THCB

How Much Is a Life Worth?

This blog continues my ongoing series of “mysteries of health economics.”

The mystery this week is “what is a life worth?” We cannot ignore this question because it seems unthinkable. As will discuss, coverage decisions by public and private insurers depend on the answer. Some payers are rather explicit about they think a life is worth.

Before I try to solve this mystery, let me acknowledge that we should not spend money on health services that are of zero value (or worse.) But what about expensive health services that might prove to be of some value? How much should we spend on these?

Let us accept the reality of insurance. When we “purchase” health care, someone else foots the bill. Perhaps insurance should contain big deductibles, but even big deductibles are quickly exhausted if we need surgery or have a chronic health problem. If we are pooling our resources to pay for medical care, then we will probably want to reach some sort of collective decision about what drugs and treatments we will pay for. The alternatives would be to invite massive moral hazard. (Let me repeat for those who bang the drum loudly for big deductibles – deductibles are quickly exhausted when serious illness strikes and moral hazard again rears its ugly head.)

Now imagine a new cancer drug that offers a small prospect of survival to patients who have no other choices. Suppose that on average, patients who receive this drug can expect to live about another three months and that there are no downsides to this drug. If the drug company offered to give the drug away for free we would surely want patients to have access to it. If the drug company asked $100 million a dose, we would probably agree to spend the money elsewhere.

There must be some price under $100 million that would cause us to stop and think this over. Should we pay for the drug if it costs $500 per patient? What if it cost $100,000?

At some point we must answer the unthinkable question. In this case, we must determine how much should we be willing to spend to offer individuals three more months of life? Regulators in many countries have already given their answer. For example, the UK recently refused to pay for the skin cancer drug ipilimubab because the cost per “quality adjusted life year” was between £54,000 and £70,000. The UK uses a threshold of about $100,000 per year of life, a threshold that is accepted in most developed countries. But is that really what a year of life is worth? By all accounts, this threshold is based on past spending norms, adjusted for inflation. What was once seat of the pants policy, driven purely by budgetary needs, has become the gold standard for measuring the value of a life.

This all seems rather ad hoc. Rather than accept a valuation that was seemingly pulled out of thin air, academics have sought to value life by looking at how people actually behave. Some researchers have asked people what their lives are worth. Carefully constructed surveys generate values for a year of life well in excess of $100,000.

Such surveys are notoriously unreliable. If we could observe people spending their own money on health services, then we would truly know what they think their lives are worth. But insurance means that we only see people spending someone else’s money. Here is where economists have gotten rather clever. Workers are often confronted with tradeoffs between relatively safe jobs and relatively riskier jobs that pay more money. (Controlling for skills and experience, the data definitely show that riskier jobs pay more.) Assuming that employers do not pay higher wages out of the goodness of their hearts, they must be paying higher wages in order to convince workers to take on more risk. Led by Harvard’s Kip Viscusi, economists have looked at the data and determined that workers can expect to get paid an extra $5000-$10,000 to take on a job that has a heightened mortality risk of 0.1 percent. This adds up to $5-10 million for every additional death, or well over $250,000 for every year of life lost. If workers insist on getting paid $250,000 extra to compensate for the prospect of losing a year of life, then they must hold their lives very dear.

So is a year of life worth $250,000 to the average worker? Many people criticize Viscusi’s work, in part because it makes strong assumptions about what workers know about job risk and about worker mobility. Some economists observe that these calculations do not take into consideration the importance of hope. But if we try to correct for any resulting biases, the value of a life would probably be even bigger! One bias might work in the opposite direction – we might insist on receiving a lot of money to take on additional risk, but be unwilling to give up the same amount of money to reduce risk.

My mother always told me that “if you don’t have your health, you don’t have anything.” She held life very dear. So do I and so do most people – more so than the UK and other regulators want to believe.

Everyone is concerned about rising medical costs, and for good reason. At some point we may spend so much on medical care that we will no longer be willing to give up so much money to live longer or better, preferring to spend the money on food and shelter. And in today’s tough economic environment, perhaps quite a few of us have reached that point. But in our zeal to cut spending, let’s not throw out the baby with the bath water. Effective medical care remains one of the greatest bargains, even when that means spending tens of thousands of dollars to save just one year of life.

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106 replies »

  1. Good day! I simply want to give an enormous thumbs up for the good data you have right here on this post.
    I might be coming back to your weblog for extra soon.

  2. You mean the section 8 neighborood I live in? I don’t have enough rich friends paul? Your just pushing more BS and avoiding the facts. What income disqualifies someone for Medicaid? Once you establish that what percentage of people making more then the number you just determined have cell phones, cable TV, two cars, etc etc. Sometimes BS is BS and your spewing BS. We know 20% or more of the uninsured make over 75K per year, are you argueing someone making 75K is choosing between food and insurance?

    The chief failue of liberals is rank stupidity and ignorance. No matter how clear the facts and how easy they are to obtain they push a narritive based purly on ideology.

    “No matter how much insurance you have, it is possible for you to contract an illness which will exhaust it.”

    How do you exhaust an unlimited policy? See above about ignorance and facts in regards to the left.

    “Then they learn that suffering is not always the fault of the sufferer.”

    And in those cases everything should be done to help those sufferers. The left on the other hand is hell bent on helping those that do not need help, at the expense of the true sufferers. People such as your self thrive on the action of assistance not the result. To you it does not matter of the person being helped is in need as you helped and that is all that matters, preferrably with someone else’s money as people like you love to talk about sacrafice but prefer it be born by the next man.

    Lets look at the largest of failures Medicare, it was passed to assist the 13% of seniors that suffered yet as passed did not help them at all, in fact it grew the problem from 13% to 19%. As typical liberals you celebrated the action of medicare even though it failed.

  3. >> I have never once meet a person that could not afford insurance, I have meet thousands that had other priorities. usually nice cars, new clothes, and comforts not needs.<<

    You travel in the wrong circles, Nate.

    The term B.S. is unfortunate, because it is often used to smear someone who espouses truths which are inconvenient. But if that term has to be used, it should be applied to the rants of ideologues like you, who would seem to take life and death issues and reduce them to ideological ones. It is interesting to note how the prejudices of people change when they discover that they are adversely affected by policies they once espoused. Then they learn that suffering is not always the fault of the sufferer.

    In my view, the chief failing of conservatives is the failure of imagination. They suppose that "it can't happen to me." Well, Nate, I'm here to tell you that it can. No matter how much insurance you have, it is possible for you to contract an illness which will exhaust it. Sooner or later, Nate, we are forced to acknowledge that our share of the world is the same In the end — six feet. To acknowledge is sooner is the beginning of wisdom.

  4. Sorry Paul but that is BS. Our poor live better then the middle class of almost every other nation in the world. When your talking about people buying policies your already excluding our poor becuase they have Medicaid, your talking about our middle class everyone of which has a fancy cell phone, cable TV, more house then they need, drinks and smokes etc etc. There is zero truth to any claim americans are choosing between food on their table and buying a good health insurance policy.

    How many policies have you sold in your lifetime? A more acurate fact would be how many policies did I not sell becuase the person choose not to buy, sometimes claiming they could not afford it. I have never once meet a person that could not afford insurance, I have meet thousands that had other priorities. usually nice cars, new clothes, and comforts not needs.

  5. Nate, you say “it was usually the greed of the individual that didn’t want to pay extra for a policy that covers the treatment they now wish they could get.” In my experience, those who avoid the “premium” health care policies do so because they cannot pay for it and still put food on the table and pay the rent. To say this decision is a result of “greed” is perverse.

    I know someone whose favorite saying is “enough is as good as a feast.” The word greed, in my understanding, applies to people who already have enough. and want MORE. It doesn’t apply here.

  6. Jeff –

    That was a very interesting and informative comment. I also hope you heal quickly and suffered no permanent effects.

    I think your emergency room experience with respect to both your own care and care administered to others reflects providers’ perception of our litigation environment and patient expectations plus a desire to generate revenue from well insured patients. As for cardiology related services, it seems that everyone wants to expand there because it pays well, even by Medicare.

    I’ve long favored high deductible health plans as a good way to mitigate utilization of healthcare services. I know liberals claim that many people, not all of them low income, will forgo some necessary care and incur higher costs later when a minor problem develops into a major one. In other words, people cannot be trusted to act in their own best interests and government needs to protect them from themselves. I don’t buy it. High deductible plans should work fine for at least the upper half of the income distribution. For the lower half, doctors and hospitals could work with patients on payment terms and even write off the entire patient portion of the bill if circumstances warrant while setting fees sufficiently high to earn a respectable living net of uncompensated care.

    I think Nate makes a fair point about people being less likely to scam someone who lives close by than a distant government entity. I also think it would be better if state and local government had a significantly higher taxing and spending responsibility as a percentage of total public sector spending. State and local government should probably be responsible for all education spending as well as transportation and finance Medicaid through a combination of state taxes and federal block grants. Benefits and eligibility criteria will not be uniform but they aren’t now either. States would capture all of the benefits from fraud mitigation strategies and would be free to use robust ID cards if they want to even if other states choose not to and there is no federal ID card.

  7. is the dog remaining silent or talking about who put him up to it? Its a dog don’t beleive him if its naming names.

    I’ll agree that means testing is needed, I would just hope for a drastic change in how and who does it. I would like to see an inversion of the responsibility pyramid. It seems responsibility starts at the federal government level then trickles down to the individual with the individual responsible for very little today.

    If we flipped that and responsibility started with the individual then finally the federal government I feel it would solve many of these problems, including means testing. Its mush easier to scam someone far away that doesn’t care then someone that lives in the same town as you. Taxes should also be inverted with local taxes consisting of the vast majority and a small amount going off to the federal government.

    I do feel sharing these stories is starting to pay off. When we do benefits meetings now and talk about the high cost of Rx or the cost of a hospital MRI versus freestanding center people are not only engaging with questions but followinbg through. One of my biggest concerns is now that we are finally making some head way reform will kill the movement.

    Hope you get well soon and there is no cosmetic damage:)

  8. Nate,
    I wanted to get back to you all week. Unfortunately I had an embarrassing incident wherein I tripped while walking my dog. With both hands occupied I did the traditional face-plant onto the concrete. As my nose touched down a foul crack echoed through the neighborhood. All I could think was ****$$$%%% that hurt! Second thought, get out of here fast before someone sees your foolishness. I trotted down the hill with Bodi ; blood dripping everywhere; bag of dog poop in one hand and dog leash in other. This all culminated in 12 hours of ER evaluation with a final diagnosis of broken cartilage but all else in-tact. Of course I had the obligatory CT of my head. I even called my primary care doc before I left for the ER stating that all I cared about was whether or not I had any cranial fractures otherwise treatment would not be a concern until it all healed. Knowing I wanted a simple skull series of x-rays; I got the full-house. This of course was due to my Blue Cross.
    While in the ER I watched the non-urgent bumped elbows, chronic knee pains and earaches come and go as three true rescues were attended to by full medical teams and in one case…a Chaplin. I kept asking myself why it hasn’t gotten any better with all of our efforts at managed care and now: Primary care Medical Homes.
    When I managed Pulmonary Rehabilitation Programs I held to strict criteria that the tobacco addicts had to be free from all tobacco products and receive counseling as required. In ten years I discharged two patients early because they elected to smoke in the bathrooms. We had a 10 bed facility and I simply stated to the patients that we had a waiting list and needed commitment: In other words a zero tolerance contract. This was the ONLY time in my clinical work where the corporate administrators of any company allowed me to sacrifice revenue for health-beliefs.
    In the early 1980’s ,my profession was blessed with all kinds of cool technologies: New high-resolution cardiac cath lab equipment, electrophysiology and 2 dimensional ultrasound. I had been hired to open a new diagnostic clinic in New Hampshire where we had three competing hospitals within 15 miles of each other. We were fortunate enough to hire the first cardiology group and I was hired from Los Angeles due to my cardiovascular skill set. Here is how we justified each purchase of new diagnostic equipment.
    Population count X (prevalence +incidence rate) X Medicare MAC (it was lower than commercial so we hedged our bets)X estimate of cases expressed as a % of diseased population. Once I had the revenue I would simply divide it by the capital cost and incremental cost of operation to establish break-even. In most cases, break-even was less than 12 months. As long as costs were below $1M we did not need a certificate of need. Between 1981 and 1982 I became the instant hero at the hospital with the new revenue centers. The small community-funded hospital eventually sold to Hospital Corporation of America (I am sure you know their history), and I went on with my career chasing revenue center to revenue center as managed care established rules which simply required us to relocate the patient to a slightly lower cost of care facility. I could tell you some great stories from the road back then.
    Within five years we had three hospitals with a combined 600 beds caring for 150,000 people: each with competing services including cardiovascular medicine and neurology.
    As I sat in the ER the other day I thought of your comment on the era of cost-control in medicine: When we had no insurance and everyone self-insured: This resonated with me as ‘truth’. Of course, back then we were just starting to experiment with open heart surgery. But you nailed it brother. My reality is that with the exception of us folks that traverse the payer-provider line few really understand how the M1 works in healthcare. The escalation in cost through value added services and no requirement for us to have the vaguest idea how to read an EOB.
    So my point all this time was that I actually agree with you on many points. For example I have what I call the Harris Index of Diagnostic Inefficiency. It is the ratio of MRI scanners to population where the USA is three times higher than other countries; and the Dartmouth Atlas linear regression of cardiac surgery rates to number of cardiothoracic surgeons per 100,000 persons. This is after correcting for illness burden of course.
    One of the missions of my Blog is to bridge the gap between the lay-public and professionals and create parity of knowledge around cost benefit and cost efficiency. Kind of like when we learned that out cars didn’t need the $800 under treatment to prevent rust after paying for it for so many years.
    So I want to thank you for putting me back in touch with a need to expose the shell game. Like you, I simply have no short term solution so want to leave blame out of my discussion other than pointing to a system run-amuck with overpriced services, too many inflationary steps in the value chain and too many people on public subsidy. I will continue to argue for some form of provision of healthcare services for those who do not have the ability to pay. But…due to our conversation and my soul searching and my trip to the ER and the 33 years of saying to myself “this doesn’t make sense” : I will push for a better mechanism for means-testing and a time limited resource to slow down our social Darwinism …perhaps.
    Let’s stay in touch as your perspective is a critical lens that needs to be added to the ‘big picture’.
    Take care,
    Jeff
    You can reach me on Twitter: @untangledhealth

  9. ” I believe that society must reach agreement on how to help those who can’t help themselves.”

