I have always appreciated Ray Stevens. I grew up in a musical family--my sons are fifth-generation guitar players (along with other instruments.) And we have always had a thing for the comical songs. I grew up on Allan Sherman and Roger Miller.
On a more serious note, one thing that to me seems to contribute to the "Fortress" issue is the decline of independent doctors. I'm 74 years old. When I was growing up, our physicians had ties to hospitals, but they had their own separate offices. The ones I have seen since I went on Medicare all work out of clinics tied to hospital chains. The man who was my primary care doctor for most of that time once had his own practice; apparently the current circumstances forced him into giving that up. (I moved to another city last fall, and had to find new doctors.) But with less independence, there will be less free thinking, and less innovation.
You are absolutely correct! I struggled as an entrepreneur in the state of Ohio because there had to be two person groups to get insurance, and I was rated with "pre-existing conditions". I survived in the 90s because Kaiser Permanence was then in Cleveland area. In the early 00s insurance became unaffordable so I took a job just to get health insurance. So happy to be on Medicare. Tired of the "3 months to get a hip replacement" in Canada stories. The ultimate test of the success of medicine in a country is lifespans, infant mortality, etc. Been experimenting with Apple AirPods as hearing aids (very disruptive possibly). Next "frontier" is breaking down the data silos that prevent interchange of information between medical providers.
I disagree for two reasons. Countries may differ in whether they classify the death of newborns as infant mortality instead of stillbirth. Also, it is no reflection on a country's health care if the population pursues unhealthy habits such as our national obesity.
Agree very much. I've seen data on U.S. mortality. If you eliminate sudden deaths from violence, we leap to the top (or near the top) in terms of longevity. Similarly, many or most European countries define live births of low birthweight infants as "stillbirths." This artificially lowers the infant mortality rates by a lot.
This is a treat. Adults discussing issues. Didn't know about stillbirths in Europe. But I do know we have agriculture and agribusiness in this country and that is reflecting in our diet. I am a fan of Wendell Berry, since I grew up in NW Ohio farm country.
You were expecting government officials to extol the virtues of free-market approaches?
It might be different if there were a political party attached (1) to some principle altogether and (2) to some principle resembling a principle of the Founding Fathers. Gosh, wouldn’t that be nice?
Nicely done, sir. I was wondering how you'd connect Stengel and Stevens -- is "peripherally" fair?
Anyway, you've said before that we've been asking the wrong questions about health care, but it never clicked until your analogy with IT. To expand that, imagine a world where people rented their iPhones and desktops, paying mysterious fees for the equipment, bandwidth, and time used, all of it prescribed by computer science engineers, and most of it paid for from large communal funds managed by third parties who don't really understand it. Our machines would be the size of Dodge minivans and half as reliable. I can't imagine how to make Kaiser work like Apple, but maybe smart people like you can. I'm old enough to remember when the fancy new HMO's were going to save the day.
And I knew about the Dr Peabody song but had no idea it was that old. Ray appears to have invented the "fungus among us" phrase, where I thought it came from a TV commercial for an athlete's foot remedy. (Remember the Puritan guy intoning "Thou hast brought the fungus among us!"?)
I'm pretty sure that you can't make Kaiser behave like Apple. For the same reason you couldn't make Sperry-Rand behave like Apple. Puritan guy? Sounds familiar. Movie?
The Ray Stevens song brings to mind PDQ Bach's "Do You Suffer?" (same idea in a classical style).
I wish there were a way to get health _insurance_, not prepaid health care. Insurance should cover the big expenses you can't plan for, not the everyday, expected costs. If auto insurance worked like health insurance, we'd bill Allstate for oil changes--and oil changes would doubtless cost twice as much because of the extra paperwork. But paying for healthcare yourself is almost impossible because of the pricing games that hospitals and insurance companies pay.
PDQ's "discoverer" just died. Prof Schickele was a bit miffed that his PDQ Bach albums completely obscured his serious compositions. AFLAC sells policies--mostly in Japan--that really are insurance. The Blues invented the prepaid healthcare "insurance" plans in the 20s and 30s and were fairly open about the fact that the idea was to boost hospital revenues.
