Healthcare Costs

SpaceX launched its huge Super Heavy-Starship mega rocket on its seventh test flight Thursday, successfully "catching" the first stage booster back at its firing stand but losing its new-generation Starship upper stage spacecraft, which apparently broke up as it was reaching space. Falling debris from the destroyed Starship briefly delayed airline traffic out of Miami, Florida, federal officials said.

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Donald Trump wants to create 'Freedom Cities.' The Federal Government owns more than half of Oregon, Utah, Nevada, Idaho, and Alaska and  nearly half of California, Arizona, New Mexico, and Wyoming.
The vast majority of this land is NOT parks.

Why would the federal government own so much land?
There is plenty of land to build new cities that could be adapted to new technologies such as driverless cars and drones.

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80% of the top 100 Lowell Putnam Math Competition scores are from MIT.

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Our industrial civilization has lasted roughly 300 years (dating, for example, from the beginning of mass production methods and power sources). This is a small fraction of the time we have existed as a species, and a tiny fraction of the time that complex life has existed on the Earth's land surface. 

Amazingly, economists, historians, sociologists, and philosophers can look at that tiny sliver and generalize.

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Healthcare Costs

An interesting article on health costs after the strange murder of the United CEO:

Insurance companies just don’t make that much profit. UnitedHealth Group, the company of which Brian Thompson’s UnitedHealthcare is a subsidiary, is the most valuable private health insurer in the country in terms of market capitalization, and the one with the largest market share. Its net profit margin is just 6.11%:

That’s only about half of the average profit margin of companies in the S&P 500. And other big insurers are even less profitable. Elevance Health, the second-biggest, has a margin of between 2% and 4%. Centene’s margin is usually around 1% to 2%. Cigna Group’s margin is usually around 2% to 3%. And so on. These companies are just making very little profit at all.

if UnitedHealth Group decided to donate every single dollar of its profit to buying Americans more health care, it would only be able to pay for about 9.3% more health care than it’s already paying for. If it donated all of its executives’ salaries to the effort, it would not be much more than that.

Americans’ much-hated private health insurers are paying a higher percentage of the cost of Americans’ health care than the government insurance systems of Sweden, Denmark, and the UK are paying. The only reason Americans’ bills are higher is that U.S. health care provision costs so much more in the first place.

Elizabeth Warren has claimed that switching to national health insurance would save huge amounts of money by reducing administrative costs. But when we look at United Health Group’s operating costs, they’re only 22.6% of the actual cost of medical care.

In fact, the Kaiser Family Foundation does detailed comparisons between U.S. healthcare spending and spending in other developed countries. And it has been concluded that most of this excess spending comes from providers — from hospitals, pharma companies, doctors, nurses, tech suppliers, and so on.

This means that eliminating all administrative waste and inefficiency in the entire U.S. health care system — not just at insurance companies, but administration of government insurance programs — could save Americans at most about $680 per person every year, and probably not anywhere close to that amount. A few hundred bucks a year is not nothing, but it’s only a small fraction of the $5683 more that we pay relative to other countries.

So the fundamental reason your health care costs so much is not that the health insurance companies are lining their pockets. And it’s not that insurers are an inefficient mess. It’s that the actual provision of America’s health care itself just costs way too much in the first place.

The actual people charging you an arm and a leg for your care, and putting you at risk of medical bankruptcy, are the providers themselves.

So the way to make our health care system affordable is not to browbeat insurers, in the hope that they will be able to reduce their profits and pay for us to have cheap health care. Insurance companies simply do not have the power to do that, even if you threaten to shoot them. What we need is to reduce costs within the actual medical system itself. One idea is to have the government insurance system play hardball with providers; negotiating lower prices is what the Biden administration had Medicare do with some drug companies. There are some risks to this approach — if it’s executed clumsily it can suppress innovation — but it’s basically what every other rich country does, so the track record is decent. There are probably other ways to foster competition and increase efficiency in the medical care system.

But focusing all our anger on the middlemen of the U.S.’ bloated health care system is just a way of shooting the messenger.--Noah Smith

Stats/"Is Schrödinger's Cat Male?"

             Stats/"Is Schrödinger's Cat Male?"

A characteristic of the modern West is the peripheral has moved to the center. Everyone is in the spotlight. This change in how we think is as important as what we think. Some stats and perspectives. (Some of this information is presented from reviews written when these questions were thought to be illnesses. The DSM-5 still classifies GD as a diagnosis.)

