurring, it's a path that we've got to travel.

Anonymous said...

The point is that people have to be responsible for their own health and health care. If they want to buy insurance, they should get insured for only those things they believe they need to be insured for, and nothing more, and the insurance agency will sell to them, considering all of their bad habits, for a price that makes them a profit. It's a perfectly balanced system and would vastly reduce costs over what we have now. I mean, how many old bachelor farmers really need pregnancy coverage?

J. Ewing

Brian said...

@ Bubba--Maybe. I don't know that we can make an apples to apples comparison between health insurance now and health insurance 60 years ago. The scope and cost of treatments is just so vastly different, and with that, the expectations of what constitutes "basic heath care".

Don't get me wrong...I'm all for deregulation...if for no other reason that as a young-ish, mostly healthy guy, I'd (probably) stand to make out like a bandit for another 20 years or so, at least. I'd happily let my health insurance company monitor how often I frequent the gym, buy vegetables, and walk to work. Hell, it'd probably give me a reason to cut my on-again, off-again, roughly half-a-pack per week "habit" down to zero, once and for all.

But I just don't see that really dealing with the problem raised by Mr. D in the post. The health care costs for people who make bad decisions and lack means (two groups that tend to overlap, substantially) are going to be shifted to someone--either insurance companies forced to cover people they wouldn't otherwise (the direction in which we are currently headed...the cost of which will be borne by policy holders, ultimately), or by the state (meaning the taxpayers, ultimately)--or we let these people languish and die.

Is there a third option I'm missing? I'd love to hear it, if there is.

W.B. Picklesworth said...

I've got a third option, though I think it overlaps with your first option. The state will "encourage" people to change their habits. Whether the coercion is relatively mild or a bit stronger, lots of people will "pragmatically" go along with it, telling themselves that they make healthy choices and won't be touched by it.

I would rather have a system in which the market is allowed to work and the people who fall through the cracks get some kind of basic, "we're not going to let you die on the streets" health care. Not insurance, mind you. This would still cost, of course, but because the market was allowed to function normally, those costs would go down over time, no? Even if not, this way of attacking the problem at least preserves liberty and removes some of the perverse incentives from the system, even if it isn't perfect. Does that sound plausible?

Gino said...

i've made lots of bad decisions.
and continued to do so for 40yrs.

and none of these things had anything at all to do with the issues i've had for the past 4yrs, and they were costly issues indeed.

i'm thinking maybe we should let insurers use genetic markers to set rates.

Brian said...

WB--slippery slope from nudging to coercion, though, isn't it?

And while I agree that some sort of minimum standard of care available to all is pretty much the only decent thing to do, doesn't that bring us back to the same problem of moral hazard, even if it is on a smaller scale? I guess I just see it as a difference of degree, not type.

This stuff is hard. I certainly don't claim to have all the answers here. Or even any particularly good ones.

Gino--I think once genetic testing for major risk factors of common diseases is reliable and widespread (and honestly, I think that is further off than a lot of people do), we're going to be talking about "health insurance" about the same way people talk about the telegraph now.

Gino said...

after i posted that...

i was thinking it's use could be tantamount to racism... ie... not your fault that you were born that way.

not that 'prejudice' is wrong ( i dont believe it is), but it is politically incorrect.

Mr. D said...

Brian,

I think you're asking the right question in re moral hazard. The issue is that, like Gino, I had a major health issue that had nothing to do with my lifestyle. I also have fought a weight issue for my entire adult life. Would that have been an impediment to my receiving care? Should it have been? In some cases, for some people, apparently the answer is yes.

Anonymous said...

I think a lot of us are missing the fact-- call it an archaic notion if you want-- that people must have personal responsibility. And if they won't choose it as something that was instilled into their value system, then it will need to be "taught" to them another way. So the first time somebody walks into the hospital with an STD and no insurance, he should be asked to pay the entire bill, and hounded by collection agents until some sort of accommodation is reached. Meanwhile, he will change his lifestyle or buy some (probably expensive) insurance. It's a harsh lesson, but it must be taught sometime. All we ever do by putting that responsibility somewhere else is to permit the irresponsibility to continue. The state doesn't have to mandate anything at all. Natural consequences and a free market (throw in a little voluntary charity if you want) will take care of it.