There is a good deal wrong with the way health care is provided in the US. First I would like to say that insurance doesn’t equal care. I spent an extra year as a fellow learning a sub specialty to treat post cancer and craiofacial patients. The reimbursements became so poor that even if covered I could no longer treat those patients. I would continue to see patients of record and lose money on every treatment. New patients I sent across state lines to the nearest large medical center.
The year my wife and I had our third child I we had only major medical insurance. Each time the older two and then the third one went to the pediatrician she had to take out the check book and pay the fee. This along with the deductible for the delivery added up to what my wife thought was significant out of pocket costs. As I had my own practice and I paid for medical insurance for myself and my staff I calculated that even with the three children and the birth it cost less to keep the major medical than to buy “regular” insurance. We kept the major medical for a few more years until our state outlawed it as junk insurance. That raised the cost for my family and every one of my employees. Instead of raises the next few years employee costs were mostly made up of increasing premiums.
My third child was born in 1982 I believe the state disallowed major medical only plans in 1984. Or changed the law so that major medical was “price competitive” with traditional medical plans.
I do not think that the Democrats care one bit about health outcomes for individuals. What they care about is winning elections. They concluded correctly that pushing legislation that was promised to improve healthcare for Americans would be popular with voters. If there were any adverse consequences from the laws, they could be blamed on right-wing opposition and be touted as reasons for yet more government meddling. This is why they also support gun control legislation. It gets people to the polls to vote for them because more proposals for gun control sends the message that they care about violence. When the laws don't accomplish anything, they return with demands for more.
As for Republicans, they calculate that full-scale opposition to the Democrats' on health care would lose them voters and therefore compromise with the least damaging aspects of the statist agenda.
Of course, my complaint is more bipartisan. At the state level, medical and hospital groups are happy to legislate and regulate competition away via scope of practice, certificate of need, restrictive licensure, etc.
Megan McArdle convinced me that the original sin of US health care was in the Roosevelt administration, when they allowed firms suffering from the WW2 wage freeze to offer insurance as a perk to entice people to switch jobs.
It is difficult to imagine a plausible way to undo that. Well, difficult for me – perhaps not for you.
That was the biggest original sin, but there were several. Licensure laws from the 1910s on. FDA. The insurance exemption from wage-price freeze, union legislation in the 1950s, Medicare, Medicaid. When I did international finance, I used to say that a country had to go to hell before genuine reforms were possible--that purgatory wouldn't do. Thus far, our healthcare problems have merely been purgatory.
I believe it was after WWII and under the Truman administration. Wage and price controls did reduce wage competition so extra-compensation packages were used to entice workers. Interestingly “the do nothing” Republican Congress that President Truman ran against actually did something very important, they did not reauthorize the depression era new deal laws that were thought to have shortened the depression but the removal of them allowed the US to produce for the war. The concern was that with the war over the country would sink into a depression again. Because the controls were lifted and not replaced the economy took off and instead of a depression there was incredible growth and unemployment.
Yup. Not much doubt in my mind that those New Deal laws greatly prolonged and deepened the Depression. (See Amity Shlaes’s “The Forgotten Man” for a great exposition. There’s even a short, graphic novel version of the book.) Warren Harding faced a deep, grave recession. As promised, he stepped aside, left things alone, and allowed the economy to fix itself. Within months, the economy was roaring, and did so for the next 8 years. (PS: I think you meant “employment,” “not “unemployment”)
The Unsettling of America: Culture and Agriculture, published in 1977. It is the only book of his I have read. People I greatly respect praise some of his fiction. He has taught at the University of Kentucky for years. He has published many books. I’ve spent my whole life in an area bounded by Muncie, Indiana; Cleveland, Ohio; and Athens, Ohio; consequently I appreciate all things rural, even though I never lived on a farm.
Please steal this idea. It won’t solve all our healthcare cost problems or all the regulatory problems interfering with your Frontier, but imo it would go a long way.