Gender dysphoria (GD) according to Diagnostic and Statistical Manual of Mental disorders (DSM 5) is defined as a “marked incongruence between their experienced or expressed gender and the one they were assigned at birth.” It was previously termed "gender identity disorder."

Children or adolescents who experience this turmoil cannot correlate to their gender expression when identifying themselves within traditional societal binary male or female roles, which may cause cultural stigmatization.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, gender dysphoria prevalence accounts for 0.005–0.014% of the population for biological males and 0.002–0.003% for biological females. In both Japan and Poland, the prevalence of gender dysphoria is higher in biological females.

According to the DSM-V, as many as 98% of gender confused boys and 88% of gender confused girls eventually accept their biological sex after naturally passing through puberty.

Rates of suicide are twenty times greater among adults who use cross-sex hormones and undergo sex reassignment surgery, even in Sweden which is among the most LGBQT-affirming countries.

Disorders of Sexual Development (DSD) are human illnesses that cause the development of ambiguous genitalia in newborns and children. This is not dysphoria.

Most DSDs can be diagnosed and the outcomes predicted; physicians use the diagnosis to advise parents on which gender the child is likely to identify with. For instance, the most common cause for a DSD is congenital adrenal hyperplasia — which can result in ambiguous genitalia for XX children. This is an illness of the adrenal glands where steroids are made imperfectly. This is a treatable biochemical defect. Between 90% and 95% of people with the condition identify as female.
Adrenogenital syndrome is 100% curable. (This was the condition of the Press sisters, two women who were untreated by the Soviet state so that they could compete in women's international sports. Tamara Press dominated the women's field events in the late 50s and 60s.}

As many as 1 out of 30,000 adult males seek sexual reassignment surgery (sex change).

At least 1 out of 100,000 adult females seek sexual reassignment surgery (sex change).

About 80% of mothers and 45% of fathers of individuals with Gender Identity Disorder had a psychiatric problem or had psychiatric treatment.
About 24% of children live with their mothers only, with the absence of a father or surrogate father figure at home according to the 2012 U.S. Census figure (double the 1977 figure.)
In homes of boys that are severely disturbed with Gender Identity Disorder, the father is absent 100% of the time.

According to a recent national survey, 1.4 million individuals (0.6%) in the United States identify as transgender.

Complete androgen insensitivity syndrome affects 2 to 5 per 100,000 people who are genetically male. Partial androgen insensitivity is thought to be at least as common as complete androgen insensitivity. Mild androgen insensitivity is much less common. In androgen insensitivity, male hormones and anatomy are normal but the cells do not recognize androgen stimulation and do not develop maleness. This, like the adrenogenital syndrome, results in a true dichotomy between the genetic and phenotypic. 

The model Hanne Gaby Odiele in 2015.

8,920: number of provisionally reported TB cases in the United States in 2019 (a rate of 2.7 per 100,000 persons) .

Testicular cancer occurs in about 1 in 100,00.

Birth defects affect one in every 33 babies (about 3% of all babies) born in the United States each year.

Each year, about 6,000 babies born in the United States have Down syndrome. This means that Down syndrome occurs in about 1 in every 700 babies.

So, how does the psychodynamic work? Or is this just a variation of the gender spectrum? And the DMS-5 definition implies "distress;" what about those who experience no distress? 

An opinion from an article on Johns Hopkins' McHugh, who works the dynamic side. A piece: "Dr. McHugh does not believe surgery cures gender dysphoria. He thinks that condition, along with anorexia and body dysmorphia, is a “disorder of assumption,” characterized by an “overvalued idea,” or a ruling passion that “fulminates in the mind of the subject, growing more dominant over time, more refined, and more resistant to challenge,” as he has written.
In the case of anorexia, the overvalued idea is that it’s good to be thin. The primary goal of the psychiatrist ought to be to help the patient change behavior. The prevailing standard of care for sufferers of gender dysphoria—“affirmative care”—is the opposite: It calls for mental-health professionals to accept both a patient’s self-diagnosis of gender dysphoria and the corresponding behavior."

We are in a fascinating time where we minutely search for norms. But that search is beginning to include diverse seekers. All data is available for comment and available to all. It is a time where the removed observer is at a disadvantage.