J. Ewing

Night Writer said...

I believe the marketplace is well able to provide solutions that - while perhaps not what you might call "affordable" - are cost effective, once we remove the dark planet gravity distortions of the third-party payor model and coverage mandates.

In short, health insurance could be bought and sold directly to the individual in much the same way as auto insurance. (Employers could choose to contribute money toward the individual's health plan as part of it's recruiting value-proposition, but would not be deciding what coverage is available).

The buyer finds a basket of coverage that fits his or her needs at the best price while geckos, Flo, cavemen and President Palmer (or Pedro Cerrano if you prefer) compete for our attention and dollars.

Folks would likely choose higher-deductible plans to "self-insure" or share lower-cost health maintenance expenses with a "major-med" backstop for catastrophic situations. While there's a reason large claims are considered catastrophic, these are statistically preictable and underwriters and actuaries are quite able to project these risks over a large group and price on a competitive basis - even to the point of offering "unlimited" per-incident coverage. That's because, unlike auto insurance, there are existing private-sector reinsurance and retrocession networks that the insurance company can access to lay-off really large or anomalous claims.

As with auto insurance, though, the risks would be priced by lifestyle and history with high-risk pools for the less-insurable (just as there are for drunk drivers). This pool coverage isn't and wouldn't be cheap, but it would drive the costs back to the insured's behavior and provide protection even if the health status was beyond the individual's control.

It goes without saying that the coverage would be totally portable and available across state lines.

Brian said...

The issue is that, like Gino, I had a major health issue that had nothing to do with my lifestyle. I also have fought a weight issue for my entire adult life. Would that have been an impediment to my receiving care? Should it have been? In some cases, for some people, apparently the answer is yes.

Yep. Once you start drawing lines around who deserves care/coverage and who doesn't, how do you know when to stop?

Personally, I'd rather risk the moral hazard of covering for someone's bad decisions than risk denying a person care they need because (say) their BMI is over some arbitrary limit.

That's probably the most compelling moral argument for no-fault universal care. Which has the distinct disadvantage of not existing.

Night Writer said...

Personally, I'd rather risk the moral hazard of covering for someone's bad decisions than risk denying a person care they need because (say) their BMI is over some arbitrary limit.

That's probably the most compelling moral argument for no-fault universal care,


Sounds great, but the fact is no-fault universal care can't help but lead to the government making arbitrary decisions on who can and can't receive care. In the U.K. it has been done based on age (including infants with severe birth defects) and potential for recovery. Demand continues to rise and resources continue to be limited, to the point now where the doctors themselves are proposing limitations on the obese and unhealthy. Once you give government the power to classify anyone as "undesireable" - even for "logical" situations - you've climbed onto a ski lift heading up a very slippery slope.

Yes, every system will find a way to ration care to some extent, but there are legal and market pressures that can be brought to bear on private enterprise. With the government, not so much. For all its faults (and many of these are caused by government interference), the U.S. healthcare system is still focused on saving and prolonging lives. We've seen over and over again that the U.K. and other nationalized health systems are all about saving money, lives be damned. I would much rather have a system where I have to file legal documents telling my doctors that I don't want to be kept alive, as opposed to having to sue my providers to keep them from making the decision for me.

For reference:
http://thenightwriterblog.com/2009/07/28/i-dont-want-to-go-on-the-cart/

http://thenightwriterblog.com/2005/04/24/charlottes-web-when-the-state-decides-if-your-baby-shall-live-or-die/

Brian said...

the fact is no-fault universal care can't help but lead to the government making arbitrary decisions on who can and can't receive care.