Eliminate the “but buying healthcare is not like buying television or hotel rooms - it’s life and death, and no one should be bankrupted for it” problem by:
1) socializing catastrophic care [the federal government pays 95%-99% of healthcare costs above some relatively high annual amount, with the exact amount based on income]
2) only “high deductible” plans (where the consumer has skin in the game) are eligible for tax benefits
3) deregulate everything else about health insurance (with the exception of the “with continuous coverage your insurance rate cannot be jacked up massively for ‘pre-existing condition’”).
No mandated coverages, and if a state imposes them, that state’s residents no longer qualify for the socialized catastrophic care money.
This gets the incentives right.
Catastrophic care is socialized, everything else is a free market like televisions and hotel rooms are (though yes we’ll still need to provide Medicaid…).
I'm afraid these are old established ideas that ended up pleasing no one in the political world. A good bit of this came out of the Heritage Foundation in the 1990s, and they more or less disowned it some time later.
The problem with health care is that progress ain't cheap but everyone thinks it should be. Back when the England established the NHS Penicillin was rather new. It was the original wonder drug. Things that killed people, now didn't. It was also cheap to make. Hey, maybe it could even cure cancer! No, it couldn't. And there were diseases that it wouldn't cure either. But then came the Mycin drugs. They worked on things Penicillin didn't. But still couldn't cure cancer. Also more expensive. Not a lot more but more. Certain things became cheaper. X-Rays. Now even your dentist has one.
You can cure diseases that could not be cured 20 or 30 years ago. But not cheaply. You can preform operations that couldn't be preformed when the NHS was founded. But agin not cheaply. Brain surgery will probably never be cheap, robots and AI or not.
Medicine has gotten better but not cheaper. When it's nationalize they deal with that via long waiting periods (hoping you die first) and other road blocks. Lots of things have gone down in price. Airplane flights as an example. People think medicine should be one of them. It's not. Plus that fact that people now go to the Dr for things they wouldn't have in the past.
People want magic. They want miracle cures, and cheap ones at that. Doubt it's on the horizon anytime soon. If you nationalize medicine you get the long waits unless you are wealthy and sometimes very wealthy. And if what you have is really bad or you waited to long (Steve Jobs) that isn't enough.
There is no solution to the problem. You might be able to make it less complicated and easier but "A" one size fits all solution? You can nibble away at things like the middle man and monopolies but that is still only nibbling.
I think for the foreseeable future inexpensive medicine is not on the horizon.
The demand for medical care is also infinitely expandable. And all the life-extending miracles allow us to live long enough to get really expensive ailments. My father rarely needed any medical care until, at 69, he suddenly went into congestive heart failure. A decade earlier, it would have killed him in a day or two, and his total lifetime healthcare expenditures would been pocket change. However, the bypass had just been invented, and he needed a quintuple. He was back home in a week, back to work, and lived a good 15 additional years. However, those 15 years were punctuated by some really expensive health problems. I'm guessing that he received a million dollars worth of care from the time his heart failure began till he finally died 15 years later.
Yes. So it goes. I'm pretty sure an uncle, a cousin and my mother just got tired and said the heck with it. Didn't exactly commit suicide but got tired of the fight. In my mother's case she had outlived everyone except me. Her brothers and sisters. My father's brothers and sisters (they had all known each other since childhood). Her friends, both older and younger. Her only connection to the world was basically me. And she was in a pain. More than she let on. That's how her generation acted. Took me a while to figure it out. Unpleasant realization when I did. But I understood. The older we get vis-a-vie our peers the more alone we get.
I have always appreciated Ray Stevens. I grew up in a musical family--my sons are fifth-generation guitar players (along with other instruments.) And we have always had a thing for the comical songs. I grew up on Allan Sherman and Roger Miller.
On a more serious note, one thing that to me seems to contribute to the "Fortress" issue is the decline of independent doctors. I'm 74 years old. When I was growing up, our physicians had ties to hospitals, but they had their own separate offices. The ones I have seen since I went on Medicare all work out of clinics tied to hospital chains. The man who was my primary care doctor for most of that time once had his own practice; apparently the current circumstances forced him into giving that up. (I moved to another city last fall, and had to find new doctors.) But with less independence, there will be less free thinking, and less innovation.
