Does That Make Gordon Gecko Linux or Windows?
Posted by
Kevin
Music City Bloggers has a post up highlighting a comment thread discussing Sicko and markets in health care. One of the commentators, Hammock, says this:
I’m glad that there is greater public discussion of the flaws in the U.S. health care system. What bothers me is that Moore and everyone else seems not to carry the argument beyond “we should get better care” and “health insurance companies are greedy”. Greed produced my clothes, my house, and the computer I’m using right now.
Even if it were an unregulated market, there are options other than single-payer or nationalization. There are policies that can guarantee care while encouraging competition to control costs and promote innovation. No one seems to be willing to discuss them, possibly because these ideas are complicated.
…
Just to make the argument clear: Greed is not a sufficient condition for an undesirable outcome. Greed is not even incompatible with desirable outcomes. In the right institutional arrangement, greed is a necessary condition for desirable results. So why denounce greed, rather than the institutional environment?
I will indeed state that making categorical statements like “Greed is always bad” are overly simplistic (libertarians run into the same problem when they invoke simple principles such as “non-initiation of force”). It is almost always possible to construct an example in which any hard-and-fast, black-and-white moral rule does not hold.
…Economics might be able to tell us something about the true nature of the problem–why does this market work poorly, whereas others work well? But that would require a careful and thoughtful discussion that would probably bore most people, so no one–not CNN, not Michael Moore–has the discussion. Instead we get grandstanding and entertainment.”
This reminds me of the Windows vs. Linux flame wars or the various “my favorite programming language is obviously superior to your favorite programming language” that infest the internet. I am a programmer and have been a sys admin and network security engineer. I have worked on, literally, almost every single operating system and programmed in most programming languages. I have networked computers in Appletalk and written code to run on Os/2. I have written programs in C for Unix and Perl for Windows. I have written fat clients, smart clients, and web based clients. I have done applets and ajax and, God help me, active x. I have written Windows services and Unix daemons. Yesterday I wrote code in three different languages on two different operating systems. And you know what? I wouldn’t hesitate to use any technology I have used in my career again (Well, okay — maybe not VB). Whatever the Linux fanboys and Windows geeks may say, whatever the Perl partisans and Python propagandists might claim, programming languages and operating systems and design methodologies are just tools. Nothing more, nothing less. The trick is to use the right tool for the right task.
Greed, or, more accurately, markets, are the same way. They are a tool, not a revelation from the burning bush. Greed is not the only tool in our possession and it must be judged the same way all other tools are: by how well it does it job. You cannot look at a situation and think to yourself “how can I make markets work better here”. That is like looking at a nail and thinking, “hmm, how could I get that nail into this piece of wood using this hacksaw”. The appropriate question is whether or not greed is the right tool for the job. And I think it is pretty clear that if the job is designing a decent health care system in thsi country, the answer is “no”.
Markets create incentives for insurance companies to behave atrociously. The simplest way for an insurance company to become profitable is to never pay out any claims. Thus, insurance companies go to great lengths to not enroll people who can be expected to have high medical costs down the line and to find reasons to deny people the benefits for which they have paid their premiums. Assuming that doctors are driven by the same greed first considerations (most aren’t; but that is a complication for another day) they too have incentives to act in something other than the patient’s best interest. If they are paid by the insurance company per patient, they have every incentive to stack the patients high and push them through fast. If they are paid by the insurance company per procedure, then they have every incentive to order up as mush work as possible. The former leads to missed diagnosis and incomplete treatment; the latter leads to over exposure to antibiotics, unnecessary pain anddiscomfort for the patient, and longer waiting times for needed treatments and equipment for everyone else. Greed, in other words, is bad for your health.
This is obvious once you step back and look at the problem without the need to make it fit into a market based solution. But you must take that first step of not picking your tool before you diagnose the problem. Markets and greed are not required in every aspect of our lives. They are not revealed wisdom or the secret to everlasting success and happiness. They are just tools, the functional equivalent of a hammer. And not every problem in the world is shaped like a nail.