    Haven’t we tried this and it failed miserably? I don’t see how this can ever work but on paper when we allow those that can’t help themselves to self identify and those seeking assistance are given power of taxation and regualtion over those with the ability to assist.

    Is it still help/assistance when its confiscated against the will of those that have it?

    “in a free market with no cost control”

    The most efficient we ever were and the most effective cost control in the world was when people paid for their own healthcare totally or paid then seeked reimbursement. The lack of cost control is a perception when in fact the implementation of managed care under the guise of cost control increased cost. ACA is a recent example, whats affordable about it? What did manage care manage?

    “Medicare/Medicaid landed on the seen far too late in my opinion: Then we passed the ACA hybrid”

    Whole lot of failed reform skipped over here.

    no need to apologize its going to take some nasty fights and maybe even worse to break through 60 years of lies and misinformation. I strongly agree with the need for an informed public, i just disagree on how we fix it. You appear to gravitate to the educated and polite method of teaching. I prefer to call an idiot an idiot and tell them to pull their head from their ass. Not so much so they change their mind and see the light, most people can’t admit when they are wrong to that level, more so other people see how wrong those people are and stop being influenced by them.

    Thank you for the lively debate

  10. Barry and Nate,
    I certainly did not mean to be anonymous and thought I had posted my personal info earlier. I also agree with all of your observations Barry.

    I have a consulting practice since 2007 that specifically focuses on local organizational needs when it comes to understanding and developing health care systems that will address the needs of the community, I address community health profiles, professional supply, and health belief culture and health information technology. I believe that health is a local phenomenon and that all citizens should take a role in defining their values, needs and ‘nice to haves’, My practice has taken me to regional health-plan and provider partnerships, hospitals, the CT Academy of Family Practice joint venture with Anthem Blue Cross, Federally Qualified Health Centers, and State Medicaid Programs. I started the consulting practice due to what I judge to be a lack of truthfulness in the industry.

    My clinical training is in Respiratory Therapy and Cardiovascular Technology and Rehabilitation Medicine. I hold three Registry Credentials and one State License in Massachusetts. I have a BS in Business Economics which I used to brighten up my thick skull.

    In 1997 I became very frustrated with hospital readmissions when patients leaked outside of our system of care and left my program management role to work in clinical informatics. I joined a start-up team formed by a physician-engineer, the CTO of Lotus Development and the former AI lead at Carnegie Melon. We went on to patent one of the first web-native, role based security care coordination platforms which applied geographically sensitive decision support rules to care plan generation. Ref: System for Managing Applied Knowledge and Workflow in multiple dimensions and contexts. United States Patent 6282531 June 12, 1998.

    Suffice it to say, I have worked with many folks that are light years ahead of my intellectual capacity and have enjoyed the excitement in medicine in the last thirty years as we have tried to squeeze more and more blood from a turnip (or water balloon), From pre DRG to UR, to UM, to CM to DM, to PCCM; I have worked in all systems and believe we need to somehow create a clean slate that is based on the values and pocketbook of our democratic society,. I believe in Universal Coverage from the perspective of basic life sustaining and episodic curative procedures but not a continual stretching of the healthcare dollar to reach the theoretical longevity of 125 years,

    On Politics: I trust NO-ONE. I call myself a communitarian capitalist as I believe that society must reach agreement on how to help those who can’t help themselves. This would include all ICDs and DSMs. I believe we should address the beginning and last two years of life and ask ourselves some serious questions on just how much society should pay when it comes to life sustaining procedures. I have an advance directive that specifically states my wishes. I have spent too many hours in the ICU listening to doctors and families hold on to the last few breaths of a person that my staff knew would be reaching their end 12 months ago. When it comes to the end, we all take it very personal and have a hard time reaching an agreement. I certainly do not believe in death panels but believe that evidence based medicine has its place in forming policy. For example: We know that without lung transplant a COPD patient has about a 10% probability of becoming ventilator free after three previous episodes of ventilatory failure. So who decides and who pays for the care of the patient after the fourth intubation. Should we have an end of life Medical Savings Account? And of course the same applies to neonates. Somehow, we need to understand that we can’t have everything, all of the time.

    Yes, I am a healthcare reformer. But there is no such thing as Obama Care and never was. What we have is an interdependent supply chain of numerous value added companies in a free market with no cost control until Managed Care and Medicare/Medicaid landed on the seen far too late in my opinion: Then we passed the ACA hybrid with all of its negotiated points. All that has value to me is the fact that my State’s High Risk Pool can now insure me for $467 per month vs. $1100 (Diabetes for 45 years): And the inclusion of pay for performance. I believe most folk are stuck in an uninformed state, listening to sound bites that are taken out of context and used to prove or disprove the agenda of the sponsoring agent. We spend more time thinking about which LCD TV to purchase than our benefits programs.

    I took 1000 hours off in 2008 to campaign for President Obama. Why???
    I liked the Man but had no faith in the system until we get term limits: and now also recognize that President Obama was a bit new inside the beltway to take on the bandits attacking from all directions.
    Well, I never thought his rhetoric or anyone else’s was the least bit achievable in a 4, 8 or 12 year time frame. But I wanted to make sure a fight got started that would force us to look at the aforementioned social issues. It is too easy to watch TV and head for the voting booth. This is why I champion for mutual respect and conversation. If I wind up with an overwhelming group of draconian folks then I will move elsewhere: Same for a Nation of Addicts seeking immortality.

    I am very sad that our nation is so divided. I am an independent consultant because I see how folks twist data to prove points just as Nate described…causation vs. correlation…

    I still hope for a solution to emerge from a group of adults who can objectively state the moral, spiritual, functional, social nature of medicine to the average citizen and a truly informed society then votes with a basis of knowledge.

    Thanks for asking me who I am. I don’t have answers. Yes Nate, I do have training in statistics, probability theory, meaningful difference and central tendency. But as I just said: data and information can be manipulated to prove a point so I try to live with that knowledge and hold myself in integrity. My friends are all the same and we have a great time calling ourselves on our own BS as opposed to flogging one another. I was a bit mean in the last few posts so I apologize.

    You can access my blog at http://www.untangledhealth.com
    Thanks for calling me out with your diplomacy Barry.
    Jeff

  11. “One area where I certainly agree with you is on the disparity in prices per procedure and per brand name drug between the U.S. and Europe and Canada.”

    Allow health plans to reimburse foreign sourced prescriptions and the price of brand name Rx will plummet. If an American can travel the world and buy Rx any place he wants along the way its redicilous to say he can’t be trusted to order from home.

    The key factor here is not that American’s will actually buy their drugs from overseas, its the fact it will create awareness. Once people see the difference in cost between the same drug in Canada or India and the US they get engaged….that and a little enraged. Our governmental policies are just as much if not more responsible for our sheltered consumption as the FFS system we have. In fact these are symptoms of government regualtion not FFS.

    Hospital charges are about to take a huge hit, 2012 might even be the year it all blows up for the good. The CA v MultiPlan & Sutter lawsuit plus a couple other things are going to get hospital bills more attention then they can withstand.

  12. Untangled Healthcare –

    Agree or not, at least Nate, I and several others use our real names when commenting. Our attitude is if it’s worth saying, it’s worth owning up to. You seem like a pretty smart and knowledgeable guy but we have no idea who you are or what you do. Are you a doctor, an academic, an insurance executive, health economists? A little more color there might better help us understand your perspective.

    One area where I certainly agree with you is on the disparity in prices per procedure and per brand name drug between the U.S. and Europe and Canada. Standard chemical based drugs, as opposed to biologics, have an extremely low (often pennies) marginal cost to manufacture. Drug companies that go along with price controls in other countries add to their profits while, in effect, forcing Americans to shoulder the lion’s share of their R&D costs. I don’t support price controls, but I do support limited formularies and tiering which we have. Some 75% of prescriptions are already generics, which are actually cheaper it the U.S., and Lipitor, the biggest seller, is about to go off patent with Plavix the 2nd biggest seller losing patent protection in 2012.

    Hospital charges are also much higher in the U.S. but so are their costs. The number of employees per licensed bed is considerably higher for reasons I don’t fully understand. Perhaps you could shed some light on that.

    Doctors also earn considerably more in the U.S. vs. their European counterparts. Aside from the issue of medical school debt, the opportunity cost of earnings in other lucrative fields such as business and finance is much higher in the U.S. than in Europe. While many doctors may happily work for half what they could earn in the business and finance worlds, they won’t work for 10% or 20% as much.

    I think we would be better served if we attack healthcare utilization through such as strategies as robust price and quality transparency tools, tiered insurance products, safe harbor protection from failure to diagnose lawsuits for doctors who follow evidence based guidelines where they exist, and a much more sensible approach to end of life care along the lines of the approach followed by the Gundersen Lutheran Health System based in LaCrosse, WI, A serious attack on fraud and fewer unnecessary back surgeries and cardiac stenting would also be helpful.

  13. You can take a wealthy African American male and live his entire life in Japan he still won’t have Japanese genetics or life expectancy.

    [comment: jeffrey harris] Actually his blood pressure will be quire lower and he won’t suffer the consequences of end organ damage from that disease.

    BETHESDA, Md., Oct 28 2011– African-Americans with two copies of the APOL1 gene have about a 4 percent lifetime risk of developing a form of kidney disease, according to scientists at the National Institutes of Health. The finding brings scientists closer to understanding why African-Americans are four times more likely to develop kidney failure than whites, as they reported in the Oct. 13 online edition of the Journal of the American Society of Nephrology.

    If the stroke doesn’t get ya the Kidney’s will, can’t run from your genetics. This sickle cell and numerous other race specific illnesses raise the question how can you compare life expectancy of Americans to Europeans and Asians and not adjust for race?

    “I was referring to the fact that disparities research proves”

    No, disparities research argues access to care relates to income which drives the majority of the loss in years of life. Its a theory like all the other bogus academic theories derived by academics who have never worked a day in the field in their life. Just because poor people suffer from X more does mean poverty causes X, all the disparity research in the world will never prove that.

    “[comment: jeffrey harris] Um, I am referring to literature published by the NIH, UNC School of Public Health, Duke metabolism and nutrition program etc.”

    This comment;

    “I can’t believe someone would point to race and minority as an issue regarding our healthcare cost burden.”

    Sure appears to dismiss genetics in favor of the poor oppresed masses 99% argument. Genetics matter far more then income and access to care.

    “why would you bring them up to begin with if you had issues with their ability to fulfill commitments. ”

    ???? Um I didn’t bring them up.

    ” I fear that you may not believe in the holocaust.”

    Thats a desperate attempt to save face when you have been terribly discredited. Name one fact I was wrong on. I can back up everything I said.

    “But even this lower ratio continues to reflect the fact that the Census data’s top “quintile” is seriously overpopulated, while the bottom is underpopulated. Once the quintiles are adjusted to contain equal numbers of persons, the ratio of incomes of the top to the bottom quintile drops to $4.23 to $1.00 (as shown in Chart 4). Moreover, even this difference is due in large part to the fact that working age adults in the top quintile work twice as many hours as those in the bottom. If such adults worked the same number of hours, the income ratio would fall to around $3.07 to $1.00.”

    http://www.physorg.com/news/2011-01-shorten-lifespans.html

    Over the past 25 years, life expectancy after 50 has risen in the United States, but at a slower rate than in countries like Japan and Australia, said the National Academy of Sciences report.

    The gap sounded the alarm among government researchers because the United States spends more on health care than any other country, said the study which examined mortality records in 21 countries.

    Men in the US showed an increase in life expectancy of 5.5 five years between 1980 and 2006 for an average lifespan of 75.64 years, while US women’s lifespans expanded from 77.5 to 80.7 years.

    “Three to five decades ago, smoking was much more widespread in the US than in Europe or Japan, and the health consequences are still playing out in today’s mortality rates,” said the report.

    “Smoking appears to be responsible for a good deal of the differences in life expectancy, especially for women.”

    Cigarette smoking also appears to have dented life expectancy in Denmark and the Netherlands, the report said, noting those two nations showed “lower life expectancy trends than comparable high-income countries.”

    I’ll be embarrased when you find a single error in my post.

  14. Thanks Bill, I agree with you. Actually their are some good examples of redesign. I point you to Ezekiel J. Emanuel (Author) Healthcare, Guaranteed: A Simple, Secure Solution for America available on Amazon or Kindle.