Munchausen’s Syndrome by Proxy

 

                                 Munchausen’s Syndrome by Proxy

Munchausen’s Syndrome by Proxy (MSbP) is a mental illness in which the sufferer fantasizes that others–usually people in their charge, such as children–are suffering from serious illness and require drastic medical intervention.

Pirong argues that the West's leadership is suffering from MSbP as evidenced by their behavior toward Covid 19.

The obsession with Covid-19 has the monomaniacal focus on “cases” (usually the result of hypersensitive tests prone to false positives), with the belief that people who test positive are sick, and huge numbers of those who become sick will die.

Given the actual experience over the last several months, these beliefs are wildly exaggerated–imaginary, fantasized illnesses, with fantasized severity, just the kind of thing that a sufferer of MSbP does.

And there’s more to the diagnosis. MSbP sufferers subject the people whom they imagine are ill with suffocating attention and unnecessary, and often harmful, health-related interventions. You know, like lockdowns; draconian restrictions on movement, social contact, and other features of everyday life; the shutting down of schools and colleges; and strident demands to wear masks–even between bites of your meal if you are in California.

This distinction between diagnosis and illness is a growing, important concept.   

Genetic Variation and Strain

The Steele Dossier prompts an important question: To what lengths will a politician go to advance himself? What is beneath a politician?


                            Genetic Variation and Strain

A reader of Cowen offers two theories on the virus and its variable behavior:

1. Genetic variation

This means variation in the genetics of people (not the virus). We already know that (a) mutation in single genes can lead to extreme susceptibility to other infections, e.g Epstein–Barr (usually harmless but sometimes severe), tuberculosis; (b) mutation in many genes can cause disease susceptibility to vary — diabetes, heart disease are two examples, which is why when you go to the doctor you are asked if you have a family history of these.

It is unlikely that COVID was type (a), but it’s quite likely that COVID is type (b). In other words, I expect that there are a certain set of genes which (if you have the “wrong” variants) pre-dispose you to have a severe case of COVID, another set of genes which (if you have the “wrong” variants) predispose you to have a mild case, and if you’re lucky enough to have the right variants of these you are most likely going to get a mild or asymptomatic case

2. Strain

It’s now mostly accepted that there are two “strains” of COVID, that the second arose in late January and contains a spike protein variant that wasn’t present in the original ancestral strain, and that this new strain (“D614G”) now represents ~97% of new isolates. The Sabeti lab (Harvard) paper from a couple of days ago is a good summary of the evidence. https://www.biorxiv.org/content/10.1101/2020.07.04.187757v1

— note that in cell cultures it is 3-9x more infective than the ancestral strain. Unlikely to be that big of a difference in humans for various reasons, but still striking/interesting.

Almost nobody was talking about this for months, and only recently was there any mainstream coverage of this. You’ve already covered it, so I won’t belabor the point.

So could this explain Asia/hetereogeneities? We don’t know the answer, and indeed it is extremely hard to figure out the answer (because as you note each country had different policies, chance plays a role, there are simply too many factors overall).

Plagues and Stats

                                  Plagues and Stats

The plague was caused by Yersinia pestis (or Y. pestis), a bacillus carried by fleas that live primarily on rats and other rodents that were common in medieval dwellings. Y. pestis causes three varieties of plague: bubonic plague, caused by bites from infected fleas, in which the bacteria moves to lymph nodes and quickly multiplies, forming growths, or buboes; pneumonic plague, a lung infection that causes its victim to cough blood and spread the bacteria from person to person; and septicemic plague, a blood infection that is almost always fatal.
A plague epidemic swept through Europe from 1348 through 1351, killing an estimated 25–60% of Europeans. Some estimates are as high as 2/3 of the population. Current estimates are that between 75 and 200 million people died from the plague. The pneumonic plague killed 90-95% of its victims. The septicemic plague killed nearly 100% of the people it infected and still has no cure to this day. Although the period known as the Black Death ended in 1351, the plague continued to return to Europe, with epidemics every few years through the end of the 15th century. A third plague pandemic began in China and India in the 1890s and eventually reached the United States. The Black Death was the second plague pandemic of the Middle Ages. Justinian’s Plague in the 6th century was deadly and widespread, but did not create the same devastation as the second pandemic.

In 2002 and 2003, SARS infected more than 8,000 people worldwide, and more than 700 of them ended up dying.

The global mortality rate from the 1918/1919 pandemic is not known, but an estimated 10%, (and up to 20%), of those who were infected died. With about a third of the world population infected, this case-fatality ratio means 3% to 6% of the entire global population died.


