Making sense of health care (r)

I've come to realize that, until we have healthy eternal life, nobody will be happy with their health care system.  That said, there are certain things that make health care a really tough thing to diagnose and repair.  For instance, in most human endeavors when people say "oh, but times have changed," one can say with fair certainty that they are full of shit.  As Baz Lurhmann said, "Prices will rise, politicians will philander, and you too will grow old.  And when you do, you will fantasize that when you were young, prices were reasonable, politicians were noble, and children respected their elders."

It's said often by both sides, for instance, that much of the problems we are having currently with Social Security are the result of health care.  Well, it's not said that way, but it's what people mean when they say the retirement age should be raised.   And that's not the whole of it - 40 years ago, you died of cancer or a heart attack, and quickly.  Now, you probably get cured once or twice, at the cost of 2-3 years productive employment.  My Pepere had open heart surgery back in '84 - he's still going strong today.  These days, you can almost bank on a few rounds of chemo, open heart surgery, 30 years of insulin shots, or a hip replacement before whatever really takes you out takes you out.  People don't save up for retirement anymore so much as convalescence.  

Make no mistake - this is progress.  However, our lives are backloaded with costs nowadays - those 20 bonus years cost a lot more than any other 20 years, and while we're paying half our incomes in taxes and burning ourselves out to keep and extra thousand sq ft. of roof over our heads, we aren't saving for the personal apocalypse.  But who would deny those 20 years to anyone?

I've heard horror stories from countries with socialized health care, and from countries with relatively open health care.  I've seen surveys that say the US has the best health care in the western world, and surveys that say the US has the worst health care in the western world.  I've talked to people from all over, and like I said, nobody likes their health care system all that much.  

This thread will try to come to some answer I can be happy with about health care.  And yes, I'm starting off biased, because I can't see how politicians and bureacrats can make better decisions for my health than I can.  But I'll try to keep an open mind, because like I said; this is a very unusual territory.  In my first 1/3 of life I have done very little to  support myself over my last 1/3 of life.  I am currently one of the uninsured millions (that link, by the way, goes to a former Bush economic staffer and includes lots of mailing list emails from inside the White House... interesting reading).  I don't think I can trust Medicare and Social Security to be there when I need it 30+ years from now.  So it's ideological, but it's also personal.

Today's entry:  primary care.  The primary care "dream" is one of house visits by doctors you call by first name.  More substantively, it is one of preventive medicine, early detection, consistent and quality care for chronic conditions, and reasonable prices and service for common ailments.  Movies and Ron Paul lead us to believe that this was commonplace in the US at least prior to the 1960s or so.  Medicine has changed a lot since then, and most ailments are not most effectively cured by whatever fits in a lunch pail.  But how many times have you waited for an hour at a megaclinic only to be told that it was nothing serious and slapped with a prescriptions that should have been easy to get over the phone?  I can count the number of times that I actually needed to be in a doctor's office in the last ten years on one hand.  To a large extent, a handful of assholes screwed it up for the rest of us with irresponsible malpractice suits, and the courts didn't help with vomit-inducing rewards.  Another big factor appears to be the guilding of the medical profession, which has priced MD degrees plum out of the primary care market.  Finally, the separation from the consumer that mandated employer healthcare has brought about has made the whole process much more bureacratic for both sides... in the end, lawyers always trump doctors.

I lived in the Netherlands, where health care is run by huge government-corporate cartels.  It is a utility model, and seems to work okay for basic care.  You are legally required to buy insurance from a list of approved corporations.  According to my Dutch friends, those companies often try to get out of paying the bill, but I'm not sure if that is an exceptional thing or the norm, much as I'm not sure which is the case in the US.  I went to a clinic there for a tetanus shot, and it was pretty similar to my clinic experiences in America: 2 hour wait for a 5 minute consult, and 80 euro minimum charge.  Not terribly unreasonable considering tetanus would have killed me slowly and painfully 100 years ago - but then again, I was paying cash.  My wife-to-be claims that Britain's health care system is awesome; but she hasn't really lived in Britain as an adult so - she knows better than me, but her depth of experience is limited.

But what about socialized healthcare in America?  How does that work?  By all accounts, Medicaid has its problems, but it's hard to expect much from a program that caters to a relatively small, and unvocal voting bloc... yes, socialized healthcare will disproportionately screw over the poor too, probably even more than our current ER and patchwork program does (unless a lot more of us are poor, but I digress).  Medicare, from personal anecdotes, is a ton of paperwork and never pays for everything you need; but it does help quite a bit.  The VA, however, is underfunded and should be a national embarrassment, except Americans really don't seem to give a shit about their soldiers after all.  

One has to expect that a socialized system would be similar to all three in terms of primary and emergency care (I'm not getting into other aspects today, like the impact on innovation).  Since it would serve all but the richest among us (who would pay for better doctors and no waits), it would have to be responsive - at least to some groups.  The groups that vote disproportionately, like seniors, would probably benefit at the cost of others.  The companies that got in bed with the government and performed well on whatever blunt-instrument statistics the bureaucrats were paying attention to that year would make like bandits.  

Another model might be public education.  The poor would get screwed, similarly to how they get screwed by our current education system.  People would probably be required to go to the nearest hospital regardless of quality, or else spend extra for private care.  Doctors and nurses would have to defer to bureaucrats like teachers must defer to curricula, but that's not terribly different than what is happening today with HMOs and PPOs and the rest of the alphabet soup.  By all accounts of socialized systems, waits for treatments, surgeries, consults, and everything else would go to insane levels - not a problem, unless you have a degenerative or debilitating illness.

Overall, we've been pretty well primed for crappy primary care in this country from 40 years of partially-socialized healthcare already.  There is some choice of company, but the regulations and judicial record have forced the hand of most health insurers and providers so that the product is uniformly meh all around.  So, going from 5 or 6 huge politically-driven corporations to 1 huge politically-controlled agency probably won't be a devastating jump, but it won't fix people's primary-care complaints either.  So it's pretty much a wash.  I think, if people had the choice, they would prefer to keep primary care private - it's still the most affordable part of the system, and it's an elastic good in that people can choose to skip this year's physical or flu shot.

Then again, as Baz says, "The real troubles in your life are apt to be things that never crossed your worried mind.  The kind that blindsides you at 4 pm on some idle Tuesday."  The whole thing gets more complicated when you introduce Really Bad Things.  That's next time: catastrophic care.  Or will it be medical innovation?  Wait and see.

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