    Certainly we are speaking of a social paradigm shift.
    To start with physicians will be paid FFS and have a health outcome component as a kicker. See the NCQA Bridges to Excellence Program and CMS pay for performance models.
    Unfortunately we still need to work on human motivation due to the tremendous issues with patient compliance.

    It is heartening to hear your comment though.

  15. Here is the new reply:
    “I can’t believe someone would point to race and minority as an issue regarding our healthcare cost burden.” I can’t believe someone would pretend to have an intellectual conversation then jump up screaming as soon as the FACT that genetics matter in life expectancy.

    [comment: jeffrey harris] I was not referring to genetics, I was referring to the fact that disparities research proves access to care and its attendant proportionality to quality adjusted life years relates to income regardless of race and ethnicity.

    You can take a wealthy African American male and live his entire life in Japan he still won’t have Japanese genetics or life expectancy.

    [comment: jeffrey harris] Actually his blood pressure will be quire lower and he won’t suffer the consequences of end organ damage from that disease.

    This isn’t middle school science class, if you can’t accept the basic scientific fact that we are not all created equal genetically there is no sense trying to discuss this with you.

    [comment: jeffrey harris] Um, I am referring to literature published by the NIH, UNC School of Public Health, Duke metabolism and nutrition program etc.

    Shocker, races have different predispositions, certain Jewish heritages are prone to illness few others are, African Americans are predisposed to certain ailments. “I have personally met and presented to executives at Wellpoint and admire their commitment to prevention.” I bet you loved Obama and his ability to read off a teleprompter as well. Have you spoken to any of Wellpoint’s clients on how those commitments are manifesting?[

    comment: jeffrey harris] Well Point has had significant changes in management leadership and why would you bring them up to begin with if you had issues with their ability to fulfill commitments.

    “Not whether or not we have treatments. What we have is disparity in access to treatment as a result of unequal distribution of resources” This is present in every country and has very little impact on outcomes.

    [comment: jeffrey harris] (Huh???)

    Personal choices are far greater issue then unavailability. If we gave away free PSAs to everyman most would still not take it. Access is a red herring of those provoking government assumption of healthcare. “does that mean if you are in poverty you should die early?” That you should die early, no it does not. That you will likely die early, yes it does. Poverty is usually the result of poor decisions and those decisions are in financial matters as well as health.

    [comment: jeffrey harris] I know like the legacy of dependency we have created with entitlements thereby creating a class of poverty.

    “countries with equal access have better health outcomes regardless of economic status.” BS, not true in the macro at all.US leads the world in many health outcomes. Anyone claiming what you just did doesn’t understand proper scientific analysis, i.e. your bogus life expectancy claims. For more bogus beliefs I bet you subscribe to let’s talk premature births, that’s another red herring of those that don’t know how to properly present data or compare disparate systems. Every race of people lives as long or longer in the US then they would in their native country, our minorities far outlive their native life expectancy. “If you look at the same WHO tables referenced above you will see this represented by the fact that our premature birth rates are high” That is because the WHO are quack academist who use different measures in different nations and don’t adjust for it. FYI if you measure temp in celsius in Europe and Fahrenheit in the US and don’t adjust you have meaningless comparisons. Go back and use the same reporting standards then tell me what your WHO data says. “everyone stop smoking (we smoke less than comparison countries)” How sheltered are you? We smoke less? Now but not until 1980s. Damage from smoking doesn’t disappear, all those people that smoked for 20-30 years are in their Medicare period and incurring claims. Again you have to know how to use data and properly adjust. You can’t look at today’s smoking rate and ignore 40 years of prior smoking. “exercise daily and take care of their families while working two $10 per hour jobs.” More complete BS, today’s poor work fewer hours then any time in measured history. “Perhaps we just don’t care and will let the trend escalate as is now to a two tier system of haves (1-3%) and have-not groups (97-99%).” Our have nots live better then the haves in almost every other country in the world. Our poor live better then the middle class of Europe. Bigger homes, more personal property, more comfort items like AC and cable. Most of the world dreams of being poor in America. “All I asked for at the beginning was for a group of us angry, polarized people to sit down and discuss the real data, information, and consider a compromise that will create access for all.” Start with real data and throw out the propaganda, our system provides care equal to any other system in the world and unlike almost every other developed system ours is sustainable. Once you start with the facts the solution becomes much easier. “Man ,what has happened to us.” Lazy people telling lies looking for free handouts. Classic case of the “homeless” guy at the intersection begging money before he goes home to his nice house. If you were working 70 hours and trying to provide for yourself you wouldn’t be poor, if you were born poor and worked that hard you wouldn’t stay poor. If you were a lazy bum working 10 hours a week once or twice a month claiming to be working so hard then a life of poverty not only awaits you but is deserved by you. These pathetic attempts at class warfare are going to blow up in your face. Sooner than later those that actually work and provide are going to get feed up with the parasites demanding more for nothing and stop supporting them.[

    comment: jeffrey harris] I can see that you have totally embarrassed yourself at this point so I don’t want to add any further comment on this post. I fear that you may not believe in the holocaust. Good luck in your life and I am sorry we couldn’t work through to an understanding.
    Take care bro

  16. All life is precious to the person but has a limited value to others. My biggest disappointment in all this is that no one is working on redesigning the model. We need to spin our thinking around to a place where health is the norm. As long as you keep paying while we are sick the incentive is to hold you between wellness and death. The perfect medicine could not be used in our society because it would end a large part of our healthcare industry and that tells me we have a deeper problem. The only solution I have ever heard was to pay the physicians or health professional when we are well and not pay them when we get sick then the motives are correct as they should be. That said there must be other ways or steps to accomplish this goal.

  17. “I can’t believe someone would point to race and minority as an issue regarding our healthcare cost burden.”

    I can’t believe someone would pretend to have an intellectual conversation then jump up screaming as soon as the FACT that genetics matter in life expectancy. You can take a wealthy African American male and live his entire life in Japan he still won’t have Japanese genetics or life expectancy. This isn’t middle school science class, if you can’t accept the basic scientific fact that we are not all created equal genetically there is no sense trying to discuss this with you. Shocker, races have different predispositions, certain Jewish heritages are prone to illness few others are, African Americans are predisposed to certain ailments.

    “I have personally met and presented to executives at Wellpoint and admire their commitment to prevention.”

    I bet you loved Obama and his ability to read off a teleprompter as well. Have you spoken to any of Wellpoint’s clients on how those commitments are manifesting?

    “Not whether or not we have treatments. What we have is disparity in access to treatment as a result of unequal distribution of resources”

    This is present in every country and has very little impact on outcomes. Personal choices are far greater issue then unavailability. If we gave away free PSAs to everyman most would still not take it. Access is a red herring of those provoking government assumption of healthcare.

    “does that mean if you are in poverty you should die early?”

    That you should die early, no it does not. That you will likely die early, yes it does. Poverty is usually the result of poor decisions and those decisions are in financial matters as well as health.

    “countries with equal access have better health outcomes regardless of economic status.”

    BS, not true in the macro at all. US leads the world in many health outcomes. Anyone claiming what you just did doesn’t understand proper scientific analysis, i.e. your bogus life expectancy claims. For more bogus beliefs I bet you subscribe to let’s talk premature births, that’s another red herring of those that don’t know how to properly present data or compare disparate systems.

    Every race of people lives as long or longer in the US then they would in their native country, our minorities far outlive their native life expectancy.

    “If you look at the same WHO tables referenced above you will see this represented by the fact that our premature birth rates are high”

    That is because the WHO are quack academist who use different measures in different nations and don’t adjust for it. FYI if you measure temp in celsius in Europe and Fahrenheit in the US and don’t adjust you have meaningless comparisons. Go back and use the same reporting standards then tell me what your WHO data says.

    “everyone stop smoking (we smoke less than comparison countries)”

    How sheltered are you? We smoke less? Now but not until 1980s. Damage from smoking doesn’t disappear, all those people that smoked for 20-30 years are in their Medicare period and incurring claims. Again you have to know how to use data and properly adjust. You can’t look at today’s smoking rate and ignore 40 years of prior smoking.

    “exercise daily and take care of their families while working two $10 per hour jobs.”

    More complete BS, today’s poor work fewer hours then any time in measured history.

    “Perhaps we just don’t care and will let the trend escalate as is now to a two tier system of haves (1-3%) and have-not groups (97-99%).”

    Our have nots live better then the haves in almost every other country in the world. Our poor live better then the middle class of Europe. Bigger homes, more personal property, more comfort items like AC and cable. Most of the world dreams of being poor in America.

    “All I asked for at the beginning was for a group of us angry, polarized people to sit down and discuss the real data, information, and consider a compromise that will create access for all.”

    Start with real data and throw out the propaganda, our system provides care equal to any other system in the world and unlike almost every other developed system ours is sustainable. Once you start with the facts the solution becomes much easier.

    “Man ,what has happened to us.”

    Lazy people telling lies looking for free handouts. Classic case of the “homeless” guy at the intersection begging money before he goes home to his nice house. If you were working 70 hours and trying to provide for yourself you wouldn’t be poor, if you were born poor and worked that hard you wouldn’t stay poor. If you were a lazy bum working 10 hours a week once or twice a month claiming to be working so hard then a life of poverty not only awaits you but is deserved by you. These pathetic attempts at class warfare are going to blow up in your face. Sooner than later those that actually work and provide are going to get feed up with the parasites demanding more for nothing and stop supporting them.

  18. 1. I can’t believe someone would point to race and minority as an issue regarding our healthcare cost burden. Please research your literature on disparities in access to preventive medicine you will find that the determinant is income. Not race. And if you head down that path I will show you some pictures of diabetic feet in a foot clinic where access was unavailable due to a lack of sufficient funding for the given county.
    2. I have personally met and presented to executives at Wellpoint and admire their commitment to prevention. Yes, chronic disease is to a large extent a result of secondary risk factors e.g. lifestyle. Not whether or not we have treatments. What we have is disparity in access to treatment as a result of unequal distribution of resources: More pictures and case studies if you want.
    ‘So we admit that socioeconomic factors are 20%, does that mean if you are in poverty you should die early?
    The point here is this: In contrast to the US: countries with equal access have better health outcomes regardless of economic status. If you look at the same WHO tables referenced above you will see this represented by the fact that our premature birth rates are high and lost well life years are far worse than other countries at roughly double the cost. If you look at the Dartmouth Atlas you will find that the density of physician sub-specialty is proportionate to expensive procedures e.g. CABG even when compared to geographic populations with identical prevalence rates.
    So here is the deal: You folks are correct: If we get rid of fast food, every one exercise 30 minutes per day at 80% of anaerobic threshold, everyone reduce LDL and eat whole foods, everyone stop smoking (we smoke less than comparison countries) our vital statistics will improve and procedures will decrease and less will be spent.
    However, procedural cost will continue to be double what it is in other countries. Why…because we have become accustomed to multiple points of ‘mark-up’ in the supply chain.
    Plans beat the heck out of providers for greater discounts and pass on their need for profit to employers who in exchange increase cost sharing to employees.
    So: We have a country where the disadvantaged are asked to shop at whole foods market, exercise daily and take care of their families while working two $10 per hour jobs. Of course, I am sure you will point out that this is their choice after five generations of entitlements (I agree and believe we need to engineer a way out of this system).
    So you see: Health is a combination of desire and ability to move into a higher socioeconomic status, reduce life style related risk factors and have the capacity to spend double the amount per invasive procedure as in any other country. Of course, now we have top executives going outside the US for these procedures to save $
    IMHO (and I am sure you know I am a poor, misinformed humble soul) Healthcare Access and cost is a symptom of a nation whose markets have become far too uninformed to know what a good return on investment is and how to rate quality. Perhaps we just don’t care and will let the trend escalate as is now to a two tier system of haves (1-3%) and have-not groups (97-99%).
    The result of complex reimbursement models and cost sharing is a shell game that is worse than looking at the window sticker on a car.
    And, as long as we can find a scapegoat e.g. Democrats (which I am not), Presidents ‘Obama), Minorities as stated by Nate, we can refrain from truly understanding the problem ourselves and let industry white papers explain our truth for us.
    Sad state for the fat, dumb and broke Americans that can not afford a movie let alone membership to a health club. And so the story goes at Animal Farm.
    All I asked for at the beginning was for a group of us angry, polarized people to sit down and discuss the real data, information, and consider a compromise that will create access for all.
    Our sick system of federal grants has created a dependency that need not be there to bring access to care to the masses. What is required is a factored analysis on cost benefit and cost effectiveness and what we consider as a society to be reasonable profit margins. No-one wants to go there as it means they might have to sacrifice something.
    It is too easy to point fingers as opposed to assuming responsibility for a broken country.
    Good luck to all: I am sure you can afford the best of care and will keep your elders tied to their ventilators while your families argue over their inheritance. Of course, those of you who have reproductive issues will certainly be able to afford your ‘in vitro’, select your genes and produce your stellar youth.
    Meanwhile the rest of us will work our 70 hour work weeks attending to the antibiotic resistant staph infections in the foot wounds of diabetic workers that wash your cars in their second jobs. Who cares, they don’t add that much social value anyway since they didn’t graduate high-school.
    So, what is a life worth?
    Income production (for you)-cost of treatment- cost of treating illnesses that would have never been treated had we not extended the life of the person with the original treatments (original Joseph Opatz book on health promotion from 1986).
    Suggested reading: Thomas Jefferson (any commentary on his concerns over industrial feudalism in America’s future.)
    Compassion: Who needs it as long as I have a good life?
    Man ,what has happened to us.