The Chinese bird flu, H7N9, is said to have a human mortality rate of 30 to 39 percent.

So, It's Worse Than You Think

                     So, It's Worse Than You Think

Models. What a nightmare. Here is an article from Israel--and commented on by Townhall--that Don sent showing some problems, real problems, that reasonable and able people have when asked for an answer to a complex question: Predict the future when an organism we do not know reacts with the human immunologic system that has never seen it before. And decisions on the estimated behavior have to be made by politicians, totally ignorant of the science and perhaps of abilities limited only to refined mendacity, who will be judged and vilified by press members who finished behind them in high school.

Professor Yitzhak Ben Israel of Tel Aviv University, who also serves on the research and development advisory board for Teva Pharmaceutical Industries, plotted the rates of new coronavirus infections of the U.S., U.K., Sweden, Italy, Israel, Switzerland, France, Germany, and Spain. The numbers told a shocking story: irrespective of whether the country quarantined like Israel, or went about business as usual like Sweden, coronavirus peaked and subsided in the exact same way. In the exact, same, way. His graphs show that all countries experienced seemingly identical coronavirus infection patterns, with the number of infected peaking in the sixth week and rapidly subsiding by the eighth week.

The Wuhan Virus follows its own pattern, he told Mako, an Israeli news agency. It is a fixed pattern that is not dependent on freedom or quarantine. “There is a decline in the number of infections even [in countries] without closures, and it is similar to the countries with closures,” he wrote in his paper. 

“Is the coronavirus expansion exponential? The answer by the numbers is simple: no. Expansion begins exponentially but fades quickly after about eight weeks,” Professor Yitzhak Ben Israel concluded. The reason why coronavirus follows a fixed pattern is yet unknown. "I have no explanation,” he told Mako, “There are is kinds of speculation: maybe it's climate-related, maybe the virus has its own life cycle.” 

But what about Italy and their staggering 12% mortality rate? “The health system in Italy has its own problems. It has nothing to do with coronavirus. In 2017 it also collapsed because of the flu,” Professor Yitzhak Ben Israel told the news agency. Indeed, Italy’s exceptionally high coronavirus mortality rate is eerily reminiscent of their unusually high flu mortality rates. Supportive of this theory, Germany, has low flu infection and mortality rates and similarly low coronavirus rates.

Professor Yitzhak Ben Israel concludes in his analysis summary paper that the data from the past 50 days indicates that the closure policies of the quarantine countries can be replaced by more moderate social distancing policies. The numbers simply do not support quarantine or economic closure. 

On the reasonableness of Israel’s unprecedented quarantine and closure, he commented to the news agency, “I think it's mass hysteria. I have no other way to describe it. 4,500 people die each year from the flu in Israel because of complications, so close the country because of that? No. I don't see a reason to do it because of a lower-risk epidemic.” 

While the American policies remain less restrictive than those of Israel, it is important to understand the origins of our own “mass hysteria” response. President Trump urged a strong coronavirus response after consulting with Dr. Fauci and his team, who relied on a British model predicting 2.2 million deaths in the United States and 500,000 deaths in the U.K. But that model was developed by Professor Neil Ferguson, who had a history of wildly overestimating death rates through his prediction models. Professor Ferguson was not known for his reliability, and his 2001 disease model was criticized as “not fit for purpose” after it predicted that up to 150,000 people could die in the U.K. from mad cow disease (177 deaths to date). Ferguson’s U.K. coronavirus deaths prediction is now down to 20,000 people, 4% of the original prediction.

Professor Yitzhak Ben Israel has mathematically shown us that coronavirus closures were a mistake. It's a tough reality. Americans lost their jobs and businesses went under because the United States, along with most first world nations, acted on the chilling predictions of a severely flawed model, a reading of Professor Ferguson’s tarot cards. Hindsight is 20/20, so we have to be realistic with our criticism. President Trump did not want 2.2 million Americans to die and did what he thought was necessary to save our lives, relying on a model his advisors told him was trustworthy. It's done. It happened. But it doesn't mean that he should continue the course. 

It’s been one month since our country declared a national coronavirus emergency and life as we knew it had ceased.  

Is a Shutdown an Overreaction?

From a blog by a guy named Mulligan. It got some angry response. The 90K is a bit hard for me to believe, based on the South Korean numbers:

                     Is a Shutdown an Overreaction?

