Tuesday, March 11, 2008

Single Payer Debate at Duquesne U, 3/10/08

SEPP Organization - SEPP Events

(The link above takes you to the details of the event.)

I attended the debate last night among Dr. Scott Tyson and Gariel Silverman, arguing the single payer case, and Sue Blevins and Nameed Esmail, arguing against at Duquesne University last night. First, props to Duquesne: Great venue in the Power Center, easy parking, nice facility all around. And props to both groups for getting attendance to a surprisingly high level (over 200, I'd guess). Pro-single payer were in the majority, I'd guess, by a significant amount.

I'll cut to the chase: Jerry Bowyer, moderator, at the end of the evening, asked if the discussion had changed anyone from their pro or anti single payer or undecided camps, and only a handful of hands went up. Sigh. But, not, of course, unexpected.

To those of us who are familiar with the issues and arguments for and against single payer, and familiar with the players (esp. Mr. Esmail's Fraser Institute), there were not many surprises. My most pleasant surprise was Dr. Tyson's excellent performance. Powerful, personal and passionate, Dr. Tyson did a very good job of making the moral, practical and economic case.

As my bias is obvious, I won't pretend to disguise it. I found the same old arguments from the status quo/free market/every man for himself side very tiresome indeed. I'll just toss out a few "highlights."

Single Payer advocates see Canada as a Panacea solution for America's woes. I don't know of any, but it somehow forces single payer advocates into the silly position of defending Canada's system, even though it is not the one we would emulate. From now on, we should respond to the Canada graphics with ones comparing us to Germany, France, Belgium, Japan, or almost anyone, and leave Fraser to shit on their own country as they seem wont to do. Heaven forbid they offer constructive solutions. And by this, I mean ones that at least 30 or 40% of the Canadian population would at least consider.

Showing a spending chart showing Canada at the high end of spending on healthcare compared to the rest of the world, and omitting the US, cause we're so off the charts as to make the chart look laughable.

Arguing that taxation sufficient to pay for healthcare would strangle economic growth. This is just too brain-dead to answer, especially sitting in a country that spends 16.5% of its GDP on healthcare. And especially from an economist who said, specifically, that there is no "government money" only our money in government's hands.

Waiting times in Canada are intolerable and/or deadly. Please click here.

$32 Billion in Medicare fraud annually is an outrage and a scandal. I don't know the source or veracity of this figure, but the 2006 Medicare expenditures were $408 billion, meaning 92% of the money gets where it's supposed to, which needs work, but isn't awful. And the suggestion that I think Ms. Blevins made was that she preferred private insurer's solution: deny care first, and then sort out who was trying to scam you, rather than covering claims in good faith and then going after the perps. I'm all for getting the perps, but not until I've made sure the patients are taken care of first. Silly me.

Patients in Canada often have to wait 10 or 12 hours to get a hospital bed when admitted through the ER. Imagine our shock. (He did know Pittsburgh was in America, right?)

Veterans Administration hospitals are horrible places. Dr. Tyson did try to set Ms. Blevins right on this one, though I think she didn't believe him.

You cannot pay for treatment in Pennsylvania outside of your contract with your health insurer.
This one got my attention. I hope somebody will post a comment for me about it, because I'd never heard this before, and it seems exceedingly odd.

The usual "anecdote-off," for which I'll just refer you to our special section.

I was pleased to see Mr. Esmail's praise of other systems, particularly those of Switzerland, Japan, France, Sweden, Germany and some others. He rightly pointed out that the old PNHP proposal, from 1993, was fairly beholden to the Canadian model, but there are newer proposals from PNHP, and besides, they are not the only proposals out there. As has been often pointed out by our side, and always ignored by theirs, we need a uniquely American system, pulling from the best of all other extant systems. Though Mr. Esmail did seem gratified to sear Dr. Tyson say this, I doubt it was the first time he heard it. (You don't suppose he didn't watch Sicko, even as an academic exercise?) Oh, and Esmail even admitted we were rubbish for Mental Health care, too.

Oh, and a personal shout out to Scott Tyson for his wonderfully dismissive treatment of HSAs. Made me chuckle and even snort a bit!

OK, folks, that's all I can remember at this late hour, but please add your comments to remind me of things I forgot to mention....

Cheers,

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4 comments:

Unknown said...

This is the usual
Single Payer anti-freedom, anti self determination response. The Power of HSAs was not presented as time was limited. An objetive review of the very powerful concept reveals the return of patient control that was removed by government over the past 60 years. You either believe in the right (and uncontestable merit) of self determination or foolishly believe in the beneficience of inefficient and corrupt government- that is socialism. I believe there is still a critical mass of Americans who respect the notion of subsidiarity and self -determination with government serving as a safety net ,not a snare to prevail in the upcoming years.

Christopher M. Hughes, MD said...

Damn! You're right! I do hate freedom and self determination to pieces!