  19. Every time I hear someone try to make a connection between life expectancy and the quality and efficiency of our healthcare system, I cringe. Leonard Schaefer, a healthcare expert and former CEO of Wellpoint, in his 2007 Shattuck Lecture, told us that our population’s health status is determined 40% by personal behavior, 30% by genetics, 20% by socioeconomic status and environmental factors and only 10% by the quality of healthcare than one has access to. Just because life expectancy is relatively easy to measure doesn’t mean it has much to do with how good or cost-effective our (or any other) healthcare system is.

  20. http://repository.upenn.edu/cgi/viewcontent.cgi?article=1012&context=psc_working_papers

    Analysts often juxtapose the poor ranking of the United States in life expectancy and the very high percentage of its gross national product that is spent on health care. In 2007, the United States spent 16% of its GDP on health care, by far the highest fraction of any country (Congressional Budget Office 2007). The conclusion that is often drawn from this combination is that the United States’ health care system is extremely inefficient (e.g., Anderson and Frogner 2008).

    One recent study estimated that, if deaths attributable to smoking were eliminated, the ranking of US men in life expectancy at age 50 among 20 OECD 2 countries would improve from 14th to 9th, while US women would move from 18th to 7th (Preston, Glei, and Wilmoth 2009). Recent trends in obesity are also more adverse in the United States
    than in other developed countries (OECD 2008; Cutler, Glaeser, and Shapiro 2003).

    What lens are you viewing PPACA, the massive failure to be through?

  21. http://health.dailynewscentral.com/content/view/0002418/42/

    The primary cause of the disparities between racial and geographic groups is early death from chronic disease and injuries, an analysis of data from the Census Bureau and the National Center for Health Statistics showed.

    Asian-American women living in Bergen County, NJ, enjoy the greatest life expectancy in the US, at 91 years. American Indians in South Dakota have the worst, at 58 years.

    The differences were attributed to a combination of injuries and such preventable risk factors as smoking, alcohol, obesity, high blood pressure, elevated cholesterol, diet and physical inactivity — particularly among people from 15 years to 59 years of age. They were not due to income, insurance, infant mortality, AIDS or violence, said the study’s lead investigator, Christopher J.L. Murray, director of the Harvard Initiative for Global Health.

    Most public health initiatives target children and the elderly, he noted.

    The study looked at life expectancy by geographical areas as well. Hawaii led the 50 states and Washington, DC, with an average life span of 80 years, while DC trailed at 72 years.

    Personal choices could be more important than access to medical care in improving life expectancy, Dr. Murray noted. Half of the people who have high-blood pressure fail to get it controlled, two-thirds of those with high cholesterol do not get medication to lower it, and two-thirds of diabetics fail to manage the disease, in spite of the fact that 85 percent of the population overall has health insurance.

  22. What does life expectancy have to do with healthcare? If you want longer life expectancy drive fewer miles in cars, change your diet, and get rid of the minorities. From your listed sources I’ll assume you have never seen an analysis of life expectancy broken down by race? An asain in america lives just as long as they do in asia. A white european lives as long as a european. The reason the US has a lower life expectancy then the other nations is because of our considerably larger minority make up. When you correctly adjust the numbers the difference disappears.

    The % citizen vs % gov are just numbers, there is no point there. In an ideal world it would be 100% citizen and 0% government but I have a feeling thats not the point you were trying to make.

    If we repeal ObamaCare our healthcare system, with all of its flaws will be the last one standing. Some people, those on the left, are all for stealing from future generations to live beyound our means today. That only ends one way, collapse of governments and civilizations. Why would we choose to go down the same path Greece and the other PIDS did 30-40+ years ago, you only need pick up a paper to see the outcome.

    Or watch the OWS movement to see what failure will look like. Why choose a failed model?

  23. Nate, I have read your entries on this topic and find that in most cases I agree with you.
    I used the wrong descriptor when I said “address universal coverage”. If you check out my blog or slide share you will find a cause and effect diagram that points historical benchmarks when we did consider coverage e.g. WWII, Medicare/Medicaid in the 60s, The Nixon era, The Clinton era etc.

    I do stay informed on international healthcare trends through sources such as Health Affairs, The RWJ Foundation, The NIH and the WHO. Most importantly I do not pick and choose from countries that are socialist, communist, have universal coverage or not as this makes it far too easy to push conservative and liberal buttons thereby loosing the attention of my audience.

    I point to data so here are some examples:
    Economic Analysis in Clinical Research from the Division of Cancer Control and Population Sciences by Martin Brown Ph.D has a wonderful model for looking at the multivariate approach needed to address the value of health interventions

    The RWJ report Disparities in Health and Health Care among Medicare Beneficiaries A brief Report on the Dartmouth Atlas Project; authors Elliott S. Fisher, David C. Goodman and Amitach Chandra. .

    The most recent WHO annual report where the following stats are recorded
    Location Per capita cost % citizen cost % govt cost
    Belgium $5104 32 68
    Canada $4380 32 68
    Japan $3321 20 80
    Germany $4629 25 75
    UK $3285 17 83
    New Zealand $2634 20 80
    USA $7410 52 48

    By the way, we have lower life expectancy, lower functional status after 60
    and higher mortality per 1000 between 15 and 65.

    Our health reform act hits the benefits and insurance organizations hard. So if that is your lens I certainly understand.

    Peace,

  24. “If we look at the world we are the only society that did not address universal coverage in 1900.”

    We are one of the few countries that didn’t try Communism/Socialism. Fascism either, are you suggesting we give those a try?

    To correct your factual error yes we have addressed universal healthcare numerous times since 1900 and every time so far we as a nation decided we didn’t want such a system.

    It’s one thing for someone to champion and push a bad idea like universal healthcare, but to champion an idea that is failing all over the world….I’ll let you pick the adjective. Have you not read the news to see what is happening in UK, Greece, Italy, Portugal, Ireland, Spain.

    Once we get rid of Obama and undo his failed ideology history will show our lack of Universal Healthcare was one of the things that saved us from going to Slaughter like the PIGS.

  25. Agreed,
    This is a personal decision that communities must address.
    My point: WHO stats
    American healthcare cost per capita $7500
    English healthcare cost per capita $4000
    MRIs per 1M pop in USA = 26
    MRIs per 1M pop in England = 7 I believe

    Friends on both sides of pond are adding valuable science in fields of medicine and chemistry so all of the technology was not created here.

    What I believe we need is an open dialog on procedural cost, quality adjusted life years gained and how much society should contribute before we grow anymore livers in RTP. Or ventilate one more neonate with TOF.

    Instead, we charge ahead blindly, creating treatments that bankrupt our country due to a sense of self entitlement.

    Here is a better question for all of us:
    How much is the latest version of GEs finest scanner worth to society.
    How much is a physicians training worth. Should it be thought of as a multiple of lowest paid person in system of care or an open cash register such as it was prior to cost controls.

    If we look at the world we are the only society that did not address universal coverage in 1900. Somehow you guys call this socialism when it is not even a close comparison. After all, if that was the case 50% of our country is socialist already (all over 65).

    How about “communitarian capitalism”.
    Or
    We could just say we disagree and meet across the field from one-another and have a good old fashioned shoot-out.

  26. Wrong end of the telescope and the wrong denominator do not make it right to plunder from people that which is theirs for the benefit of unseen others favored by the politbureau.

  27. Sounds a bit angry to me. Surely you have others in your life who add value. I here your frustration.

    I have had diabetes for 45 years and had it not been for public assistance would not be here. My value is to my patients, their families, the numerous health systems I have contributed to and the old man at the supermarket that needed an extra $3.00 to complete his grocery transaction.

    The question is: Who are you, and what do you want. If you define your world by who and what makes you more successful, or less miserable I suggest you step into some charity work and try loving the unlovable.

    If this pisses you off, lets talk.

  28. My life is worth what I have it insured for. The lives of my wife and children are worth all I have. My mother and sisters and their families are self-sufficient.

    Anyone else’s life is worth regarding but not funding.

    There is no shortage of human life on this planet. It gets thrown away every day.

    Why would we want to pour money down a rathole that returns nothing?

  29. This fits very nicely with what I read on the right, though I mostly read Goodman, Suderman and a bunch of libertarians. The right wing writers actually knowledgeable about health care dance around end of life issues for the most part. That seems to be because the politicians are so eager to instill fears of govt rationing that they promise everything possible will be done at the end, satisfying the part of the base that actively wants no limits on end of life care. The health care pundits know that it is not economically feasible to do what the politicians suggest.

    Steve

  30. I am an ex-sailor and an ex-airman. About 1/4 of my 50 co-workers are ex-military. We reviewed this and liked it. I have had two bishops review it. They liked it. Yes, some religious people are offended by the blunt language. Just the right’s version of PC.

    Again, a single payer like the NHS was never seriously proposed or considered outside of Bernie Sanders.

    Steve

  31. so the constitution and equal protection only apply when you feel like using it as a tool to discriminate. Your perfectly ok with a guy today being held accountable for actions someone else engaged in hundreds of years ago. We all know how bias the left is its just nice to see you admit to it for a change.

  32. This “sexual discrimination” was initiated by the almighty in his infinite wisdom.
    All through history and through today, women everywhere have payed a high price for being the gender tasked with creating, carrying, delivering and raising babies, instead of being the gender that is taller, more muscular and better suited for hard labor (read Genesis).
    Women have been (and still are) abused,beaten, raped and exploited on a daily basis by men. For many years women have been treated like property, like second class citizens and those were the lucky ones. There is no full equality even today, even in the U.S.

    In view of all that, I find it hard to sympathize with the pain of a deadbeat male who is forced to partially support a child (not a woman). Though luck. Look at it as a form of affirmative action.

  33. except a women does, at her sole discreation a women can confiscate a portion of a mans labor for 18 years, a man has no equal right to subject a women to such a demand. There is no clearer example of sexual discrimination.

    A women can chose to give birth to a child the man does not want and then collect from the man for 18 years. Why can the man not collect from the women for 18 years is she aborts a child he does want?

  34. “If a women doesn’t want to get pregnant why don’t we demand she live a chaist life if thats how you feel”

    You don’t get to demand anything. A woman has complete jurisdiction over her body, and a man has complete jurisdiction over his body. This does not extend to the body of the man or woman either one has relations with.
    It doesn’t matter how much you twist things around. Men have no right to use women bodies without explicit consent in any way shape or form. And vice versa.

  35. What a shock, a liberal being nypocritical and not holding women to the same standard. If a women doesn’t want to get pregnant why don’t we demand she live a chaist life if thats how you feel.4

    Spin all you want margalit you can’t square a double standard. Your sexist, embrace it.

  36. Oh, I’m sorry, I thought you were advocating for “life”, but it seems that you want men to have the power to force women to have abortions so they don’t have to pay child support.

    There is a much easier solution for men who don’t want to support children, don’t you think? Or is that an infringement on your right to pursue happiness?

  37. its always easy to justify taking away someone else’s rights isn’t it?

    How does 9 months of giving birth even begin to compare to 18 years of labor? You can hire a women to give birth for you for a fraction of what 18 years of child support cost.

    What were you saying MG about conservatives not respecting individuals rights? Seems the left is equally as happy to deny individual rights.

  38. Nate, you are off on a tangent again. Ms. Sanger was also opposed to abortions and in spite her activism held what would be classified today as racist views.
    Planed Parenthood today should not be held responsible for its founder’s views anymore than the U.S. as a whole should be accused of blatant racism based on the fact that it was founded by white, racist slave owners.

    As to a man’s right to his own body, by all means, men should have complete discretion whether to abort, or keep, a fetus growing in their own bodies.
    Contributing one cell to the effort does not constitute “labor derived from his body” (labor??), and even if it did, this is not about rights to the fruits of one’s labor. It is about one’s physical body. Sorry, but men have no standing in this argument.

  39. You are also choosing to completely overlook is that the key proponent in promoting eugenics/forced sterilization was Harry Laughlin.

    Key by what measure? I could pick any number of progressives and say they were key.

  40. very complicated and one that mostly likley doesn’t have a solution either side would be happy with, but as of right now the male has no say over the labor derived from his body inspite of the left harping for 40 years about freedom of choice and doing with ones body as they please. In spite of the hypocracy of the left in this matter they are never confronted with it when they accuse conservatives of deny women control of their bodies.

    While there surly many conservatives with their hands in eugenics again the left was just of not more instrumental in it yet like everything else with liberals and the left they excape all calpability and blame. The ability of the left to project their short commings and to never be called to task for it is the only reason the ideology has not collapsed under its ignorance. In this regard the failure of communism, Stalinism, moaism etc was not they were any less sustainable then liberalism they just didn’t have anyone to blame their failures on.

  41. That is a slightly different argument and a complicated one without a clear and straight forward answer because it involves more than one person.

  42. Yes there was a definite element on the left at the time in the early 20th U.S. century who believed that using eugenics to sterilize people to reduce certain ‘undesirable elements’ out of the population was beneficial for the population as a whole and not harmful to those it was imposed on.

    Linking it to ‘feminism’ and elements it shared around controlling reproduction is really a stretch though. The reason forced sterilization was opposed by the Catholic Church at the time was not for the harm or taking away of personal liberties from individuals but that it stopped procreation.

    You are also choosing to completely overlook is that the key proponent in promoting eugenics/forced sterilization was Harry Laughlin. He was a virulent anti-Semite, anti-Catholic, anti-immigration opponent. Some of his most controversial ideas were readily adopted by Southern conservatives (overwhelmingly Democrats at the time) who were more than readily and willing to pass antimiscegenation laws and pass into laws regarding forced sterilization especially of African Americans in Southern states.