Keep those guitars a'strummin. And yes indeedy to your second paragraph.
You are absolutely correct! I struggled as an entrepreneur in the state of Ohio because there had to be two person groups to get insurance, and I was rated with "pre-existing conditions". I survived in the 90s because Kaiser Permanence was then in Cleveland area. In the early 00s insurance became unaffordable so I took a job just to get health insurance. So happy to be on Medicare. Tired of the "3 months to get a hip replacement" in Canada stories. The ultimate test of the success of medicine in a country is lifespans, infant mortality, etc. Been experimenting with Apple AirPods as hearing aids (very disruptive possibly). Next "frontier" is breaking down the data silos that prevent interchange of information between medical providers.
I disagree for two reasons. Countries may differ in whether they classify the death of newborns as infant mortality instead of stillbirth. Also, it is no reflection on a country's health care if the population pursues unhealthy habits such as our national obesity.
Agree very much. I've seen data on U.S. mortality. If you eliminate sudden deaths from violence, we leap to the top (or near the top) in terms of longevity. Similarly, many or most European countries define live births of low birthweight infants as "stillbirths." This artificially lowers the infant mortality rates by a lot.
Tried to explain/show that to grad students in a US Health Policy course. They mostly simply rejected the idea. <sigh>
I never had trouble persuading them, though I believe students are far less open-minded than they were when I last taught (around 7 years ago).
This is a treat. Adults discussing issues. Didn't know about stillbirths in Europe. But I do know we have agriculture and agribusiness in this country and that is reflecting in our diet. I am a fan of Wendell Berry, since I grew up in NW Ohio farm country.
I do not know Mr. Berry, but he looks interesting. Any recommended short works?
You were expecting government officials to extol the virtues of free-market approaches?
It might be different if there were a political party attached (1) to some principle altogether and (2) to some principle resembling a principle of the Founding Fathers. Gosh, wouldn’t that be nice?
Expecting? Never. But there are plenty of folks who THINK they are market-friendly. More often they don’t like markets but love “markets.”
Given that the game is not “heal the sick” but “fleece the taxpayer,” the major league teams are astonishingly good, year in and year out.
Nicely done, sir. I was wondering how you'd connect Stengel and Stevens -- is "peripherally" fair?
Anyway, you've said before that we've been asking the wrong questions about health care, but it never clicked until your analogy with IT. To expand that, imagine a world where people rented their iPhones and desktops, paying mysterious fees for the equipment, bandwidth, and time used, all of it prescribed by computer science engineers, and most of it paid for from large communal funds managed by third parties who don't really understand it. Our machines would be the size of Dodge minivans and half as reliable. I can't imagine how to make Kaiser work like Apple, but maybe smart people like you can. I'm old enough to remember when the fancy new HMO's were going to save the day.
And I knew about the Dr Peabody song but had no idea it was that old. Ray appears to have invented the "fungus among us" phrase, where I thought it came from a TV commercial for an athlete's foot remedy. (Remember the Puritan guy intoning "Thou hast brought the fungus among us!"?)
Peripherally is, indeed, fair. And intentional.
I'm pretty sure that you can't make Kaiser behave like Apple. For the same reason you couldn't make Sperry-Rand behave like Apple. Puritan guy? Sounds familiar. Movie?
No, it was a TV commercial for Tinactin or some such. A group of them pointed at some poor schmo who was appropriately ashamed of his fungus.
The Ray Stevens song brings to mind PDQ Bach's "Do You Suffer?" (same idea in a classical style).
I wish there were a way to get health _insurance_, not prepaid health care. Insurance should cover the big expenses you can't plan for, not the everyday, expected costs. If auto insurance worked like health insurance, we'd bill Allstate for oil changes--and oil changes would doubtless cost twice as much because of the extra paperwork. But paying for healthcare yourself is almost impossible because of the pricing games that hospitals and insurance companies pay.