Statements like, greed produced my clothes are curious.
Greed did not produce your clothes, people and machines did. Greed created the conditions by which the company that employs those who produce your clothes decided to outsource textile jobs to Sri Lankan teenagers for pennies on a dollar, leaving your neighbor who used to work in the industry, at a protected union wage, unemployed.
Greed produced your clothes is a huge extrapolation, moreso than even saying that greed left your buddy unemployed.
If we’re going to play the extrapolation game, then people like me might as well make such simple, generic, and unqualified statements like, “greed produced 9/11.”
I mean is this to imply that a socialist society would be, per se, naked?…
Furthermore, “greed” is not handsome compensation for a job well done, or an important innovation. “Greed” is the desire to extract more than your performance dictates you are worthy to. “Greed” is increased compensation for failure or mediocrity - for providing less service, for declining quality of service, etc.
The market model as applied to social services creates a glitch in which declining quantity and quality of services nets greater returns.
Furthermore, our desire to relate everything to greed is very telling. It is like how Americans say that greed is human nature, while several other cultures believe that charity and compassion define human nature.
Bottom line is, greed is an unhealthy surrogate for those who lack positive motivational values, such as work ethic, civic responsibility, and pride.
Comment 7/12/2007
Wise words indeed.
As a Brit I can tell you our health service comes in for a lot of criticism here in the UK, some of it unfair, but any person who gets ill in this country knows that they are going to get decent health care.
I hope people in the States sit up and take notice of Moore’s movie and realise they are being duped. A national health care system is just so obviously the way to go.
Comment 7/12/2007
You poor man. Why?
No, that seems more like the simplest way to never get customers and go out of business. If you want to make real money, you have to keep customers, preferably live ones, in some manner in which they believe they’re getting a good amount of results for their money.
Patients aren’t sheep or cattle walking through with little more than a moo. Trying to analyze the economics of the situation without looking at the patient’s potential reactions — avoiding doctors who don’t pay attention to them, refusing medical treatment that the doctor can’t actually give a good reason for, or going to insurance companies willing to take a bit more money in exchange for superior coverage — is like trying to build a network security plan without configuring a Syslog server. You’re ignoring how half of the set-up reacts.
Comment 7/12/2007
And again, the market model creates the rub.
The argument against national health care is one directed at the lowering of the ceiling - and not at its inability to raise the floor. Those in the policy making decisions reside near the ceiling, so they perceive themselves as the ones who stand to lose.
But, that’s not even truly the case. One can always seek out the free market for wishes that are beyond the capabilities of a socialized system to fulfill.
Some say that all the best medical minds are drawn here because of the financial opportunity. To what extent this is true is debatable. But, the market for “above and beyond” care for those with the financial means to seek it would not totally dry up as a function of guaranteeing adequate care to others who were previously without it.
And, indulging that argument for a second, is that to imply that the only redeeming quality of our country is the ability for a medical practitioner to become filthy rich? Were that ability to theoretically be curtailed, would we no longer be able to draw successful foreigners here? If so, that’s pretty fucking said, if you ask me.
You want to talk greed, well how would you define justifying complete disregard for the health of millions in order to prevent a (theoretical) sacrifice from our most privileged?
Furthermore, our obscene wealth would be able to elevate the base level of care to where many of the complaints about other countries’ nationalized programs become moot - if implemented efficiently. KTK made that point not too long ago.
One real problem I will grant is that of immigration and the provision of care to illegals. However, that’s tricky too, because if they are working here anyway… Whatever, that’s another discussion.
The kicker is that we spend this money anyway. We pay for our healthcare through our paychecks, as much as we don’t believe so. Our employers factor in the costs, and it is reflected in our salaries. What’s the difference where the money is taken? I can never understand why we are so adamant about defending the rights of a privileged few to exploit the rest and laugh all the way to the bank…
Comment 7/12/2007
“You poor man. Why?”