60,000 - 80,000 Americans died from the 2017-18 flu, without exceeding the capacity of ICU beds. This flu was experienced around the world. Not a single country found it worth shutting down their economies in that situation.

In 2020 the forecast is that about 90,000 Americans will die from COVID-19, including some deaths due to insufficient ICU capacity. Shutting down "nonessential" businesses is now the norm.

This forecast comes from the Institute for Health Metrics and Evaluation IMHE at the University of Washington. Unlike me, IMHE are not amateurs with contagious disease time series. With "about 500 statisticians, computer scientists, and epidemiologists on staff, IHME is a data-crunching powerhouse. Every year it releases the Global Burden of Disease study...."

At what point is a reasonable person allowed to ask why the economic policies of 2017-18 and 2020 are so disproportionate?
Some people will say that the 90,000 would have been much higher without shutting down the economy. At what point can a reasonable person follow up with "Why were ALL of the 2020 costs, which were in the $ trillions, taken on the economic (and civil liberty) side of the ledger, and essentially NONE on the mortality side?"

The Cost of the Outlier

                             

                           The Cost of the Outlier




One of the problems in modern life is our inability to face things squarely. This is probably a good thing; the terrible inevitable outcome of life might otherwise paralyze us, the risks of daily living send us to the basement. But the hard questions are beginning to become elephant-in-the room-like. The East Germans solved the problem of drunk driving years ago this way: If you tested positive for any alcohol on blood test initiated by a breathalyzer, the State took the car you were driving. There was no appeal. 
The basic question seems to be this: To what lengths will we go to deal with the outlier?

This is from a 538 article:

https://fivethirtyeight.com/features/what-should-the-government-spend-to-save-a-life/




New York Gov. Andrew Cuomo dismissed Trump’s push to get the economy moving again, saying, “No American is going to say, ‘accelerate the economy at the cost of human life.’ Because no American is going to say how much a life is worth.”

Cuomo’s sentiment might be a nice bit of political rhetoric, but it’s not really true. Economists might not be able to say how much an individual person’s existence is worth, but they have figured out a way to calculate how much the average person is willing to pay to reduce the risk of death — which allows them to put a price tag on the collective value of saving one life. That figure, which currently hovers somewhere around $9 or $10 million, is known as the “value of statistical life,” and it’s the basis for all kinds of high-stakes decisions that involve tradeoffs between public safety and economic cost — from food and automobile regulations to our responses to climate change.

As cold-blooded as it might seem, several economists told me that, at least in theory, a pandemic is exactly the kind of situation this metric is designed to help with. “Essentially, we’re trying to figure out what our society is willing to pay to reduce the risk of mortality,” said W. Kip Viscusi, an economist at Vanderbilt University and one of the leading experts on these calculations. “In that sense, a pandemic isn’t so different from a terrorist attack or a pollutant that’s threatening to kill large numbers of people — it’s just happening very quickly and on a very large scale.”

Plague

In 1918, the influenza pandemic took the lives of more people than died in World War I; it was the most devastating epidemic recorded in world history.  It infected 500 million people around the world, including people on remote Pacific islands and in the Arctic, and resulted in the deaths of 50 to 100 million. You could not hide.

In two years, a fifth of the world's population was infected. The flu was most deadly for people ages 20 to 40, unusual for influenza which is usually a killer of the elderly and young children. It infected 28% of all Americans (Tice). An estimated 675,000 Americans died of influenza during the pandemic, ten times as many as in the world war. Of the U.S. soldiers who died in Europe, half of them fell to the influenza virus and not to the enemy. An estimated 43,000 servicemen mobilized for WWI died of influenza (Crosby). 

Compare this to the Black Death. The Black Death is estimated to have killed 30–60% of Europe's total population. In total, the plague may have reduced the world population from an estimated 450 million down to 350–375 million in the 14th century. It took 200 years for the world population to recover to its previous level. The plague recurred as outbreaks in Europe until the 19th century.

