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April 23, 2005


I believe the US gets the worst of both worlds because of the mixed public-private, politically driven for profits for a few, system that we do have. Look at the vaccine issue to really see how this mixed system is failing at the most basic successful part of medicine. If you cannot do vaccines right, what the frick is left to do right--Medicare?

If we had a totally private system without any regulation and unlimited ability to produce providers of all sorts, I think we would do somewhat better than the schizophrenic mixed system we have now. If we had a totally inclusive, government run or highly regulated system, I also believe we would do much much better than we do now.

We must get by this in limbo phase, and move onto one or the other type of system. Powerful political forces seem to be preventing such a plunge, probably because the political will for an all public system is not there. There is just too much money being made by the some very powerful industries (politcally speaking) under the current wasteful, inefficient system! When we get to 25% of the population without access to care, and those with access spending all their retirement savings on healthcare, then many there will be a revolution in this area. Maybe?

Don't miss Ezra Klein's kickass rundown on healthcare systems in other countries.

thanks, Petey. Great link that I hadn't seen.

NG, I keep waiting for the next election to be THE election about health care, or industry finally realizing the costs... still hasn't happened. Someday it will because it must.

Krugman also nails a key phrase: "Passing the buck". That's what devours the missing percentage of GDP without producing any corresponding increment of avorable outcomes. There are fancier ways to say it, but "passing the buck" is concise, commonsense coinage for general discourse.

"I keep waiting for the next election to be THE election about health care ... Someday it will because it must."

Now, this is why I'd like to see the filibuster eliminated.

One of the many lessons of 1992, the last THE election about health care, is that it's dangerous to run on sweeping legislative change when 41 Senators can doom you to failure.

One of the many lessons of 1992, the last THE election about health care, is that it's dangerous to run on sweeping legislative change when 41 Senators can doom you to failure.

Hmmm. Something to really think about in the big picture when asking oneself how we are where we are with the healthcare issue after so many tries at a universal system since 1950 (4, I believe)--all defeated! The public generally seems to want such a universal system, but it just is a non-responsive issue. You may have nailed the reason, mainly that powerful opposition forces only need to get 41 votes against.

Industry /banks/big buisness etc weren't behind health care reform before. Next time, they'll be leading the charge.

Somewhat OT, but I remember hearing Ralph Nader (before he went completely cuckoo) on NPR and he mentioned that doctors spend more on office administration than on malpractice insurance. Kinda another way our priorities are AFU.

Krugman, as usual, brings up critical issues ignored by other commentators, and does so in a lucid way with intelligent priorities. There is no question that administrative costs in private health care systems are astronomical: figures I've read in the 2000-2002 time frame varied between 15-19%. Public systems, of which the VA is the most representative example, generally run 3-4%.

Health care access is a critical issue as well. Access is complicated, but perhaps the most important aspect to measure is access to primary care services: the family internist, pediatrician, or family practitioner. Primary care is where the most impactful care is delivered: pediatric vaccinations and screening, adult cancer screening and heart disease risk modification, mental health screening and most treatment, etc. Access to emergency rooms is usually only relevant in a failed system: one in which primary care services are unavailable to a large number of people. Access to MRI's, plastic surgeons, LASIK surgery and the like is of minor importance by comparison.

Quality is difficult to measure, but there have been any number of attempts. The HEDIS panel of criteria is the best known, and has been generally accepted by insurers and monitoring groups. This is a set of measures (retrivable by billing data) such as mammogram rates, pediatric vaccine rates, measures of diabetic control, and the like. These are combined into a structured, normalized quality score. Results consistently show that overall spending and quality of care are almost entirely unrelated. The distribution of spending is crucial: disproportionately high spending on primary and preventive care yields higher results.

I've worked in a couple of regional VA systems, and I can vouch for their quality. They'd do a better job with more money, but they generally provide an excellent primary medical service to many veterans who wouldn't necessarily have other coverage, at a very low cost relative to other systems. Specialty services are more spotty, and some competition would probably be beneficial to incentivize better quality and patient satisfaction. They're not perfect, by any means, but they show how a basic universal health care service can begin to be structured.

all good points, Dallasdoc. it's doable... just not simple.

I really believe that it''s dangerous for primary care physicians to be in the business of providing mental health care, particularly prescribing psychotropic drugs unless they are in regular contact with psychiatrists and are able to consult with them over appropriate protocols.

Far too many bipolar patients get SSRIs which make their condition worse, because the internist was not trained to do a thorough evaluation and doesn't spend all of his/her time studying the effects of these drugs.

in my view of choosing the right policy for health care. Learn how to alleviate financial losses by transferring risk of loss from one entity to another.

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