Cause I was paid to
That particular shop had an aversion to anything not MS approved, but they wanted an applet like functionality.
as for the rest, the way I have described things is pretty much how they work. You cannot name me one insurance company that has gone out of business for those kinds of tactics, not a major one, for the simple reason that people need insurance companies to afford health care. Believe, I was a contractor –I know how expensive health insurance is for individuals. not to mention the fact that most people have no or little choice in who their insurance company is going to be.
You are making the same mistake I warned about: you think that markets are the best tool, so they must be the best tool for a health system. It just isn’t so. Insurance companies do act as I have laid out, and the financial incentives for doctors are as I have laid out. And that doesn’t even get into the fact that consumers don;t have enough information to to effectively bargain, nor do they generally have enough time, not do they generally, because of the price of health care in general, have a lot of bargaining power.
The market has gotten us insurance companies that are content to watch people die to make money, a nation with millions un- or under- insured, sky rocketing health costs, and very near the worst health outcomes of any liberal, industrialized democracy.
Comment 7/12/2007
Not when you’re paying almost all of your income to a nationalized healthcare system that’s unwilling to provide the care you want. Or someone like Hillary or the Swedes decide that private health care is teh ebal.
60% of new drugs research goes on in the United States. To quote the NYT, “In the last 10 years, for instance, 12 Nobel Prizes in medicine have gone to American-born scientists working in the United States, 3 have gone to foreign-born scientists working in the United States, and just 7 have gone to researchers outside the country… By 2003, [American biomedical research] spending was up to $94.3 billion…, with 57 percent of that coming from private industry. The National Institutes of Health’s current annual research budget is $28 billion, All European Union governments, in contrast, spent $3.7 billion in 2000.”
You’re entitled to your own opinions, but not your own facts, and I think the facts are crystal clear here
Comment 7/12/2007
Nah, the free market fails in a lot of places. The ‘invisible hand’ is slow, can’t deal with environments where entering the business side of the market is too expensive, and completely fudges things when politics gets too quick.
With the exclusion of the last part, however,
At the very least, it’s intellectually dishonest to blame higher health costs on the market. Claiming that the existing mess is only because of the free market is pretty close, too.
Under the free market, ambulances wouldn’t be legally required to transport a woman wanting a pregnancy test to the ER, and doctors wouldn’t be stuck doing a CT and bloodwork on a known never-paying drug seeker claiming a 12/10 on the pain scale but alert, looking for food, and whining about a cold seat.
We wouldn’t be seeing the current 10x markup on basic medications if more than one in three patients ever intended to pay their bills.
Comment 7/12/2007
First of all, the context of the first comment you highlighted was as it related to those for whom the ceiling is more relevant than the floor. The financially elite, those who currently consume elective care.
Rest assured, that Lindsay Lohan would still be able to afford her labial reconstruction and the daddyballers in Beverly Hills will still be able to pay out of pocket for pre-emptive Tommy John surgeries so their trophy kids can make the run to Williamsport. Dick Cheney can get whatever heart care we wants. And so forth…
Secondly, what kind of new drug research? Greed is the cause of new drug research? Okay. So greed is the reason why we have a dozen drugs for erectile dysfunction and we’ve been using the same TB regimen for nearly 50 years. We cure disease, and develop drugs based on the financial incentive to do so.
So, we got a lotta drug research going o n- whooptie-fucking-doo. Where are we directing that effort? With all that innovation we are still one of the most unhealthy societies in the industrialized world. I don’t count the bullets, I count the kills.
What about the fact that our top medical students are increasingly entering the field of elective medicine? You think that has anything to do with the market (and the cost of med school)? Our beloved market model has our most gifted medical students aspiring to perform calf implants on the girls of My Super Sweet 16, instead of heart surgery on your grandmother.
Comment 7/12/2007
Gatt
I’m not trying to say that markets are always bad — but just that the market isn’t the tool for what we need in health care. Your examples proves it: unless we are willing to let people openly die (i.e. let emergency rooms turn people away) we don’t have a complete market in heath care. What we do not is that, within the constraints that our society has allowed, and considering the financial incentives tend toward denying care not providing it,using markets as a tool to deliver health care has been an absolute disaster.