The most widely accepted estimate for the Middle East, including Iraq, Iran and Syria, during this time, is for a death rate of about a third. The Black Death killed about 40% of Egypt's population. Half of Paris's population of 100,000 people died. In Italy, the population of Florence was reduced from 110,000–120,000 inhabitants in 1338 down to 50,000 in 1351. At least 60% of the population of Hamburg and Bremen perished, and a similar percentage of Londoners may have died from the disease as well. In London approximately 62,000 people died between the years between 1346 and 1353. Before 1350, there were about 170,000 settlements in Germany, and this was reduced by nearly 40,000 by 1450. In 1348, the plague spread so rapidly that before any physicians or government authorities had time to reflect upon its origins, about a third of the European population had already died. In crowded cities, it was not uncommon for as much as 50% of the population to die. The disease bypassed some areas, and the most isolated areas were less vulnerable to contagion. Monks and priests were especially hard-hit since they cared for victims of the Black Death.
Caregivers always die first.

(couple of sources, incl wiki)

Canadian Medicine

​

In 2014, more than 50,000 Canadians left the country for medical treatment, a 25 percent increase from the previous year. A similar number left the country for treatment in 2015. 63,000 left in 2017.

The Fraser Institute released a study last year showing that wait times in Canada were on the increase and had hit an all-time high in more than two decades of the think tank conducting the survey. Patients reported waiting up to 20 weeks for “medically necessary” procedures such as organ transplants and heart surgery. Experts have blamed this increase in wait times on a number of factors, including different branches and departments of provincial government not communicating effectively, a lack of doctors in some areas, and people living longer and therefore requiring more care.

“Everyone has access to free medical care that is ‘good enough.’ If you want to pay for better health care, you can’t. That’s why those who can afford to, tend to go down to the U.S. for care if they have anything serious happen to them. You can have the greatest doctors in the world, but if the bureaucrats that run the system are making them treat patients with one hand tied behind their back, are they going to be delivering the best possible care?”(one of the Frazier researchers)

Whatever the underlying causes of these excessively long wait times or the motivation of patients to seek quicker medical treatment, they are leading some to worry that medical tourism is creating a two-tier system: one in which the wealthy can afford to get quicker treatment and the poor have to wait or go without.

 

Jeremy Snyder, a professor at Simon Fraser University's faculty of health sciences, said the Fraser Institute is sending a strong message that Canada has a big medical tourism problem due to massive wait times at home, which is not true.  "While we do know that a lot of Canadians are going abroad for care, the numbers the Fraser Institute is producing in this report aren't really accurate," Snyder told CTV News. "I don't think there's a really strong backing for them."
Snyder said there is no question that wait times are an issue in the Canadian health-care system and that some Canadians seek medical care elsewhere. But they do so for a number of different reasons, he said.

​
And there is another element, to quote  the advice to Dustin Hoffman: Plastics. The number of plastic surgery procedures (not covered by most state insurances) is not revealed here.
And Frazier has some Koch funding--everybody has a motive.

Health Care, American and British

As the battle on Quora over medical care in the U.S. and G.B. continues, this from some studies in 2016:

A recent study found older women are three times as likely to die from breast cancer in England compared with other European nations.

Research on 120,000 patients over the age of 70 shows a gulf in survival between different nations, with major differences in access to surgery and other treatment.

For every three women in England who is diagnosed early, yet dies within five years, just one life is lost in Belgium.
A previous study found that in some areas, no women over the age of 75 were being offered surgery for breast cancer, despite legislation which came into force in 2012 making it illegal to deny treatment on the basis of age.

Legislation was necessary?
 

A study of 1,000 elderly cancer patients found four in five believed they had fallen victim to age discrimination, with some saying they had been wrongly told they were too old for breast cancer screening, while others has been refused treatment.

Every transaction is influenced in some way. This is certainly one way of controlling costs. Loving your triage agent helps too.

Triage

Cost, Price and Triage


The cost of medical care has always been confusing because the target has been the collective cost, not the price of individual encounters. And people often confuse cost with price. For example increasing availability of providers would presumably drive the cost of their services down but might increase the aggregate cost by making them more affordable to marginal patients. The classic way of managing this problem is through restricted access. The free market restricts on the basis of expense; not everyone can afford dental care or plastic surgery so not everyone gets it. Government controlled systems control access through bureaucracy--meeting arbitrary milestones and restricted access through bottlenecks. Should a drug addict get a liver transplant? Should an eighty year old man get dialysis?


Survey results this week showing that a third of people with chronic or persistent illnesses who had been rejected for insurance claims said their conditions worsened following the rejection. According to CBS, the survey is the latest development “in the ongoing tug of war between doctors, pharmaceutical companies and insurers over just how much insurers should be involved in the decision-making role for patient care.” The article adds that this study may “raise questions about how insurance practices have changed,” in particular, since the ACA took effect.