    Southern Democrats at the time hardily ‘progressive’ or liberal in any regards. They were generally ‘drys’ who were vehemently against alcohol consumption, almost entirely Protestant (mostly Baptist but also some Lutherans/Methodists/other off-shoots of Protestants), and had strong positions that were anti-Catholic & anti-immigration.

    There was a huge schism in the Democratic Party too in early 20th century U.S. politic between the ‘big city’ Democratic politicians in the Eastern seaboard and Midwest large cities and the rural voters in the South who were Democrats that had existed for years and years. They shared some ‘progressive’ ideas/policies together but the ‘big city’ Democrats were largely Catholic, recent immigrants from Southern & Eastern Europe, and weren’t that concerned with agricultural policies.

    It wasn’t until the New Deal coalition came together around Roosevelt in the ’32 election that they were finally able to largely get together behind a presidential candidate and vote for him in large numbers.

  43. “An individual’s choice with their body should be their own”

    So you also support a fathers right to decide if his child is aborted, you wouldn’t want to subject a man to 18 years of labor to pay for a child he didn’t want correct? Or do only women get control of their body in your argument?

  44. “yet time and time again ‘conservatives’ at their time in America tried to prevent this with the most horrific examples being the various practices of eugenics that predominated late 19th century/early 20th century American”

    “There are a few conservatives who are true libertarians and really believe in personal freedom & liberties. My experience in life though is that these people make up a limited minority in the modern conservative movement in America today.”

    My experience with Liberals is they are projectionist liars who blame all their personal faults on conservatives. Your Eugenics claim struck me as, how shall we say, BS, ya that sums it up pretty good.

    Lets see what the Democratic Underground has to say about eugenics, that bastion of conservatism it is.

    “It’s actually quite easy to describe who the most active critics of eugenics and birth control were. They were the same groups that now oppose legalized abortion–predominately religious conservatives: Catholic, Jewish and Protestant. Supporters of the eugenic and birth control movements of some eighty-plus years ago are equally easy to describe. They’re the same highly affluent, feminist, liberal and progressive people who are now the eager and vocal supporters of legalized abortion. There’s no question about that political divide. As we saw in Topic 7, during the first half of the twentieth century, the left regarded its support for eugenics with pride, as yet more evidence that it was more enlightened and progressive than its ‘reactionary’ and religious opponents.”

    Wait, what’s this planned parenthood was conservative before it was ultraliberal, who knew.

    “One of the most important developments in the expansion of eugenics was its relationship with feminism. The alliance between the two movements was a curious tangle from the very beginning, and remains a tangle today. Feminists and eugenicists had very different goals, but some of them agreed about some things that they wanted in the short run. The person who brought the two movements together in an alliance that has lasted to this day was Margaret Sanger, the founder of Planned Parenthood. Sanger was an eloquent writer, but Planned Parenthood has not made much of an effort to publish and distribute her books for the last 50 years. But if her followers did not want people reading her books, her opponents did. When the copyright on her books finally expired and it became legal for anyone to publish them, Planned Parenthood’s critics began to distribute her books, precisely because she was an eloquent eugenicist.”

    “The BBC is running an article on its news website on the legacy of the eugenics-inspired forced sterilisations carried out in North Carolina in the middle decades of the last century.

    It’s a powerful piece, which begins with an account of how a 13-year-old African-American girl was deemed to be ‘feeble-minded’ and sterilised after she was raped and made pregnant by a neighbour. There’s a fair bit of background on the eugenics movement, and it’s interesting stuff as far as it goes.

    There is, however, very little in the way of political context. The article might have mentioned, for example, that eugenics was a pet project of the American Progressive movement, the forebears of the modern liberal-left; or that one of the leading lights of eugenics was Margaret Sanger, who founded the organization that became Planned Parenthood and who remains a hero to liberals, and feminists in particular; or that North Carolina was run by Democrats during the period when forced sterilisation policies were in full swing, as were other southern states in which the practice was prevalent. If reporter Daniel Nasaw wanted to bring the story up to date he might even have written about how the racial aspect of eugenics and forced sterilization is perpetuated in the disproportionately high number of abortions of African-American babies.”

    So why is it MG I can’t find a single link to eugenics and conservatives?

  45. “My recolection on schaivo was it had everything to do with denying food and water and nothing to do with living wills. It was a very distinct argument about someone being able to naturally eat and drink but killing them by not providing it. Which was different then keepng someone alive with IV fluids and nourishment.

    Do you think people should be allowed to commit sucide that have no underlying health condition? Someone that can stay alive without the assistance of medicine wouldn’t they be commiting sucide if they just decided to stop eating and drinking water?

    Argument isn’t so clear then is it?”

    Absolutely not true. The whole Schiavo case stemmed from the fact that she didn’t have a living will made out. If she had, the wishes of her parents to keep her alive with assisted feeding/water really wouldn’t have mattered because they almost certainly would have had the case thrown out in court immediately or lost their suit easily. The Schiavo case stemmed around the fact that her husband’s wishes (and supposedly her wishes as conveyed to her husband) were in opposition to her parents about assisted feeding.

    Yes, I believe that someone should be allowed to commit suicide even if they have no underlying medical condition although the state should offer them resources and education to do their utmost to convince them to do otherwise.

    An individual’s choice with their body should be their own yet time and time again ‘conservatives’ at their time in America tried to prevent this with the most horrific examples being the various practices of eugenics that predominated late 19th century/early 20th century American life including the forced sterilization by the state of various categories of tends of thousands of individuals over the years and arguably the most horrendous court decision ever rendered by the Supreme Court (Buck v. Bell) which in ’27 essentially legalized eugenic sterilization by the state in the US until Skinner vs. Oklahoma in ’42 largely overturned it.

    There are a few conservatives who are true libertarians and really believe in personal freedom & liberties. My experience in life though is that these people make up a limited minority in the modern conservative movement in America today.

  46. I am thrilled that we are asking the difficult questions.

    I am a humanitarian, fiscal conservative with a deep commitment to diffusing and reiterating for the umpteenth time the interconnectedness of human-kind and the responsibility that comes with that reality. I also represent the values of compassion and tolerance; recognizing that each one of US is living out a reality defined by our physical and mental health, environment, experiences, hopes, fears, doubts and insecurities. My breadth of experience in healthcare really takes second place to my mission. It is one vehicle which has allowed me to appreciate how what we normally see as a compassionate, socially-centered industry without disparities has somehow achieved a very low score on the Worlds Stage. If you think of a water balloon as a visual, the last thirty years of my life have focused on how to assure care was in place for those who don’t thrive in society by applying pressure to the balloon at various points.

    I can remember being a young cardiovascular technologist having learned a brand new technique called 2D echocardiography performing the procedure on a 16 year old boy in an ICU at Dartmouth Mary Hitchcock Medical Center. The boy had what we call a ‘frog heart’ or single ventricle VS the two in a normal human heart. He would not have lived if it were not for the available technologies when he was a newborn and the multiple surgeries’ to follow over the first decade of his life. As he peacefully allowed me to perform my procedure and make videos of his heart a group of young cardiologists stood around his bed. Fascinated by ‘his case’ –the fact that he was still alive- they discussed his prognosis. I briefly looked down from my video monitor and realized the boy was silently weeping: I processed his and fear, felt the darkness of his life and wished I could throw up my hands and scream STOP.
    The changes in our healthcare industries business construct such as prospective payment and managed care coupled with a flood of disruptive technologies such as Extracorporeal Membrane Oxygenation (ECMO), recombinant DNA, CAT and MRI imaging and our sequencing of the human genome, where extremely important have changed my perspectives on the definition of life quality. If the payer (government or private) constricted cash flow in one sector such as hospitals we would simply invent an industry such as post-acute care and skilled nursing facilities; causing the balloon to expand on the opposite end. As a program administrator my challenge was to find new technologies that Medicare would pay for and rationalize how the early discharge of an unstable patient to a nursing home made sense. In 1996; my company flew me to NYC in our corporate plane to evaluate five patients whose last days were spent coupled to a mechanical ventilator and other life support devices. These individuals had been identified to have capital assets worth our CEO’s focus. When I returned to Boston with my case reports my CEO asked me to calculate the resource cost of moving and caring for each patient and then asked me “how long do you think this case will live Jeff?”…I left my work in the clinical world behind the following year and ‘remade’ myself to add some form of value using computers to help physicians and case manages make sound patient and family centered decisions.

    The next four years were spent designing a product that was acquired by a wealthy VC in New York who had kept our little start-up company alive while we developed, tested and deployed the technology. By the time we were granted our patent the VC acquired us through a stock trade with a dilution factor of 1000 to 1. The VC then formed a company to package services around the thought capital and sold his company for $465M to Aetna Insurance in 2004. The amazing thing is that his company was only booking $30M in revenue. Carol and I had moved to NC to work in Public Health where I formed a cross NC team to build a virtual, updateable and secure care plan for Medicaid recipients.
    In 2005 I received a check for $50K for my four years of product invention experience. In 2006 I was asked to take a dead-end job within State Government as it appears my lack of political correctness when it came to evaluating program efficiency had caused me to fall out of favor with the administration at the time.

    This experience served me well as I realized that humans were humans and I really needed to let go of my hopeful altruism.
    Venturing into the consulting field I traveled the US meeting all sorts of folks in both private and public sectors. In Connecticut I hooked up with three healthcare economists who had made their own fortunes in the industry. Over the next year we managed to bring a commercial insurance company and the Connecticut Academy of Family Practice to the same boardroom at the same time to discuss ideas on how to address the burden of overcrowded emergency-rooms and the cost of care associated with treating illness that should be handled within the lower-cost physician practice. I started our first meeting by asking each body about their business fears. For the first time in my life I saw senior executives take a risk by discussing their insecurities.

    When our project was complete the group continued to pay me to fly up to their homes and offices. At one point I asked why since I really wasn’t adding much besides an occasional discussion with the CAFP. Their response: “We like having you around as a healthcare resource and you add some other asset to our company that we need, yet can’t quite define.” We are still friends to this day and last year came to the conclusion that I provided a voice for the group and constantly reminded each of the necessity for system adaptability and financial sustainability. They are very active today as senior leaders trying to change the conscience of a sick industry. We commiserate a few times per year when one or more of us becomes hopeless.

    The greatest six months of my life were when I worked for my wife Carol in the Obama campaign. Suffice it to say that on any given day I would sit in a room of people ranging in age from 18 to 80 with a single mission. I was witness to numerous senior citizens with congestive heart failure performing labors of love for twelve hours per day. I assisted some with getting access to care as I measured the edema in their feet. I was up until 3AM every night using a brilliant statistical package that the campaign had invented to activate voters. I have never been so exhausted in my life and never been so content. On election night I had the joy of hugging the daughter of a share-cropper who had been born into slavery.

    When I reflect on those days I realize that I had no expectations for the new administration other than to stir things up a bit and make small progress toward reforming our healthcare system. Many of my friends from that time are frustrated with the compromise that our president has made along several key issues. I remind them that our ‘nirvana’ for one may not even be the correct ‘nirvana’ and that social adaptation requires generations. Herein lies the problem of our “society of addicts”, we all want a quick fix to our pain and don’t want to pay too high a price whether it be in cash, labor or simply listening to others with intent.

    What I fear today is that my Country is broken. We have somehow split into ‘sound-bite’ justified hateful clicks. The glaring irrational judgments of extremists on all sides of our political spectrum seem even sillier as each day arrives. I judge we now illustrate a classic tragic-comedy. I listen to historians speak of the rise and decline of social structures over the centuries as if our problem here in America is predestined (like Animal Farm) and we are in the transition stage. My sense is that this historical observation refers to our need for power. I believe if we continue to deny our mortality and fail to embrace our frailty the historians will be right and once again we have a self-fulfilling prophecy.

    I still have hope. I see the work your organization is doing and the cerebral light flickers. I see your introduction or perhaps re-introduction of philanthropy as a necessary behavior to achieve self-fulfillment. I see that you are redefining both philanthropy and success; making each available to whomever wishes to experience the reward regardless of social or financial status. I judge that NC Gives may have created a mechanism for people to once again realize how good it feels to have a heart. This very well might be the most important first step necessary for us to sit down and come to a set of common definitions regarding wants, needs and quality of life. This is a critical step as we make decisions regarding future investments in science and industry. You may in-fact have identified a way to get at the foundation of human society…a striping away of the power of acquisition and creation of a much more powerful force called generosity.

  47. Nate –

    It’s been an interesting and stimulating discussion about end of life care. I appreciate your contribution, along with that of Margalit and Steve. I took a look at Palin’s Facebook page on end of life care and all that comes across to me is a visceral distrust of government and a view that every patient should have complete access to any medical service, test, procedure or drug in our arsenal and that someone else (insurers or taxpayers) should have to pay for it. I don’t buy it.

    My take is that conservatives are coming at this debate from a perspective that seeks to maximize individual freedom and liberty and to minimize government interference in their lives. In the context of healthcare, my priorities are more in the direction of efficient utilization of resources to ensure that we can afford other worthwhile priorities both public and private. This means that treatments should be cost-effective and doctors should be able to apply common sense depending on circumstances without having to worry about being sued when patients themselves have not articulated in writing their end of life care wishes and priorities or appointed a surrogate who knows what they want and don’t want to act on their behalf if they can’t communicate.