Comment 7/12/2007
False choice, Kevin.
There are lots of individuals who currently *must* be given transportation to the ER, and *must* be given a fairly high level of care, and any doctor worth more than their scrubs can tell you that they’re not in any risk of openly dying. Clearly non-emergent cases make up a majority of any Emergency Room’s time, space, and money.
Digglahhh, I’ll assume you’re not an idiot. Just because we come up the drugs doesn’t mean we’re the only ones that get to use them — we’re providing a good deal of the medical innovation for the joyous NHS and other socialist systems. As for the lifespan and mortality distinctions, anyone with a high school education should be able to recognize the problems with trying to compare statistics from entirely different cultures with different measurements, cultural groups, and societal trends.
Comment 7/12/2007
Gatt
How is that a false choice? Do we as a society or do we not demand certain things form our health care system, things that a market would not support and that make the system less than a free market? and has or has not the market aspect of your health system not resulted in less care with poorer outcomes for the nation as a whole?
As for the NHS, even assuming that all drugs come out of private research(they don’t), a reduction in prices here would inevitably lead - -if it did actually cut innovation down — to a raise in prices to other systems.
Comment 7/12/2007
The free market has repeatedly stated that there are certain levels of care that are necessary — otherwise that sort of thing wouldn’t have been standard before the current stupid and overlawyered laws. It’s just not efficient or economical to turn away people who actually need services. The result wasn’t always great, since you’d end up with a few folk with fudgered credit ratings, but it was a hell of a lot better than this current mess or passing things through a federal “I don’t have a medical degree or ability to tell my backside from an atlas, but give me 5% for my wages and let me pick what it ‘necessary’ anyway” filter.
I don’t see how a reduction in prices here would result in a raise in prices in other systems. There are governmental price caps over there right now, ones unlikely to change. I don’t see the NHS deciding to suddenly pick up more of their current tab (it is already legally bankrupt). I see it more likely that the politician’s demand for new innovation would be fundamentally different and lower from that of the people in both locations.
I’m sure it’s somehow possible to get medical companies to spend money making drugs that it will actually cost them money to produce… but I haven’t seen it happen yet.
Comment 7/12/2007
“The free market has repeatedly stated that there are certain levels of care that are necessary”
how do you reconcile that wit the well known and wide spread practices of the insurance companies? the free market has said just the opposite.
“’m sure it’s somehow possible to get medical companies to spend money making drugs that it will actually cost them money to produce… but I haven’t seen it happen yet.”
if this actually happens, which it won’t considering all the factors, then the NHS would have to pay more in order to get drugs, wouldn’t it?
Comment 7/12/2007
Gatt,
Let’s go back to the basics.
Do you recognize and admit that whatever iota of compassion, or basic human rights our healthcare system guarantees are addendums to a market-based system that would not exist in a pure, unfettered model?
Do you recognize that despite the number of drugs developed by our society, our fastest growing branches of medicine are elective?
Do you recognize the problems with using drug development as measure of meaningful advancement, especially when you call to attention that those drugs are predominantly developed in a society in which advertises drugs as consumer products? A society in which pharmas enlist PR agencies, ad agencies, and pay Hollywood to write their medication into the scripts of blockbuster movies and must-see-TV?…
And, yes, to echo Kevin’s point, not all funding and development comes from private entities. In fact, I work for a global health non-profit that develops drugs, but it is funded by American philanthropists and foreign governments.
Do you admit that it is myopically American to imply that “greed” is the only legitimate motivator to cure disease?
Comment 7/12/2007
Kevin
By rather simply pointing out that insurance companies aren’t the ones supplying medical services. Insurance companies are only supposed to provide reliable insurance for those who are at enough risk for the costs of insurance to be viable.
The hospitals and, at least in the discussion of “life-or-death” care, Emergency Rooms are the ones in charge of providing care. They are only interested in providing services to individuals willing to pay for said services.
No, I’m pretty sure it wouldn’t. There’s very little incentive, after all, since the politician’s demand for new drugs is pretty low in most cases.