Seriously, as Dr. Tyson said, the idea that one can know when to use and not use one's money for healthcare is just ridiculous. It's nice for physicians, but we prove our stupidity in these matters over and over again, neglecting our own illnesses and chronic problems, etc, etc. I'll simply refer you to the moral hazard article by Gladwell (click on the moral hazard subject link on the right.)

I believe government is "us", not "them". (You remember the Gettysburg Address, right? We were fighting, then and now, for Gummint "of the people, by the people, and for the people.") The fact that over the past 7 years it has behaved like a "them" with secrecy and authoritarianism being the modus operandi, while it has shaken my faith, the reemergence of anti-authoritarianism and the soon to be rejected policies of the current administration have renewed my hope that we will become "us" again.

But, really, I am always disappointed in those who think Americans are incapable of administering such a program as a single payer system. Again, granted, BushCo's ability to screw up things is unprecedented, perhaps in world history, but they will be gone soon. And the idea that every first world country in the world can do this (and for the most part do it reasonably well) and that America cannot disturbs me. That is the kind of anti-American sentiment that I find sad. I think we can run government agencies at least as effectively as the French or Germans.

Finally, I prefer self-determination that allows me to choose my doctors and hospital, not insurer driven choices.

Cheers,

Anonymous said...

When I read both sides, and parse out the name calling, I think we all have a similar spirit. But in such a complicated issue, none of us is sufficient expert to be correct.

We live in a society an order of magnitude more complicated than the French. The Olympic coverage should have highlighted that. Just look at our team. So, I don't assume that we could do it as well as the French. This notion really goads me, as my mother taught ESL--so I know that our much criticized education system endures burdens and accepts challenges no other educational system answers.

Self determination--yes it's a joke here. Our insurers already have a stranglehold on doctors and patients.

Freedom in this issue means--freedom from worry, freedom to choose doctors, but also responsibility. America is based on the tightly woven concepts of Freedom and Responsibility.

What is insurance? It's principle is an exchange of risk and money. You're betting against one another.

The insurers believes that they can create a group of people, estimate their risk, blend them together so that individualism falls out, and statistical truth emerges.

Individuals are lumped into risk groups--you have a bunch of speeding tickets, your insurance goes up. This seems to follow logically, speeding equals greater accident risk. When my dad was in the army he was assessed to be a greater risk--When you get weekend leave, you're more likely to go out, party, and get in an accident.

So that's the insurer. They're betting that they can sell you peace of mind at a price greater than the actual risk you are statistically likely to incur.

The individual can't play on statistics because they don't work on a sample of 1. If I roll the dice, I'm fairly likely to come out ahead by NOT buying any insurance, ever. I might save $100K in my lifetime. But if I have a bad roll, I'm giving back my prize.

But you can't get through life without dying.

In 10 years of driving, I have a perfect record. I might go my entire life without a wreck. But while I can roll the dice in my mid-20s, I can't do that when I'm 70, when I know that my first heart attack could be around the corner. That something, has to be around the corner.

The principles of insurance completely fall apart...

So insurers are playing sneaky. When you have the heart attack, they find pre-existing condition. They wait until you have the problem, because only when they have to pay on your behalf do they have financial incentive to put their people to work to find a loophole.

When investing you don't have this luxury. Buy a stock and try to call Wall Street after a bad quarter. Tell the NYSE that there was a pre-existing condition, the company's CEO is an idiot, as well documented here in their college records. I looked them up, found out where they went to college, broke a few laws, invaded some privacy, but it's here--see, they had to retake Finance 101. Clearly unfit to run a company, so refund on my 100 shares, now.

IF we solve this problem. We stop bickering about insurance. You can't insure against a 100% certainty.

Cost control. Efficiency. Trust--give trust to Doctors who say, you're fine! no need for a complete run-down with CAT scans, MRI, the works.

Prevention. Uh, an abdominal ultrasound costs $100...women probably get half a dozen while pregnant. So give them every 5 years for a man over 50, 2 years once over 65. Holter monitors. Get one at 25. Find the pre-existing conditions. Don't hide them.

Right now, prevention has a disincentive. Why figure out what's wrong with you when it's just going to raise your insurance? At 26 would I do anything about a slight murmur or a few PVCs? I don't think I would...I'd just monitor it. But if I find one today there's a certainty that it is filed as pre-existing condition. So I'll wait until I have good insurance, because right now I'm not going to do anything about the problem if I have it.

Christopher M. Hughes, MD said...

Mark, I don't have much to quibble with in your comment.

I do think we can do this as a country, if we really work hard and have an OPEN national conversation (as compared to the closed discussions the Clintons supervised). I currently favor a Bismarckian solution (Link on right).

Finally, I'd urge you to read the Moral Hazard article by Gladwell:
http://www.gladwell.com/pdf/hazard.pdf

Cheers,