Health insurers denied coverage for nearly a quarter of the Americans with chronic conditions or persistent illnesses. The U.S. General Accounting Office study based on early 2010 data indicated that denials then were only 19 percent, and a study by the American Medical Association in 2013 found that figure even lower. 


The desire to feel better is universal. Resources are not. That conflict must be resolved in some way.  After all, politicians cannot repeal the laws of supply and demand, they just say they can. Costs can sometimes be pressured but price is arbitrary. The essence of decreasing price is where, and how, to create the shortages.

Rago

Joe Rago of the WSJ died this week at the age of 34. He had won a Pulitzer Prize.
Here is an excerpt from his article on the ACA just before it was passed,  "The Obamacare Crossroads," March 20, 2010:

Democrats are on the cusp of a profound and historic mistake, comparable in our view to the Smoot-Hawley tariff and FDR's National Industrial Recovery Act. Everyone is preoccupied now with the politics, but ultimately at stake on Sunday is the kind of country America will be. . . . In our world of infinite wants but finite resources, there are only two ways to allocate any good or service: either through prices and the choices of millions of individuals, or through central government planning and political discretion. This choice is inexorable. Stripped of its romantic illusions, ObamaCare is really about who commands the country's medical resources. . . .
A self-governing democracy can of course decide that it wants to become this kind of super-welfare state. But if the year-long debate over ObamaCare has proven anything, it is that Americans want no such thing. . . . The ugliness of the bill, and of its passage, means that some or all of it might be repealable, but far better not to make the tragic mistake in the first place.

Some Health Care Musings

One of the many problems of this year's terrible election is the failure of anyone to make sense out of the nation's significant multi-faceted problems. Both the press and the esteemed candidates are content with insults and shallow personal revelations but resistant to anything of substance. Questions about the national debt, the direction of the deficit, the underfunded pension funds, the growing entitlements, the rise of hostile and well armed self-declared enemies, the obvious security problems in both government and industry, terrorism--all of these topics are ignored for the apparently more important topics of accusations of misogynies, bribery, spousal infidelities, crypto-fascism and religious bigotry.

One topic that should be of interest is health care, an area the federal government has volunteered for more and more responsibility. The Obama administration has spent mush of its political capital in the creation of what they feel is a health care solution. The debate over the Affordable Care Act is intense and partisan but strangely is an untouched area in the national campaign. What is more surprising is that Hillary Clinton, for all her faults, is uniquely qualified to comment upon it as she designed an overhaul of medical care while her husband was president. Still, she has said little. One might wonder why. Maybe, as with so much of her responses, she really does not remember. Or, more likely, we poor working stiffs do not deserve or --more likely--would be scared witless to know.

As you will see, a lot is known. And there is plenty of room for discussion. But we have become a people of fortitude who have leaders of single-mindedness. Those qualities are quite different.
Here are a few graphs and statistics to ponder from recent national articles on the state of the health of health care. Ponder on:


                  

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The costs of providing health care to an average American family surpassed $25,000 for the first time in 2016 — even as the rate of health cost increases slowed to a record low, a new analysis revealed.

The $25,826 in health-care costs for a typical family of four covered by a employer-sponsored "preferred provider plan" is $1,155 higher than last year, and triple what it cost to provide health care for the same family in 2001, the first year that Milliman Medical Index analysis was done.


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2010, prescription drug costs grew by just 1.2 percent while hospital and physician costs grew by 4.9 percent.
 

A 2014 study by the private American foundation The Commonwealth Fund found that although the U.S. health care system is the most expensive in the world, it ranks last on most dimensions of performance when compared with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom. Recent studies find growing gaps in life expectancy in the U.S.based on income and geography.

The United States life expectancy of 78.4 years at birth, up from 75.2 years in 1990, ranks it 50th among 221 nations, and 27th out of the 34 industrialized OECD countries, down from 20th in 1990.

Some errors in comparisons exist in how infant mortality is determined. There is also a risk in the U.S. of violent death in young people--homicides and auto accidents--that other countries do not experience and which weigh heavily upon American cost and survival statistics.

Wasteful spending likely accounts for between one-third and one-half of all U.S. health care spending. PricewaterhouseCoopers calculates that up to $1.2 trillion, or half of all health care spending, is the result of waste. An Institute of Medicine (IOM) report estimated unnecessary health spending totaled $750 billion in 2009 alone. The biggest area of excess is defensive medicine, including redundant, inappropriate or unnecessary tests and procedures.