Economics involves how much the potential purchaser is willing to pay as much or more than how much the seller worked to produce the good or service.
digglahhh, I see little point in presenting emotionals, just as you’d see little point in my attempting the same with references to Cuban health ‘care’ or the myriad problems with the NHS.
Comment 7/12/2007
gattsuru:
Part of what you miss, I think, is just how much of that pharmaceutical research (and, in particular, the private dollars) goes to non-essential medicines. The big money in pharmaceuticals is not in finding a drug that cures cancer. It’s made in finding a new use for a minor variant of an existing drug. Why do you think you see ads advertising drugs that stop your toenails from turning brown, or a new birth control pill that helps prevent “PMDD?” (Never heard of PMDD? That’s because the makers of Yaz essentially invented it.)
People make a lot more money off of things like ibuprofen than they do off of things like penicillin, and patent law is only a small part of that equation.
Also, the term “health insurance” is, in my opinion, a misnomer. What most “insured” Americans have isn’t really insurance at all, but a managed health plan. And we’re in a catch-22 where such plans are too expensive for many to obtain, but health care is far too expensive without one.
(And, ironically, these plans suffer from precisely the sort of skyrocketing costs, bureaucracy, and lack of choice that we were warned about with “HillaryCare.” Despite the failure of that initiative, all of these things happened anyway. So how, again, was HillaryCare supposed to be worse?)
Like it or not, Kevin is right. Insurance companies make their money in large part by denying expensive claims. Sure, they’ll pay the routine stuff, and they’ll pay some of the expensive stuff — just enough, as you say, to keep people believing they’re better off with such plans than without them.
But I think the broader disconnect is this: Do you believe, or do you not believe, that quality health care should be accessible to all US citizens? I submit that you do not believe this. Because if your assumption is that it should be, then it’s abundantly clear that the market simply cannot provide this.
Comment 7/12/2007
“Presenting emotionals?”
I don’t really know what that means. Perhaps you conflated my penchant for silly pop-culture references with some sort of evidence that the core of my argument isn’t solidly backed by empirical data and the basic premises of economic models.
Dismiss what you will, ignore what you (don’t)like.
But to indulge your cognitive dissonance, thinly veiled as a vague pejorative dismissal, I submit that it is perfectly reasonable to get “emotional” about millions being denied basic health care, while being marketed unnecessary medication for fabricated conditions. In fact, I’ll go a step further and submit that it is pathological not to. Remind me not to feel for you if you are ever denied necessary medical care for any reason, and to accuse you of grandstanding if you complain about it.
You can spout all the problems with any other model you like, my friend of sound mind and able body. But that doesn’t fix ours…
Comment 7/12/2007
The list of reasons why the health care industry(and especially health care as it is currently configured in the US)does not constitute a well-mannered free market is so long as to boggle the mind. And that holds true for every aspect of the market. Consumers, their co-funding employers, doctors, labs, hospitals, big pharma, and the insurance companies too.
I don’t think we need to villify anyone. I think we need a rational discussion of the realities of the situation. This will be more effective in advancing the cause (assuming the “cause” is health care for everyone in the country commensurate with our national wealth). Which, if one reads the entire content of Hammock’s comments, is what he is trying to say.
Well, that and a catchy name, like “The Patriot Act”, “The Clear Skies Initiative”, or “No Child Left Behind”.
Comment 7/12/2007
Depends.
For example, if you just mean basic health care that treats significant problems, right now every single United States citizen has the option of getting health care. It’s actually a felony for any ER that accepts Medicare money to refuse to provide diagnosis and basic care, even if there’s obviously no actual issue. I think that level of care should be available, although the current laws making it impossible to effectively bill people for care are far from ideal.
But I don’t think that’s what you mean. What you want is something closer to the United Kingdom, or Sweden, where everyone has ‘insurance’ and doesn’t have to think about costs to get any sort of remotely health-related issue dealt with.