PDQ's "discoverer" just died. Prof Schickele was a bit miffed that his PDQ Bach albums completely obscured his serious compositions. AFLAC sells policies--mostly in Japan--that really are insurance. The Blues invented the prepaid healthcare "insurance" plans in the 20s and 30s and were fairly open about the fact that the idea was to boost hospital revenues.
There is a good deal wrong with the way health care is provided in the US. First I would like to say that insurance doesn’t equal care. I spent an extra year as a fellow learning a sub specialty to treat post cancer and craiofacial patients. The reimbursements became so poor that even if covered I could no longer treat those patients. I would continue to see patients of record and lose money on every treatment. New patients I sent across state lines to the nearest large medical center.
The year my wife and I had our third child I we had only major medical insurance. Each time the older two and then the third one went to the pediatrician she had to take out the check book and pay the fee. This along with the deductible for the delivery added up to what my wife thought was significant out of pocket costs. As I had my own practice and I paid for medical insurance for myself and my staff I calculated that even with the three children and the birth it cost less to keep the major medical than to buy “regular” insurance. We kept the major medical for a few more years until our state outlawed it as junk insurance. That raised the cost for my family and every one of my employees. Instead of raises the next few years employee costs were mostly made up of increasing premiums.
Interesting. What were the years you were talking about?
My third child was born in 1982 I believe the state disallowed major medical only plans in 1984. Or changed the law so that major medical was “price competitive” with traditional medical plans.
I do not think that the Democrats care one bit about health outcomes for individuals. What they care about is winning elections. They concluded correctly that pushing legislation that was promised to improve healthcare for Americans would be popular with voters. If there were any adverse consequences from the laws, they could be blamed on right-wing opposition and be touted as reasons for yet more government meddling. This is why they also support gun control legislation. It gets people to the polls to vote for them because more proposals for gun control sends the message that they care about violence. When the laws don't accomplish anything, they return with demands for more.
As for Republicans, they calculate that full-scale opposition to the Democrats' on health care would lose them voters and therefore compromise with the least damaging aspects of the statist agenda.
Of course, my complaint is more bipartisan. At the state level, medical and hospital groups are happy to legislate and regulate competition away via scope of practice, certificate of need, restrictive licensure, etc.
Megan McArdle convinced me that the original sin of US health care was in the Roosevelt administration, when they allowed firms suffering from the WW2 wage freeze to offer insurance as a perk to entice people to switch jobs.
It is difficult to imagine a plausible way to undo that. Well, difficult for me – perhaps not for you.
That was the biggest original sin, but there were several. Licensure laws from the 1910s on. FDA. The insurance exemption from wage-price freeze, union legislation in the 1950s, Medicare, Medicaid. When I did international finance, I used to say that a country had to go to hell before genuine reforms were possible--that purgatory wouldn't do. Thus far, our healthcare problems have merely been purgatory.
I believe it was after WWII and under the Truman administration. Wage and price controls did reduce wage competition so extra-compensation packages were used to entice workers. Interestingly “the do nothing” Republican Congress that President Truman ran against actually did something very important, they did not reauthorize the depression era new deal laws that were thought to have shortened the depression but the removal of them allowed the US to produce for the war. The concern was that with the war over the country would sink into a depression again. Because the controls were lifted and not replaced the economy took off and instead of a depression there was incredible growth and unemployment.
Yup. Not much doubt in my mind that those New Deal laws greatly prolonged and deepened the Depression. (See Amity Shlaes’s “The Forgotten Man” for a great exposition. There’s even a short, graphic novel version of the book.) Warren Harding faced a deep, grave recession. As promised, he stepped aside, left things alone, and allowed the economy to fix itself. Within months, the economy was roaring, and did so for the next 8 years. (PS: I think you meant “employment,” “not “unemployment”)
Correct unemployment. I am at the age where editing on the IPhone is beyond my ken.