Agreed. That's why I point out that no-fault universal care doesn't even exist (if they are making arbitrary decisions about who gets care, it isn't really universal.)

That said, if the rationing in the UK leads to cost saving at the expense of prolonging life, why is their life expectancy (slightly) higher than ours?

I mean, I fully acknowledge that the comparison is not so simple (different demographics, etc.) but if state-managed care was vastly inferior to whatever you want to call what we have here, shouldn't you expect some clear indication of that in terms of measurable health outcomes? By pretty much any health metric you care to look at (life expectancy, mortality rates for major causes of death, infant mortality, etc.) the US does a good job relative to most of the world, but is rarely (if ever) at the top of the heap, and almost always surpassed by countries with some form of single-payer system.

I'm sympathetic to the free-market arguments. Really, I am. I'm just not very convinced that the data actually bear them out in the real world.

Gino said...

i'm finding myself more in favor of a flat sales tax on everything to fund universal care.

everybody pays 'the same' and is covered the same.
even politicians.

Night Writer said...

Gino, not a bad thought. The problem remains, however, that if everyone assumes the government will just backstop everything then there is no incentive to manage costs. It is like what happened with Fannie and Freddie - as long as the government was going to backstop bad loans, the risk-taking entities didn't have any risk to take and proceeded accordingly.

Here's a medical insurance example: in the HMO business, has already been working in a no-annual or lifetime limit basis, which is a centerpiece of Obamacare. This would seem like a carte blanche for the providers (hospitals, specialists, et al) but they have had SOME discipline knowing that the HMO margins (with a few exceptions) are pretty thin. If they get too out of line the HMOs fail, or the insureds move to indemnity plans with their limits. The providers have to play nice or kill the goose.

Now, if you apply the no-limits policy to the entire marketplace, with the government essentially being the ultimate reinsurer, the Providers have little incentive to price reasonably since the ultimate payer can just print more money. Cynical and short-sighted, yes, and also the opposite of what Reform is ostensibly trying to do, but it is the result of the government presence.

Of course, the government can push back saying there's only so much money, so we're going to withhold treatment for the most expensive cases or least useful people. When that happens the focus becomes, "We need to pay more taxes to help these people who can't get treated!" instead of "Why the hell does a knee replacement have to cost $250k?" - a question that an efficient marketplace asks and resolves every day.

Night Writer said...

Fwiw, I had my own significant health scare last year. I was looking at different treatment options, including one still considered by my insurer as experimental. I told my wife that the cost of the treatment, sans insurance, would be $60,000.

She smiled sweetly and said, "I'm afraid you're totaled."

Gino said...

the $60k wasnt the cost.
it was the price to be charged after the indigent got their care for 'free' (ie, on you.)

instead of 'single payer', we have 50 million payers who carry the other 300 million.
this has to change. it HAS to if we want to even think about restoring a small measure of sanity.

get everybody paying first(even the wetbacks through the sales tax), and then add cost safeguards.

that, and my income will rise since my compensation wont include a health plan that includes those without one.

Gino said...

for thought:
health care is reported to consume 17% of the economy. why does it consume nearly 40% of my economy (and my co-worker's) before i even see the doctor?

Velas Kesakes said...
This comment has been removed by a blog administrator.
Anonymous said...

Hi there! Very interesting post. Nowadays, we know that people can't control themselves when they are really free to do. Still great post you have. I love it.

Kidd said...

WB--slippery slope from nudging to coercion, though, isn't it? And while I agree that some sort of minimum standard of care available to all is pretty much the only decent thing to do, doesn't that bring us back to the same problem of moral hazard, even if it is on a smaller scale? I guess I just see it as a difference of degree, not type. This stuff is hard. I certainly don't claim to have all the answers here. Or even any particularly good ones. Gino--I think once genetic testing for major risk factors of common diseases is reliable and widespread (and honestly, I think that is further off than a lot of people do), we're going to be talking about "health insurance" about the same way people talk about the telegraph now.