    The people at Gundersen demonstrated that most people, when the treatment options, risks and benefits are laid out for them and a nurse draws them out on their individual values and priorities, choose more conservative care but by no means all. Those who want to throw everything modern science and technology has to offer at their medical issues and require taxpayers or insurers to pay for it can still do so.

    You didn’t address the issue of how to determine what’s paid for and not pay for. Do you really think we should pay for a long shot cancer treatment if it cost $5 million? How about $ 1 million or $500,000? Is $100,000 OK? The reality is that we have to set limits somehow as demand for services is potentially infinite or close to it. We can do it with QALY metrics. We can do it with age based rationing. Or, we can do it by an individual patient’s ability to pay.

  48. Well, this is very interesting. CMS guidance for E&M codes is that if during the visit over 50% of the time was spent on counseling, then you can calculate the E&M level based on time instead of complexity up to 60 minutes for a new patient and up to 40 minutes for an established patient. I think a diagnosis of liver cancer and Alzheimer’s should establish medical necessity just fine. You’d be shooting yourself in the foot if you reject a claim like that.

    Also since 2003 there is G0337 “Hospice Pre-Election Evaluation and Counseling Services”, which Medicare will also pay for, but that one is only for terminally ill patients with less than 6 months left to live.

  49. no, it would not meet the medical necessity test to treat an illness or injury nor fall under the new essential preventive benefits asw I know them, its something I could see an executive order or HHS dictate requiring but as of today now.

    if it was covered I wouldn’t even know where to begin. What would you reimburse it at? I would not want to pay the same rate for this as treatment that requires diagnosis and care which comes with liability.

    What liability will doctors have in giving these consultations?

    Should the individual have their attorney their?

    This is as bad as the new independent review rules that are comming out

    Why would a doctor not bill this every time they treated a patient with a new condition or every new patient? Can you imagine how much billing abuse this could generate!

  50. wow your more the typical liberal then I guessed, So you will attack her and other conservatives for their opinion without ever bothering to actually learn what those opinions are?

    Your exact words;

    “I haven’t heard them say something like,”

    ” It would be helpful, though, if they stated what they would support in its place. Maybe I’ve been looking in the wrong place but I haven’t seen or heard anything from conservatives on how to vastly expand the percentage of the elderly population especially that has made its wishes known in writing to medical providers and family members. The CMS proposal is an attempt to do just that. A constructive alternative that would get the job done would be useful. Where is it?”

    They do, your just to lasy and bias to go read it. Her facebook page specifically answers the questions you have yet you rather mischaracterize their beliefs and attack them then take the time to learn the truth.

  51. “If the government says it has to control health-care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending.”

    That’s not the goal at Gundersen Lutheran but it turns out to be a favorable by-product of their process as end of life care costs are 30% below the national average. Their process does not rely on the patient to initiate the end of life care discussion either. They’re proactive on the matter and it works.

  52. Nate –

    No, I’ve never read Palin’s Facebook page, nor do I have much interest in doing so. She’s not running for President and, even if she were, I don’t view her as presidential timber and wouldn’t vote for her. I am interested in what, if anything, Romney, Perry, Cain, Gingrich and Huntsman have to say but I haven’t explored that (yet) either. It’s too early in the 2012 election process.

    On executing living wills and advance directives, I think people should do it while they’re healthy but I recognize that they could easily think differently about the subject when faced with a terminal illness. If they can still communicate and understand what’s being said, they can execute a new set of instructions then if they choose to.

    I think we need to find ways to drastically increase the percentage of people who have expressed their end of life care wishes in writing. It would be fine with me if nursing homes and assisted living centers required these either upon admission or very shortly thereafter, at least if the patient is still capable to do so. Oncologists could view it as standard practice to initiate this discussion very early in their relationship with the patient. Primary care doctors and cardiologists could do so as well. Personally, I think it’s unethical for patients, especially the elderly, to leave this issue unaddressed knowing that the default protocol is to “do everything” whether the patient actually wants that approach or not. To have 70%-75% of the population not having thought through end of life issues and put their wishes in writing is unacceptable. We can’t afford to wait for patients and families to initiate the process when so many just don’t want to face up to it because it’s uncomfortable for many of them.

    Finally, with respect to the UK’s NICE, you know better than anyone that insurers, whether public or private, can’t afford to cover everything and they need some rational basis for determining what won’t be covered. I think a QALY approach is reasonable. Preventive services that science shows are either ineffective, do more harm than good or help too few people relative to the number treated should also not be covered. People who want those can self-pay.

  53. “In my opinion its something that has no business being covered by insurance.”

    I understand, but if you get a claim from a physician with a 99215 for a 197.7 and a 331.0 to top it off, with a note saying:
    “A total of 60 minutes of a 60 minute visit was spent counseling the patient about end of life choices”, will you pay it in full?

  54. it gets cloudy, depending who is involved you could get into a question rather it is group or individual and who do you bill. In my opinion its something that has no business being covered by insurance.

    Ideally these decisions are made while one is healthy, if you wait till your under deress of illness your already clouding the decision. Further a husband and wife, or wife and wife, or husband and husband or wife wife wife husband should do it together. They shouldn’t be secerts, your family should know what your wishes are. So if the entire family sits down to write them who’s insurance do you bill? Who’s doctor do you invite? If your religious do you invite your pastor? Which doctor do you do it with, your oncologist or your primary care?

    A point the public seems to forget is the PPACA proposal didn’t only offer to pay if a patient requested it. It called for doctors to initate it and to pay them for performing it. Even Democrats had issue with this. Same bill your psuhing ACOs and reducing cost your paying doctors to advise people on when to call it quits on treatment? That part didn’t seem to get mentioned much by the media.

    So are these usually friendly pundits wrong? Is this all just a “rumor” to be “disposed of”, as President Obama says? Not according to Democratic New York State Senator Ruben Diaz, Chairman of the New York State Senate Aging Committee, who writes:

    Section 1233 of House Resolution 3200 puts our senior citizens on a slippery slope and may diminish respect for the inherent dignity of each of their lives…. It is egregious to consider that any senior citizen … should be placed in a situation where he or she would feel pressured to save the government money by dying a little sooner than he or she otherwise would, be required to be counseled about the supposed benefits of killing oneself, or be encouraged to sign any end of life directives that they would not otherwise sign. [9]

    Even columnist Eugene Robinson, a self-described “true believer” who “will almost certainly support” “whatever reform package finally emerges”, agrees that “If the government says it has to control health-care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending.” [8]

    As Lane also points out:

    Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren’t quite “purely voluntary,” as Rep. Sander M. Levin (D-Mich.) asserts. To me, “purely voluntary” means “not unless the patient requests one.” Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that’s an incentive to insist.

    Patients may refuse without penalty, but many will bow to white-coated authority. Once they’re in the meeting, the bill does permit “formulation” of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would “place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign,” I don’t think he’s being realistic. [7]

  55. Barry, have you ever read Palin’s actual facebook page on the subject? I’m curious how the arguments you make derive from her actual comments. THe more you talk the more you seem to agree with her.

  56. I don’t know why CMS felt it to be necessary to single one type of counseling out and this is exactly why I question this entire exercise. I don’t believe any insurer, including a public one, has any right to dictate or steer the contents of conversations between doctors and patients, which should be private.

    The way I understand it, counseling is counseling and it will be paid if coded correctly, but I will defer to Nate on this one.

  57. It’s unfortunate but America in general allows our opinions to be feed to us. Most people have a very strong opinion of people like Sarah Palin yet have never heard a single word of hers not edited by the Media.

    Do a search for Alaska Healthcare Decision Day, and it will completely clear your confusion on this matter. Hopefully you will become more confused how you could not have known about this yet held such strong opinions against a group of people then hopefully you will start to question what else has been withheld from you to frame your opinion of groups the media doesn’t want you to know about or give thought to. Notice if you go to the liberal sites how they just can’t grasp the difference between the government pushing these discussions and people having them independently. You’re not alone in your bias nor the most vitriol. At least you seem more open than most to considering you might be missing something.

    From Palin’s proclamation, yes Palin said exactly what you haven’t heard, almost every conservative says the same thing, your just not being told the full story by your choice of Media sources.

    WHEREAS, Healthcare Decisions Day is designed to raise public awareness of the need to plan ahead for healthcare decisions, related to end of life care and medical decision-making whenever patients are unable to speak for themselves and to encourage the specific use of advance directives to communicate these important healthcare decisions. […]
    WHEREAS, one of the principal goals of Healthcare Decisions Day is to encourage hospitals, nursing homes, assisted living facilities, continuing care retirement communities, and hospices to participate in a statewide effort to provide clear and consistent information to the public about advance directives, as well as to encourage medical professionals and lawyers to volunteer their time and efforts to improve public knowledge and increase the number of Alaska’s citizens with advance directives.
    WHEREAS, the Foundation for End of Life Care in Juneau, Alaska, and other organizations throughout the United States have endorsed this event and are committed to educating the public about the importance of discussing healthcare choices and executing advance directives.

  58. http://www.telegraph.co.uk/comment/columnists/janetdaley/7883381/Copying-the-NHS-is-the-last-thing-the-US-should-do.html

    The US government, meanwhile, is galloping doggedly in the opposite direction, bizarrely determined to occupy precisely the ideological ground which Britain is abandoning. Barack Obama has, indeed, appointed a man as head of the American public health care programmes who professes a passion (no other word will do) for some of the most discredited features of our NHS. Dr Donald Berwick is to head the Centers for Medicare and Medicaid Services, which effectively means that he will be in charge of Obamacare – the new universal health care system on which the President has staked his political credibility.

    Seems the concern about Obama and NHS crosses the pond. Many of people see parts of NHS appearing in Obama’s reforms, and not the good parts

  59. Better yet Steve why not talk to a few soliders, sailors, airman and see what they think of it. Do all or most of them have a problem with it, no but enough do that it was revised. Most of the book is fine but it only takes 1-2 pages to turn it from a non bias resource to a proponet of Euthanasia.

    page 21 and 25 of the old version were the most mentioned pages. Why was an advocate of assisted sucide one of the main drafters but the chaplins left out until soliders complained?

    In regards to item 2 this is the difference between government dictate and private choice. Did you see that Barry, government! If you don’t like the Catholic doctrin and want to die they will transfer you to a facility that will withhold food and water. When the government makes the rules individuals lose choice. Does it matter if you starve to death in a Catholic Hospital or in another facility or at home ideally?

    What models are on the table? Are you saying no one in power now looks to the NHS for influence? No one in power has suggested we mnodel the NHS?

    A case in point involves a proposal put forth by Obama’s “health care czar,” Tom Daschle. It is unlikely that many of the President-elect’s supporters realize that Tom Daschle advocates the creation of a federal health care bureaucracy whose decrees will supersede the judgment and decisions of physicians and their patients. This “Federal Health Board,” as Daschle refers to his proposed behemoth, would be modeled on Great Britain’s National Institute for Health and Clinical Excellence (NICE). In the UK’s socialized medical system, NICE is the bureaucracy responsible for determining the value and effectiveness of medical treatments and procedures.

    If you want to split hairs you could argue NICE is not exactly NHS but they are the system over there.

    seems when you break it down to specifics there are lots of valid concerns that should be discussed before we rush head first into govertnment imposed end of life planning, what is the left afraid of having these discussions?

  60. Nate –

    I think you may be right when you suggest that I don’t get it.

    First, I agree that most people should be able to afford end of life counseling. I’ve thought about the subject a lot and probably wouldn’t need a session at all beyond a doctor laying out treatment options and the risks and benefits of each. Others may need several hours of discussion from a team (doctor, nurse, social worker, etc.) before feeling comfortable making a decision. That could easily cost hundreds of dollars which many people might not be able to afford.

    Where I’m most confused is the following: When I hear Sarah Palin and others speak of “death panels,” my take is that they don’t want any part of Medicare paying for end of life discussions. I haven’t heard them say something like, we’re against Medicare paying for end of life discussions for the following reasons but we think people should make their wishes known to providers and family members so here’s what we support and here’s how it could be accomplished. They may be perfectly comfortable with the Gundersen Lutheran model but other institutions and systems that are more financially stressed might need to be specifically paid for the effort.

    Normally, private insurers feel more comfortable when CMS provides leadership and associated political cover in making payment decisions, especially when the decision is to NOT cover and pay for a service, test, procedure or drug. Something like end of life discussions, though, could easily be covered by private insurers whether Medicare covers them or not. Would it be OK by you if Medicare Advantage plans cover those services but standard Medicare doesn’t?

    It’s easy for interest groups to articulate what they oppose and to try to prevent it from happening. It would be helpful, though, if they stated what they would support in its place. Maybe I’ve been looking in the wrong place but I haven’t seen or heard anything from conservatives on how to vastly expand the percentage of the elderly population especially that has made its wishes known in writing to medical providers and family members. The CMS proposal is an attempt to do just that. A constructive alternative that would get the job done would be useful. Where is it?

    Margalit –

    If E&M codes will pay for these services, why did CMS find it necessary to propose to specifically pay for end of life counseling sessions every five years? While physician time may be covered through an E&M code, what about nurse and social worker time which is really the majority of the time spent, at least with the Gundersen Lutheran model?

  61. Did you ever read the VA book? I linked to it below. I have read it several times. Please tell me what is disagreeable. It goes out of its way to provide different POVs. It mostly emphasizes talking it out with family and deciding what you really want. I think it is exactly what we should be telling people.