I don’t think that’s a good idea. I’ve seen too much of where our current system offers ‘free’ care to want that cesspool expanding. When something’s ‘free’, people use it to replace anything that directly costs them.
It’s a felony to deny anyone at an Emergency Room diagnosis or care for any significant issue on any basis as long as the owning hospital takes Medicare money.
Comment 7/12/2007
Gat, you refer to EMTALA, yes? Note it is not named BMTALA.
Comment 7/12/2007
Gatt:
As Ted points out, what you’re referring to is emergency health care, not basic health care. The problem with what you advocate is that it falls into a classic libertarian trap: whether you realize it or not, what you advocate is a preference for a pound of cure over an ounce of prevention. (Because people who have to worry about cost are going to “wait until it hurts,” by which time the actual costs are likely to be much, much higher.) Things like preventative care, early screening, etc., are precisely the types of things that should be readily accessible to all citizens.
Contrary to what you think of me, I wouldn’t totally eliminate the market from the equation, nor do I think socialized health care is a panacea. I’m on record as supporting a government-run network of hospitals, clinics and doctors offices, paid for by the taxpayers, and open to everyone. These facilities would do a basic triage to bubble the highest-priority patients to the top based on imminence of need, and treat the others on a first-come, first-served basis. At the same time, private-sector facilities would continue to exist and operate for-profit, providing services to those who are willing to pay to bypass the public system (whether to reduce wait times or to obtain elective services not provided by the public system). Opting to do so would not exempt one from the requirement to help fund the public system, just as opting to send your child to private school (or opting not to have children) does not exempt you from paying a share to support your local public school system.
Comment 7/12/2007
“By 2003, [American biomedical research] spending was up to $94.3 billion…, with 57 percent of that coming from private industry. The National Institutes of Health’s current annual research budget is $28 billion, All European Union governments, in contrast, spent $3.7 billion in 2000.”
I love these stats, because they illustrate a couple of issues that so often get overlooked in health care debates. First, the free market is an excellent way of generating drugs that people will pay for (which is not the same as the drugs people need) and there’s no reason why that should stop under a public-sector health system. The only condition needed is that people are allowed to buy whatever other (safe) medications and treatments they wish. Some socialized systems prevent that, I believe, and that’s a mistake.
The second, more fundamental, point is that the free market is an excellent way of generating the money to pay for health care. That is a completely separate point from how best to provide the health care. From (http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=372221) we can see that while the US spends around 2.5 times as much per head of population as other OECD countries, that’s less than twice as much of its GDP. Being able to throw money at a problem can buy you a better solution than anyone else, but that shouldn’t be confused with the best possible solution. If the US took all that extra cash and spent it wisely, well just imagine what they could have.
An average wage earner in the US would pay about $8,000 per year in HMO insurance and incidentals for his or her family (I’m making that up based on my own experience, but I think it’s close enough). In the UK the same worker would pay around £4,000 ($8,000) in National Insurance premiums, but included in that would be long term disability insurance, unemployment insurance and a pension. In both cases the worker would receive excellent care, with very similar outcomes for almost all conditions, though if I had something really serious I would in almost every case choose the US to be ill in - that’s the power of the extra dollars spent.
But compare that to the amount spent by an average low paid worker, say at half the average national salary. In the UK they’d give up around $4,000 for all the benefits I mentioned, to exactly the same standard as the average worker. In the US they wouldn’t give up anything, because they wouldn’t be able to afford the $8,000 they’d still be expected to pay. Their only option would be to hope they stayed well, and try to file for bankruptcy if they were unlucky.
“every single United States citizen has the option of getting health care. It’s actually a felony for any ER that accepts Medicare money to refuse to provide diagnosis and basic care”
This was in answer to whether “quality health care should be accessible to all US citizens?” Accessible, in this case, doesn’t mean that there are wheelchair ramps at every door, or good parking and infrastructure links. It means that people can actually use the care, and in that sense health care is accessible in the US in the same way Ferraris are - you can have as much as you want, but you’ll be in trouble when the credit card bill arrives.
Comment 7/14/2007