The politicians and medicrats believe 'money is the root of all fixes'.
$$$
The Unsettling of America: Culture and Agriculture, published in 1977. It is the only book of his I have read. People I greatly respect praise some of his fiction. He has taught at the University of Kentucky for years. He has published many books. I’ve spent my whole life in an area bounded by Muncie, Indiana; Cleveland, Ohio; and Athens, Ohio; consequently I appreciate all things rural, even though I never lived on a farm.
Please steal this idea. It won’t solve all our healthcare cost problems or all the regulatory problems interfering with your Frontier, but imo it would go a long way.
Eliminate the “but buying healthcare is not like buying television or hotel rooms - it’s life and death, and no one should be bankrupted for it” problem by:
1) socializing catastrophic care [the federal government pays 95%-99% of healthcare costs above some relatively high annual amount, with the exact amount based on income]
2) only “high deductible” plans (where the consumer has skin in the game) are eligible for tax benefits
3) deregulate everything else about health insurance (with the exception of the “with continuous coverage your insurance rate cannot be jacked up massively for ‘pre-existing condition’”).
No mandated coverages, and if a state imposes them, that state’s residents no longer qualify for the socialized catastrophic care money.
This gets the incentives right.
Catastrophic care is socialized, everything else is a free market like televisions and hotel rooms are (though yes we’ll still need to provide Medicaid…).
To the Frontier…
I'm afraid these are old established ideas that ended up pleasing no one in the political world. A good bit of this came out of the Heritage Foundation in the 1990s, and they more or less disowned it some time later.
The problem with health care is that progress ain't cheap but everyone thinks it should be. Back when the England established the NHS Penicillin was rather new. It was the original wonder drug. Things that killed people, now didn't. It was also cheap to make. Hey, maybe it could even cure cancer! No, it couldn't. And there were diseases that it wouldn't cure either. But then came the Mycin drugs. They worked on things Penicillin didn't. But still couldn't cure cancer. Also more expensive. Not a lot more but more. Certain things became cheaper. X-Rays. Now even your dentist has one.
You can cure diseases that could not be cured 20 or 30 years ago. But not cheaply. You can preform operations that couldn't be preformed when the NHS was founded. But agin not cheaply. Brain surgery will probably never be cheap, robots and AI or not.
Medicine has gotten better but not cheaper. When it's nationalize they deal with that via long waiting periods (hoping you die first) and other road blocks. Lots of things have gone down in price. Airplane flights as an example. People think medicine should be one of them. It's not. Plus that fact that people now go to the Dr for things they wouldn't have in the past.
People want magic. They want miracle cures, and cheap ones at that. Doubt it's on the horizon anytime soon. If you nationalize medicine you get the long waits unless you are wealthy and sometimes very wealthy. And if what you have is really bad or you waited to long (Steve Jobs) that isn't enough.
There is no solution to the problem. You might be able to make it less complicated and easier but "A" one size fits all solution? You can nibble away at things like the middle man and monopolies but that is still only nibbling.
I think for the foreseeable future inexpensive medicine is not on the horizon.
The demand for medical care is also infinitely expandable. And all the life-extending miracles allow us to live long enough to get really expensive ailments. My father rarely needed any medical care until, at 69, he suddenly went into congestive heart failure. A decade earlier, it would have killed him in a day or two, and his total lifetime healthcare expenditures would been pocket change. However, the bypass had just been invented, and he needed a quintuple. He was back home in a week, back to work, and lived a good 15 additional years. However, those 15 years were punctuated by some really expensive health problems. I'm guessing that he received a million dollars worth of care from the time his heart failure began till he finally died 15 years later.
Yes. So it goes. I'm pretty sure an uncle, a cousin and my mother just got tired and said the heck with it. Didn't exactly commit suicide but got tired of the fight. In my mother's case she had outlived everyone except me. Her brothers and sisters. My father's brothers and sisters (they had all known each other since childhood). Her friends, both older and younger. Her only connection to the world was basically me. And she was in a pain. More than she let on. That's how her generation acted. Took me a while to figure it out. Unpleasant realization when I did. But I understood. The older we get vis-a-vie our peers the more alone we get.