    Steve

  62. Barry, all E&M codes can be used for counseling, in which case the visit is coded by time spent instead of complexity. All the provider needs to do is state that X number of minutes were used for counseling for Y subject, and he/she will be paid according to time spent, up to 1 hour per code.

  63. “Conservatives view government as an entity whose sole concern is to defend the rights of property.”

    replace property with
    freedoms
    rights
    liberty
    and your close

    “Liberals view government elected by the people as the embodiment of the wishes of the people”

    And thats why they are always trying to subvert it?

  64. we are being compared to the UK all the time when people complain about cost. How can we say our cost should be more like the UK if we aren’t willing to adapt the same limitations? No industrialized nation is like us, thus are all complaints about our cost illrelavant?

    If families in the US took care of our elders like they do in Japan we would spend a fraction of what we do on nursing homes and long term care.

    The cancer guy didn’t die from pneumonia or a misdiagnosis he died because they with held food and water from him and kept in sidated. There is no comparision to killing someone via dihydration and misdiagnosis

    Can you point to one example of a conservative ever objecting to the Gundersen Lutheran model? The argument is you attacked conservatives for your lack of understanding of their beliefs and arguments. You can’t defend your argument by replacing the government proposals with one conservatives haven’t objected to. Are you still not ready to admit you were wrong and conservatives have valid concerns about the governments roll in end of life? Conservatives, in the broad sense you refer to them, object to government in end of life decisions unless there are clear and upfront limits and protections. Your painting their argument any other way is dishonest.

    Who can’t afford $40 for an end of life consultation? This i9s BS. There is no reason to insure a benefit 95% of the population can afford, your inviting abuse and problems by doing so.

    “you deplore the potential to guide families toward undertreatment in order to save money ”

    Are you this dishonest in debate or do you just not get it?

    Government, government, government take government out and I support it 100%. How many times do I have to say government before you stop leaving it out of your framing of my argument?

  65. Margalit –

    The reason end of life counseling needs to be authorized for payment is because much of the work as measured by time spent is done by specially trained nurses and social workers. If you watch the Religion and Ethics News Weekly segment on living wills and advance directives, you will see that it’s a nurse that’s leading the discussion with the patient and his family. While doctors can and should be involved as well, appropriately trained nurses can lay out treatment options, in consultation with the doc, as well as likely side effects and their potential impact on the quality of life. They also try to draw the patient out regarding their values and priorities and how they would most prefer to spend their remaining time. These are generally not 10 or 20 minute talks. They can easily take a number of hours over more than one visit. There needs to be a billing code to reimburse that time. Right now, there isn’t as far as I know. At Gundersen, their doctors are salaried and the organization made a commitment to push end of life discussions whether they are specifically reimbursed for it or not. I applaud them for that but other institutions may not be as able to do it without being reimbursed for the time and effort.

    Also, it’s not unusual for a patient’s view of end of life care that was articulated when he was perfectly healthy to change, at least somewhat, when actually faced with a terminal illness or condition. So even if documents were executed years earlier, it’s good to review the matter when the end is near for patients who can still communicate and understand what’s being said. For those who can’t communicate, any wishes expressed earlier will provide guidance that’s a heck of a lot better than nothing.

  66. Oh no, the receipt is not dreamed by a liberal, unless it was a harrowing nightmare, equal in magnitude to that efficient link to federal and state taxes.
    I thought we have gotten over this particular disgrace many years ago, but I guess not… Either way, thanks for the clarification.

  67. ” It did not tell people what to say.”

    Who does tell people what to say?

    Same people that wrote the book for the VA?

    LPC didn’t tell people who to deny coverage to, it just laid the frame work

    You don’t have a problem with the language in the Obama VA book? Is that how you think we should be advising people?

  68. The broader issue with creating standards and regulations for treatment is that everything we can say about treatments and disease is always prepended by the word “probably”. It is impossible to standardize what we don’t know and it is impossible to adjust regulatory language to reflect the statistical nature of the little that we think we know at any given time.
    This is why it would be better to leave these, necessarily one off, decisions to those affected and those who care for them.

    I support advance directives and conversations of all types between patients and physicians. I don’t understand why CMS needs to single this particular subject out for separate payment. It should be part of routine care and I think the mentality that you need to pay doctors to do the right thing, as defined by current government flavor, is just wrong and to a large degree offensive to both doctors and patients.
    I think I mentioned this before, but how would liberals react if President Bush would have decided to pay doctors extra for a pre-abortion “conversation”? Not forcing anyone to do anything… Just pay if it takes place. Very innocent, no?

    As to conservatives having it both ways, I don’t think this is true. Liberals view government elected by the people as the embodiment of the wishes of the people, and as such it is empowered to make decisions for the people. Conservatives view government as an entity whose sole concern is to defend the rights of property.
    Therefore when it comes to health care, government has no standing. The only entity entitled to make health care decisions is one’s property. And this by definition will eliminate overspending by the masses.

  69. We need to remember that the default is do everything. If there is no discussion, everything will be done. The ACA only paid for end of life counseling. It did not tell people what to say. If you want to assert that physicians are going to start killing people because they are getting paid to discuss end of life decisions, make that argument.

    Steve

  70. 1) Everyone should read Your Choice, Your Life at teh link so you can what Nate and that F***ing A**hole Towey are talking about. It is about as even handed as you get. It asks people to talk over what they want and to define terms so that the family will know what to do. (thanks to people like Towey I get to torture old people to death at night when I am on call)

    http://www.rihlp.org/pubs/Your_life_your_choices.pdf

    2)Catholic thought on end of life issues is a bit mixed. In general, it does not require extraordinary care. It does seem to require hydration and feeding, sometimes by what one would consider extraordinary means, even when against that person’s wishes. Have had power outages and cannot get to main archive, but this brief article discusses some of it, and yu can Google it.

    http://www.newjerseynewsroom.com/healthquest/when-end-of-life-conflicts-with-catholic-church

    3) The NHS model has never been on the table for this country. If you want to offer examples of medical errors, this country has its share also, and more based upon over aggressive care.

    Steve

  71. My recolection on schaivo was it had everything to do with denying food and water and nothing to do with living wills. It was a very distinct argument about someone being able to naturally eat and drink but killing them by not providing it. Which was different then keepng someone alive with IV fluids and nourishment.

    Do you think people should be allowed to commit sucide that have no underlying health condition? Someone that can stay alive without the assistance of medicine wouldn’t they be commiting sucide if they just decided to stop eating and drinking water?

    Argument isn’t so clear then is it?

  72. in regards to war your forgetting those that pay for it, those that labor to support it, and the families of those that fight it. War affects all of a society, at least it should.

    A receipt sounds like a system dreamed up by a liberal so they can corrupt it. I think an easier and safer system would be to have registration linked to your state and federal taxes. We can fix our corrupt voting process at the same time.

  73. Off hand Nate I would need to look but I remember it was brought up predominantly in the Schiavo case back in ’05 and all of the nonsense that occurred at that time regarding the issue of living wills.

    Schiavo didn’t have a recorded living will but there was some vehement opposition from various social conservatives at the time regarding the concept of a living will that allowed people to choose termination (death) instead of doing the absolute maxim to preserve life.

    It is the same people who oppose any aspect of the ‘right-to-die’ movement or are still working to overturn laws like the ‘Death with Dignity Act’ in Oregon today.

    While I would agree that it is not a majority-held belief though (mainly because evangelicals are a minority in this country), these aren’t fringe groups or very extreme minorities either. Same groups of people generally who espouse ‘individual liberties/freedoms’ and are only more than happy to use the gov’t bully pulpit to legislate their view on morals & ethics on select issues even if their views clearly reflect a minority opinion.

    You still see a number of cases that pop up at various state levels where an individual has made a living will that relatives/care givers try to over turn especially in cases where the person is incapacitated physically/mentally.

  74. Whatever the reason, people that do not pay taxes, either because their incomes are judged too low by current tax law, or because they choose to evade taxes, or whatever… (minors cannot vote)

    Should a receipt from the IRS be required to vote?

  75. “Voting should not be an opportunity to inflict expense or obligations on others you are immune from.”

    And does this mean that only military personnel, and those eligible for the draft, should be allowed to vote on going to war?

  76. What’s no money to pay taxes? Is that becuase their cell phone and cable bill are to high? Or after buying cigs and the weekly 6 pack they just can’t afford to contribute?

    There is no such thing as not enough money to pay taxes. Unless your underage or disabled there is money to pay taxes

  77. Nate –

    I’ll offer a few thoughts here.

    First, I don’t think comparisons to the NHS and stories that happened in the UK are as relevant to the U.S. as you suggest. The UK society long ago made a political decision to spend a considerably smaller share of its GDP on healthcare than even its Western European neighbors let alone the U.S. The U.S. will always spend far more on healthcare than the UK does and probably considerably more than Western Europe and Canada as well. The differences are more cultural than economic, I think.

    Second, the case of the cancer patient who turned out to have pneumonia but died because doctors thought the cancer returned when it didn’t was a serious medical error that probably could happen anywhere. In the U.S., by contrast, we have people who are diagnosed with early stage prostate cancer, progress to treatment and die of complications or suffer serious lasting side effects like impotence or incontinence when their cancer probably never would have progressed to the point where it caused harm. Overtreatment can be as bad and pernicious as undertreatment.

    I don’t know about the VA experience specifically but the Gundersen Lutheran process seems to work very well for patients, their families and the healthcare system generally. It can be replicated fairly easily by other healthcare systems that choose to make the commitment to a similar approach. There are no guarantees in life, but I, for one, would be perfectly willing to live with a Gundersen-like model for myself and my family and I would support allowing CMS to pay for the end of life consults though I could personally easily afford to pay for my own if I needed to. Many people can’t though.

    Finally, you seem to suggest that conservatives want to have it both ways. On the one hand, you deplore the potential to guide families toward undertreatment in order to save money for the broader system. On the other hand, conservatives are vehemently opposed to higher taxes that would be needed to support a system that was biased toward too much treatment rather than too little. I make this comment as one with a very strong free market bias in most areas of commerce.

  78. Does this only apply to “hermits”, or does it also apply to people who are engaged in the community, whatever that means, but have no money to pay taxes?
    Should a receipt from the IRS be required to vote?
    Should votes be weighted based on the amount on that receipt?

  79. how are you defining property? If you mean someone that doesn’t own real estate no I am not saying anything like that. If you mean the broader legal definition do I think a hermit who doesn’t work, live within the community, or engage as part of society should be allowed to come in and vote to raise taxes to support hermits no I don’t. Voting should not be an opportunity to inflict expense or obligations on others you are immune from.

    Equal protection, forgotten part of our constitution is fundamental to a sustainable society for a reason. As soon as people learn they can vote their obligations onto others, hello OWS free college crowd, they will endeavor to do so. This goes on long enough and soon people are living as babies in diapers on the public dime.

  80. Theory is one thing and real life is another.

    Do you really believe that the ONLY thing affecting people’s financial status is choices THEY MADE?
    Could it be choices their parents have made long ago? Could it be natural disasters? Could it be Russian roulette games played by high powered financiers with other people’s money? Could it be politics as usual games played by supposedly representative politicians? Could it be bad luck when stepping in front of some random drunk driver on a Friday night? Could it be genetic? Could it be that that there is no mathematical theory asserting that everybody can be equally rich in any given society?

  81. can you document or link to this? I have never spoken to one or seen it. I have seen countless liberals claim this, but never the actual opposition to them.

    I’m sure if you spend enough time looking you can find a person out there, but this is by no means a common or widely heald belief that can be ascribed to conservaitves generally or even evangelicals more specifically

  82. if they are paupers as the result of choices THEY MADE in life then yes. It is not the responsibility of Federal government to take care of those able to take care of themselves that choose not to

  83. When the government can steer vulnerable individuals to conclude for themselves that life is not worth living, who needs a death panel?

    When Towey debated Tammy Duckworth, Assistant Secretary of Veterans Affairs, yesterday on Fox News Sunday, it is instructive, to say the least, that Duckworth refused to be on the air at the same time. Forced to defend an unconscionable document, Duckworth–herself a decorated veteran–was reduced to denying the undeniable.

    For example, as an increasingly exasperated host Chris Wallace patiently pointed out, the VA, under the Obama Administration, did resuscitate Your Life, Your Choices last July after the VA, under the Bush administration, had suspended it in 2008. And the directive did “urg[e] providers to refer patients to it.” And the “Note” now on the VA website [which states that the document is “currently undergoing revision” and “will be available soon”] did not exist until after Towey’s op-ed appeared in the Journal.

  84. “Maybe your ok with killing innocent people to save the headache of balancing budgets and matching tax revenue to expenses, conservatives are not.”

    So Nate, if the innocent people in these stories would have been paupers and had no money to pay for these life-saving treatments, would you then be OK with letting them die?

  85. Barry,

    Have you read up on the VA’s advance care directive problem? Its pretty much what the Medicare program is based on, Doctors are asked to have an innocent conversation with patients and just plan, what can we wrong with that….naive people ask.

    The material psuhes people to choose death over life based on cost to the system not on important measures.

    http://www.nrlc.org/News_and_Views/Aug09/nv082409.html

    How can you advocate this Barry then say we will just work out any kinks down the road? How many peope would need to die before you took issue with such a system, or if it saves you enough money do you not care?

  86. the other thing I have never seen a liberal or someone attacking conservatives over this do, no matter how many facts disprove them wrong, is be honest enough to admit they were wrong and conservatives are in their right to question how these laws are being written and passed.

