A year or so ago my wife and I were staying at a bed-and-breakfast in Banff, Alberta, Canada. There were 2 other couples staying there at the same time. One morning the wife of the younger couple came down and said her husband (let's call him Bob) wouldn't be at breakfast because he was feeling horrible. Bob was a big guy who obviously didn't exercise much but had been very active the day before. We all thought it might be something serious. The owner of the B&B said, "I have a doctor friend who has an office just a couple of houses down, I'll call him." She did, he saw Bob about 15 minutes later, checked him out, gave him something and Bob was much better within an hour or so.

In the US there's no way something like that would have happened that quickly. We were all impressed by how well and quickly Bob had been taken care of. There was some discussion, though, about the system in Canada being under pressure due to rapidly rising costs and lack of funding to keep up with the costs.


Even if taxpayer-funded care were universally available in the US, I have to believe there would continue to be a 2-tier system. The rich and powerful would want to be able to buy additional insurance and pay for more rapid access to specialists and for elective procedures. Cosmetic surgeons would still want income from discretionary surgery. How would we prevent a 2-tier system from decaying to the state that it (supposedly) did in the USSR? Roughly: Party hacks had clean, modern facilities while the proles were treated in dirty, unheated shacks without proper equipment or medication.

There is no silver bullet. I think most people have anxiety about catastrophic medical expenses. If they have insurance for such things, they worry about having enough money for the deductibles and co-pays, and worry about being dropped if they do develop and recover from an expensive condition. Or losing coverage if/when they change jobs. The middle-class worries about the expense of normal medical conditions (braces, root canals and crowns only get nominal coverage in my health insurance). The poor I've known realize that it's hopeless to be able to pay medical expenses. They worry, but the costs are just so large that they know there's little they can do about it when they need care. Public health demands that we do preventive medicine (to protect against epidemics, etc.). Compassion demands that we take care of the sick and dying. Politics demands that people not be bankrupted by catastrophic medical expenses. How does an affordable system address all of these concerns?

A system that encourages people who have insurance to think about visiting a physician (or a walk-in clinic) during normal hours rather than going to the emergency room at 2:00 AM is probably a good idea. But other than some elderly folks, I don't know of anyone who enjoys going to the doctor, so I don't think that having people pay $10-1$5 to visit a physician has much of an impact on who does and who doesn't go. Do co-pays make sense or do they just limit access to medical care by the poor?

How can market pressure be put on rising costs then? I'm not sure that it can. Getting medical care isn't like buying soup. Many people go into medicine because they can earn a very good living in the field. Drug companies push the development of new medicines because of the hope for big profits. Tinkering with these incentives will have some impact on the number of people who enter the field and the spending on medical research and development. How will, or should, that be addressed?

I don't think many are asking the right questions about why medical prices are rising so much.

1) Why does it cost so much to bring a new drug to market? Is it government paperwork? The cost of new technology to make the stuff and control the quality? The cost of people with the necessary expertise? The cost of advertising and marketing? The inefficiencies in the companies that cannot survive without a golden-goose drug that brings in huge profits (and thereby support all the more common drugs)? The cost of lawyers, settlements, and liability insurance? Greed? It's the way it's always been done and there are too many vested interests who want to keep it that way? Something else?

2) Why are hospitals so expensive but so often in financial trouble? Is it personnel costs? Disposable equipment costs? Stupid regulations (e.g. having to fill out 10s of pages of the same paperwork every time one visits)? Lack of study of how to make things more efficient in a hospital setting? Liability insurance? Lack of funding from the community and the government?

3) Why does the estimated federal contribution to Medicare and Medicaid increase so much every year? Increased salaries? Increased paperwork costs? Drugs? Keeping people alive past all hope? Etc.

4) Why are 40+M US people without health insurance for at least part of the year? Is it mainly due to changing jobs? Aren't there federal or state programs designed to ensure coverage continues between jobs? Are they working or not? Why are the poor lacking health insurance? Is it just lack of money, or is it lack of money-handling skills, or something else? What type of insurance would be necessary and beneficial for those who don't have it now? What should it cover, and what should not be covered? Should private companies provide it, or should it be a single, national system? Why or why not?

5) How would care be rationed in a single-payer system? How would controversial medical topics be addressed? Who decides whether abortion or electro-convulsive therapy or stomach stapling or special diets or crowns or LASIK surgery or knee replacement or liver replacement or experimental drugs or ... is justified and appropriate and thus covered, or not?

Without knowing the answers to questions like these, just saying that a taxpayer-funded single-payer system will be better is naive, IMHO. We need to know why costs are rising so much and why so few of the approaches tried in the past have resulted in medical inflation falling to the general rate for the economy as a whole.

My $0.02.

Cheers,
Scott.
(Who sometimes would like to see things more in black and white rather than shades of gray...)

Created as new thread #243432 titled [link|/forums/render/content/show?contentid=243432|ICLRPD.]