Health Care Thoughts

Lately I have been reading free Philosophy course notes from MIT here.  I have been surprised by how much I have enjoyed the section on Justice, and particularly course notes that address justice and healthcare here.  The notes are about 12 pages long, and I would like to summarize them below.

What is the problem with health care in America?

1 – To much money being spent on it.  Americans pay more money, and a higher percentage of their money on health care than any other nation.

2 – Not enough value for the money.  When it comes to things like life expectancy, infant mortality, and general health issues, America ranks quite low amongst industrialized nations.

Why is it this way?

The current insurance system leads to being less health conscious, and to over-consumption of health care services which are sometimes unnecessary.

How can it be fixed?

If we want to try and fix it through some type of government action, then a just system would be based on:

– How much insurance would people have if they had good information about health care costs and actual health risks?

– How much insurance would people have if there was a balanced distribution of resources?

– How much insurance would people have if they had no knowledge of their own susceptibility to health problems?

Thoughts?

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13 Responses to “Health Care Thoughts”


  1. 1 Mike S September 16, 2010 at 10:38 am

    4 main problems as I see it:

    1) Disconnect with costs: Historically, patients want everything possible. I am an orthopedic surgeon. There are many times I explain how an MRI isn’t going to change anything in a particular situation. I have many patients say that they have good insurance, it’s not going to cost them anything, so they want it anyway. Now that patients are having to pay an increasingly high share of their costs, things are changing. People think twice about expensive tests that may or may not make a difference.

    2) Rationing: There is not the money available in any system to pay for everything possible. Care is necessarily rationed. In this country, it is done through access/insurance/economics. In other countries, they simply don’t pay for things. Example: there are some drugs for breast cancer that work marginally. For a small minority of patients, they work well and patients live 5-10 years. For the majority, they don’t work at all. They cost tens of thousands of dollars for an average increase in life expectancy of 2 months. Other countries look at this and say they they aren’t going to pay for them, as they don’t make economic sense. In the US, we obviously want them used in case our wife/mother/etc is in the lucky 5%.

    Other examples: in other countries, an elderly person with a hip fracture and other medical problems does NOT have their hip fixed. They are given pain medicine and generally pass on within a few weeks. Imagine the commercials on TV if we were to do that here: Family grieving around grandma’s hospital bed. Senator So-and-so wants to kill grandma….

    3) Liability: I spend around $1000/week in malpractice insurance in case I’m sued. I see around 30 new patients per week, in addition to follow-up patients, etc. It therefore costs me around $30/new patient, just in case that patient decides to sue me at some point in their care. And this doesn’t include all of the extra tests, etc. I order “just in case”. With MRIs costing at least $1000 each, these easily add up to $5-10k / week. So just me – I probably cost the system $500,000 per year just to CYA.

    4) Poor health choices: We are a fat country. With the exact same genetics, we have become much more obese over the past 30 years. This has a tremendous impact with regards to heart disease, blood pressure, diabetes, arthritis, etc. Just for knee replacements: if you are a normal weight and live to be 80, you chance of needing a knee replacement is less than 20%. If you are overweight, it is more than 80%. At a cost of $30-40,000. The cost of obesity alone in the US adds $150 BILLION to our annual costs. Putting this in perspective, the cost of “Obama’s” healthcare package is $1 trillion over 100 years, or around $100 billion per year. If we weren’t so fat, we could easily pay for all of the uninsured and the entire Obama plan.

    And this doesn’t include smoking, etc.

    So, those are my thoughts. What is the current package doing to help these?

    1) Costs: With the government paying for more things, we are going to me MORE insulated from costs. This is why the plan is actually going to cost more money.

    2) Rationing: This is needed and is the only real answer. We need to pay for care that makes economic sense. Unfortunately, there is absolutely no one who will step up and do this. It would be political suicide.

    3) Liability: All liability reform was pulled out of the current plan. When government is full of lawyers, this is pretty obvious. People are still going to sue.

    4) Poor health choices: We will hopefully realize that our diets are killing us. I don’t hold out much hope for this happening. We want the quick fix.

    At the end of the day, costs are going to go up, taxes are going to go up, it is going to continue to spiral out-of-control until it truly breaks. Then we will ration care like other countries.

  2. 2 Chris H. September 16, 2010 at 10:43 am

    I am fat. I apologize for destroying America.

  3. 3 Chris H. September 16, 2010 at 10:45 am

    I will take a closer look later, but I do want to say that Joshua Cohen is one of my heroes.

  4. 4 Eric Nielson September 16, 2010 at 11:34 am

    I am very novice at this, but the model in the note is based on Dworkin.

  5. 5 Eric Nielson September 16, 2010 at 11:34 am

    Mike S:

    I think the points in the post would have a chance at addressing your concerns, other than liability.

  6. 6 Stephen M (ethesis) September 16, 2010 at 9:42 pm

    Mike, your med malpractice insurance rate indicates you make between $1.25 million and $2 million a year after taxes and overhead. Do you feel that doctors in the United States should be compensated in line with what they make in Europe as a part of reducing medical expense that goes along with reduces malpractice exposure from changes in the system?