    Who is really doing the disservice Barry? Those that are aware of all the facts, good and bad, and want to have open and honest discussion on how best to achieve these goals, or the left and those that attack conservatives that want to slience and dismiss any that oppose them no matter the reason for the opposition?

  87. ” If they are pushed in a different direction or if there are unintended consequences, we can bring them to the fore and deal with them then rather than try to block their implementation in the first place.”

    http://www.firstthings.com/blogs/secondhandsmoke/2009/10/12/liverpool-care-pathway-man-misdiagnosed-with-cancer-dehydrated-to-death/

    Yesterday, I reported on a case in which a woman misdiagnosed as dying, was spared dehydration only due to the persistence of her daughter. I asked at the time, how many other such cases there are? We now know of at least one–only the ending wasn’t happy. A man misdiagnosed with recurrent cancer was apparently sedated and dehydrated to death. From the story:

    A grandfather who beat cancer was wrongly told the disease had returned and left to die at a hospice which pioneered a controversial ‘death pathway’. Doctors said there was nothing more they could do for 76-year-old Jack Jones, and his family claim he was denied food, water and medication except painkillers. He died within two weeks. But tests after his death found that his cancer had not come back, and he was in fact suffering from pneumonia brought on by a chest infection. To his family’s horror, they were told he could have recovered if he’d been given the correct treatment.

    Today, after being given an £18,000 pay-out over her ordeal, his widow Pat branded his treatment ‘barbaric’ and accused the doctors of manslaughter.

    How do you bring the issue to the fore and deal with it when your dead Barry? Take 30 minutes and read about LPC and the people its murdered. One of the most annoying things about people that attack conservatives over the death panel debate is how uninformed they always are. Never once have I meet a liberal making the argument that had the slightest idea what they were talking about.

    This was 2 years ago that LPC was confirmed to have killed people, it hasn’t changed. If your the government responsible for funding the NHS, billions underfunded, closing facilities, and bleeding money like Medicare, do you think they are really going to tack on a couple billion more in cost to save a few dozen lives per year? Of course not, even an healthy and innocent life is worth a billion in taxes to the government.

    Maybe your ok with killing innocent people to save the headache of balancing budgets and matching tax revenue to expenses, conservatives are not.

  88. This has been vehement opposition among various social conservatives (mainly evangelicals) against living wills in which an individual chooses a course of action which would possibly decrease their life.

  89. This reminds me of the stories comming out of the OWS and how the naive little kids are getting a series of life lessons, feeding people that don’t contribute gourmet meals wears on everyone after awhile it appears. The irony of OWS complaining about free loaders is priceless.

    “since this is tax-payer money after all, we should decide by referendum.”

    Margalit, why would the 48%+ that don’t pay any federal income tax not vote for a cadilliac plan that covers everything? Why wouldn’t the 99% percent demand everythoing be covered at 100% since the 1% will be footing the bill anyways?

    You can’t have referendums on consumption when you have unequal contribution, that is why our saftey nets are 100 trillion in debt and killing this nation.

    life threatening should have read life ending. We aren’t talking low risk low cost. Insurance covers heart attacks, cancer, and everything just fine as long as moral hasard is avoided. In fact this is exactly what high deductible insurance protects against, the opposite of your argument.

  90. Nate –

    First, I share your objections and concerns regarding global warming though I prefer market based solutions like higher gas taxes to reduce energy consumption as opposed to top down auto mileage (CAFÉ) standards. To the extent that more federal revenue is needed to restore fiscal balance, I would rather pay higher energy taxes than more income taxes because the former have fewer adverse economic incentive effects and will help to achieve other worthwhile objectives such as lower energy consumption and less air pollution in the bargain.

    Regarding the end of life discussions, I understand that conservatives have some concerns about where they may lead. I think they can do a lot of good assuming they are used as intended – to help people articulate their wishes for the benefit of both medical providers and family members. I want to see them go forward on that basis. If they are pushed in a different direction or if there are unintended consequences, we can bring them to the fore and deal with them then rather than try to block their implementation in the first place.

  91. Interesting… there seems to be some convergence on what a free market can accomplish:

    Nate: “It would be very easy to design an insurance policy that only covered cure’s or treatments of non life threatening conditions”

    Steve: “I just do not see it working very well, except for fairly well circumscribed (usually lower cost) areas”

    I think all those high deductibles and minute clinics and concierge docs are really moving low-cost/low-risk medicine to a free market model, but none of this is applicable to what really matters in terms of cost, and what is discussed here.

    To go back to the NHS for a minute, I would assume that the NHS makes exceptions to its QALY valuations of life. If it didn’t Prof. Hawking would probably not be alive today. I would also assume that the Prime Minister is not kicked out of the hospital if he/she exceeds the QALY limitations.
    And herein lies my problem with these types of decisions: they are made by an elite group of people fully knowing that the decisions they make will never apply to them and their families.
    There is something immoral about that. And in my opinion this is as immoral as leaving everything to the “free-market”.

    Back to the US, I just read the IOM advisory to HHS on how to go about establishing an essential benefits package and the report actually uses the term “elites”.
    So either we force these elite decision makers to live by their decrees, or, since this is tax-payer money after all, we should decide by referendum.

  92. wouldn’t that imply conservatives are not opposed to them but maybe have concerns about government and how government might now or in the future involve themselves? How is that discussion a disservice?

  93. I want to add that the concept of living wills and advance directives is intended to provide direction not just for medical providers but for family members as well. This idea is now supported and endorsed by both the Catholic Church and the National Association of Evangelicals.

  94. Barry you were doing so well.

    “Conservatives are doing the public a disservice by suggesting that they are.”

    Liberals are projecting and are the ones doing a diservice by misstating conservatives concerns about death panels and pretending there is nothing that anyone should be concerned about.

    Its the same evil projection Liberals engage in with global warming. Conservatives don’t deny the tempature of the earth changes we disagree on what percent of that change is natural and what percent is man made.

    In global warming we know why liberals are being dishonest, they are trying to implement taxation and changes to society and using bogus science to justify it. Instead of admitting the hockey stick was a lie, the polar bears aren’t drowning, and they have no idea how clouds effect tempature they dismiss conservatives and these concerns as deniars.

    The question then is Barry what are you hiding and what are you really after that you insist on covering up legit concerns and mistate valid concerns?

  95. Steve and Nate –

    I also think political cover would be extremely useful for insurers. CMS needs to provide leadership here but, so far, Congress won’t let them. Under current law, CMS is not allowed to take cost into account in determining what it will and won’t pay for. That needs to change.

    If it were up to me, the standard of care would call for no interventions, other than comfort care or pain relief for patients with advanced Alzheimer’s or dementia. Cancer patients should all get an honest assessment of their prognosis. The benefits as well as the risks and financial cost of a course of treatment, even if covered by insurance, should be clearly disclosed to them. When the end is near, which doctors can usually tell in cancer patients, at least the family member with the healthcare POA should be told and all patients should have access to a palliative care team. Elderly patients with CHF and ESRD might be more willing to choose medical management without dialysis if told that kidney dialysis probably will not extend their life if they are passed 80 already.

    Interestingly, at the Gundersen Lutheran Health System based in LaCrosse, WI, which I wrote about previously, fully 96% of their patients have executed living wills or advance directives compared to something like only about 25% of the U.S. population. The great majority of them, when asked about their end of life wishes, say they would prefer to die at home and not in a hospital ICU. In short, they are choosing higher quality of life over more days or months of life at the end. At the same time, while nobody is encouraged to choose conservative treatment over aggressive treatment, end of life medical costs at Gundersen are 30% below the national average.

    All too often, when the full court press is applied, the patient can no longer communicate and the family doesn’t know what he/she would have wanted. The purpose of living wills, advance directives, and end of life discussions is to help the patient articulate their preferences. Such discussions are NOT death panels. Conservatives are doing the public a disservice by suggesting that they are.

  96. “Political cover, not sure this is the right word, is the key. When Insurance companies deny something that is not covered by the plan an individual chose to buy we can’t have politicians looking to score cheap points and demonize them.”

    You need no involvement by politicians, though it does happen. About 10 years ago, Aetna refused to cover some procedure on a patient in our area. I cannot even remember what it was. The local paper ran a small series on it. Aetna lost major market share. To this day, I cannot get my own group to even consider Aetna for coverage because of what they did 10 years ago. And, this is all market based.

    There are emotional aspects to medical decision making that just are not common to most other purchases. It is not just a loss of money, but also a potential loss of life, limb or health. You can take back that piece of clothing with a tear. You cannot take back (or you can at great cost) that faulty aortic stent. The chronically ill are faced with large costs and very real geographic limitations in their care choices. Medicine is such an imperfect market I just do not see it working very well, except for fairly well circumscribed (usually lower cost) areas.

    Steve

  97. Political cover, not sure this is the right word, is the key. When Insurance companies deny something that is not covered by the plan an individual chose to buy we can’t have politicians looking to score cheap points and demonize them. We also can’t have activist judges making up the law and requiring them to cover treatment that clearly is not allowed by the policy.

    Insurers should be required to provide a clear list of benefits and exclusions but they should be protected from people trying to add to them after the fact.

    We need to break down major illness and how insurance interacts with them. When your talking about a double valve that isn’t an elective decision and not one individuals usually have done when the need is questionable, this is not the type of large claim insurance struggles with, insurance actually handles these very well…although I just had an off lable Melody Valve used in the aortic position which is raising some interesting questions.

    Lets take something like embrel though, $1500 to $2000 per month for arthritis. If it is someone else’s money people don’t question it, only those with the most painful arthritis would spend $2000 a month of their own money on it though. This is where insurance struggles, more so as Pharma comes out with more such Rx and more expensive Rx. People want the benefits without the premium.

    Another case where insurance struggles is someone with stage 4 cancer, you don’t cure this, so the tens of thousands spent on Chemo and radation is not to cure an illness but delay the inevitable. Again people will usually not spend their/beneficiaries money on this but will spend other peoples money.

    It would be very easy to design an insurance policy that only covered cure’s or treatments of non life threatening conditions. It would also exclude most of the high cost injectables that offer no or minimial improvement over other treatments.

    Where this concept fails is our penchant to forgive buyers remorse. Our pathetic excuse for media loves stories of unfortunant individuals who can’t get “needed” treatment becuase some greedy eveil insurance comapny, ignoring it was usually the greed of the individual that didn’t want to pay extra for a policy that covers the treatment they now wish they could get. Its akin till waiting till someone has an auto accident to choose their deductible. Let them pay for liability only then add comprehensive with low deductible just when they need it.

  98. “So is a year of life worth $250,000 to the average worker?”

    Let me echo Nate above. Valuation of life at the age of 30 is probably different than at the age of 70 or 80. I know, personally and professionally, of many patients who refused expensive, life extending care so they could leave more money to their children.

    I will disagree, mostly, with Nate about the free market solution. It would be nice if we could make it work. It would be simplest. I just dont see how to make it work. As Dan noted, major illnesses and lots of chronic care easily exceed any high deductible insurance plan. Most of our spending goes in these categories. 3% of medical spending is done by 50% of the people in this country, ie, most of us dont spend that much. When we do, issues such as geography, convenience, familiarity and stress tend to override economic decision making. When I pre-op someone for their double valve at 8:00 PM, they arent asking what it costs.

    If you have to use insurance, and I think you do, how do you use market forces well? Insurance is a distortion in the process which is difficult to overcome. Also, insurance companies, at least in my area, are extremely averse to negative press. Market share seems to be very important. One bad piece of press coverage about failing to cover some, usually dubious, treatment, and they all end up covering it. TBH, I think that insurance companies need the political cover of some kind of agreed upon QALY definition to help lower costs. Then, let them also offer plans that provide extra care.

    Steve

  99. First take away is for all the readers on the left at nauseam repeating we spend twice as much for poorer results. Here is one of many examples of where this excess money goes. No country in the world spends anywhere close to as much as we do on the miracles. We keep more and younger premature babies alive, we try more, volume and expense, experimental treatments, and we don’t have anything, yet, like the Liverpool care pathways.

    Second a life lost while in the prime of labor is not the same as a life lost while in bad health. If a 30 year old values their life at $250,000 you can’t argue the life of a 70 year old with prostate cancer is also worth $250,000. You could it’s just not actuarially valid. In many cases our current system does not distinguish between the two. Even worse it doesn’t take into account the quality of the additional time or the efficacy. A treatment with 1% chance is valued just as much as a treatment with 10%. Its only 9% by one measure but 1000% by the more accurate measure.

    Finally the only viable and fare solution is the free market. If you want coverage for expensive treatment then pay the premium for a policy that includes it. If you want to save the premium and spend the money now, my choice, I rather spend $100 enjoying today then have an extra 6 months in the nursing home, then that is also my free choice. No government mandate/dictate will ever be fare or rational. Nor does our constitution allow for the federal government to take such a decision away from me.

  100. While I think the QALY metric approach has merit, it’s not the complete answer. Personally, within a society, I would be willing to spend more to save a premature baby, a young child and a young or middle aged adult than someone who has already lived a normal lifespan and then some. How much should society really be expected to spend to keep an 85 or 90 year old Alzheimer’s or dementia patient who can no longer recognize family members alive?

    I also think people and their families need to ask themselves at what point it’s no longer fair or ethical to impose high costs on the rest of society if the prognosis is hopeless and the care demanded and expected is likely to prove futile. When spending one’s own money, the sky’s the limit. When spending someone else’s, it isn’t or at least it shouldn’t be. I think the people in other developed countries deal with this issue better and more sensibly than we do.

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