    Eric, the philosophical basis of How much insurance would people have if they had no knowledge of their own susceptibility to health problems cuts directly against the basis of accurate understanding of risks and costs 😉

    Chris H — as long as you don’t become a non-compliant diabetic you are not part of what is destroying America.

  7. 7 Chris H. September 16, 2010 at 10:46 pm

    Eric, the MIT course in by Cohen.

    Stephen, my apology was insincere. I am all for destroying America.

  8. 8 E September 16, 2010 at 11:43 pm

    I also think about costs a lot. I am a primary care physician, and I do a lot of preventive care and chronic disease management (diabetes, high blood pressure, etc.). In addition to the points Mike makes above, I have a couple of observations.

    One, almost everything I do could be done for very little money, and would be very inexpensive if it weren’t for the enormous costs of doing business imposed by the government and insurance companies. The vast majority of the drugs I prescribe are $4 per month at Walmart. The vast majority of my patients need one visit (healthy people) or two visits a year (people with chronic illnesses who are otherwise stable). I could charge half of what I charge for care if I did not have to employ an army of people to beg for money from insurance companies and make sure we are in compliance with a lot of ridiculous government regulations, and if I did not need to order a lot of CYA tests and consultations. I seriously think primary care could and should be very inexpensive, maybe a couple hundred dollars per year per person on average.

    Two, right now, patients have a lot of input into what type of care they get, and many times they do not make good decisions. It’s not just the extremely expensive drugs and procedures that Mike discussed above. People also refuse inexpensive preventive care like vaccines based on pseudoscience. I absolutely believe that everyone has the right to refuse care, but we have a problem in our culture of not being able to judge good information from bad, and feeling that once we have googled something, we are “informed”.

    There are some ethicists who argue that there is generally no such thing as truly “informed consent”, and the longer I am in practice, the more I would tend to agree. People are just not that rational, and I don’t know that there is a solution for this. But in countries like Canada and the UK, people are much more apt to just accept the treatment offered them.

  9. 9 Mike S September 17, 2010 at 12:35 am

    I’m not sure how your calculations come about. I would certainly love to make $1.5-2 million (although I know I’m absolutely NOT worth it) but I make far less than that.

    Regarding the $30 it costs me in malpractice insurance per each new patient, for a Medicaid patient, I get around $40-50. By the time I pay for my staff, rent, supplies, etc., I lose money for each Medicaid patient I see. And around 10% of my practice is patients with NO insurance, so I actually lose money for each patient I see. I still see Medicaid patients, however. I still see uninsured patients. I feel it’s part of my responsibility to society.

    And my premiums are actually low. In other parts of the country, orthopedic surgeons pay as high as $150-200k per year for malpractice insurance, or $3000-4000 per week. For someone seeing 30-40 new patients per week, that’s $100/patient, just in case they are sued.

  10. 10 Eric Nielson September 17, 2010 at 6:56 am

    StephenM:

    This is addressing understanding risks and cost on the population as a whole, not for me in particular. It is a statement for a lack of self-interest.

  11. 11 ff42 September 17, 2010 at 7:48 pm

    What is the proper/just way to allocate scarce resources?

    What moral principle justifies forcibly taking from some and giving to others?

    What moral principle justifies preventing selection of an ‘unaccredited’ person to provide care?

    What moral principle justifies prevention of self-medication?

  12. 12 Stephen M (ethesis) September 18, 2010 at 12:02 am

    Mike, the orthopedic surgeons I depose generally are making 2-3 million dollars a year. The recruiter I talked to in Paris was recruiting surgeons to work in England from Europe — by moving to England a surgeon can make as much as 100,000 euros a year (or could when I was in Paris on my 20th wedding anniversary).

    Those that stay in France or Germany, etc., make less.

    Malpractice rates generally run as a %tage of one’s income for doctors, with modifications by region and specialty.

    I was calculating your income from the rates and your specialty and the orthopedic surgeons I’ve used and seen used as experts.

    Sorry if I was wrong.

    Chris, if you are sincere, you need to do more than get fat.

    Eric, usually the analysis I’ve seen is what would people buy if they really understood the risks and benefits individually, but it is interesting that you are supposing an analysis that divorces the individual’s personal risk profile on all axis, rather than on one axis of analysis.

    ff42 — the superbugs (the antibiotic resistant strains of bacteria) that are surfacing are all surfacing from areas of the world that allow self-medication.

    E — primary care is hard work, and often poorly rewarded. My own thoughts, years ago, were that doctors should move into specialties and cede all primary care to advance practice nurses.

  13. 13 Eric Nielson September 18, 2010 at 7:44 am

    ff42:

    The series on justice in the links I provided discuss these types of issues at length. One of the things that are talked about a lot is the idea of ‘starting gate equality’. This was a new idea for me. We usually think of equal opportunity as a lack of legal barriers to opportunity. Some would forward that a persons economic/social status that they are born into gives more advantages and opportunity based only of the circumstances of birth. This inequality would be seen as a moral justification.

    If you really want a good explanation read the course notes in the links. I am still trying to get the ideas down.


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