How these determinations are made are not clearly known but many studies include "bad lifestyles" like smoking, drinking and obesity as "waste."  For example, obesity accounts for an estimated 12 percent of the health spending growth in recent years.

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A Yahoo Finance analysis places the health insurance sector’s average profit margin in 2012 at just 4.5 percent. But admin costs are 27-30%.  By comparison, major drug manufacturers have an average profit margin of 16.7 percent; medical instrument and supply companies, 13.6 percent; biotechnology, 11.9 percent; and medical appliance and equipment companies, 13.7 percent

Health care spending will account for nearly 20 percent of gross domestic product (GDP), or one-fifth of the U.S. economy, by 2021.

58% of US community hospitals are non-profit, 21% are government owned, and 21% are for-profit.

^{Of each dollar spent on health care in the United States, 31% goes to hospital care, 21% goes to physician/clinical services, 10% to pharmaceuticals, 4% to dental, 6% to nursing homes and 3% to home health care, 3% for other retail products, 3% for government public health activities, 7% to administrative costs, 7% to investment, and 6% to other professional services (physical therapists, optometrists, etc.).}

​One percent of the population accounts for 30 percent of the nation's health care expenditures.
10 percent of Medicare beneficiaries account for 70 percent of program spending.

​According to one study (Banarto, McClellan, Kagy and Garber, 2004), 30% of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with 1/3 of that cost occurring in the last month of life.

And finally, a trip down memory lane. When Hillary was chosen, for no reason anyone can discern, to come up with a plan to change health care, she amassed a large group and spent millions on the effort. Over one thousand people contributed to the process. What emerged was a plan loosely based upon the writings of economist Uwe Reinhardt. Of those thousand people, three were physicians. Why so few, you ask? Because health care is only a small part of it.

The ACA Reconsidered‏

The estimated "tax penalty" for not having insurance under the ACA in 2016 will be $1450.

Several articles have been discussing the status of Obamacare, the Affordable Care Act (ACA)

The fact is that Obamacare has fallen apart without Republicans’ dismantling it. Almost all of its basic promises have failed, it is an economic shambles, and it is a political mess.

The ACA combines compulsory coverage of pre-existing conditions with a weak mandate that healthier people subsidize those conditions. But that mandate is self-defeating, guaranteeing coverage whenever the patient is afflicted. So not signing up has no risk.
As James Freeman reports in the Wall Street Journal, the ACA’s plethora of exemptions — there are at least 30 of them — ensure that a great many people — 12 million last year — will simply opt out. “It is easy to avoid or limit exposure to the penalty with some simple tax planning,” he writes. In 2016, there were supposed to be 21 million people enrolled in ACA programs; the Obama administration currently predicts that the actual number will be somewhat less than half of that.

Co-ops were created to avoid those insurers afflicted with the dreaded profit motive. Half of the co-ops have gone belly-up already, including large, prominent, splendidly subsidized ones in Kentucky, New York, Louisiana, and South Carolina. Hundreds of thousands of customers have lost their coverage as a result. Hundreds of millions of dollars in taxpayers’ money has been poured into these enterprises, to no avail.
Kevin D. Williamson writes, "markets work for most people, and of course there are exceptions to that. For 93 percent of the population, the solution to health-care reform is: Let markets do their thing. The only real argument is how big a check to write to those looking after the other 7 percent, and how to structure the payments."

AIDS and Networks

The origin of the Aids pandemic has been localized to a single source, a colonial-era city then called Leopoldville which became, as Kinshasa, the biggest urban center in Central Africa and a bustling focus for trade, including a market in wild “bush meat” captured from the nearby forests.

A genetic analysis of thousands of individual viruses has confirmed beyond reasonable doubt that HIV first emerged in Kinshasa, the capital of the Belgian Congo, in about 1920 from where it spread via the colonial railway network to other parts of central Africa.
The study, based on analyzing the subtle genetic differences between various subtypes of HIV, found the human virus had evolved from a simian virus infecting chimps which were hunted for food by people who had probably carried HIV with them into Kinshasa.
"Commercial sex workers" (aka "whores") and the re-use of dirty syringes, aided the transmission of the virus which was also carried to distant parts of the Congo by the millions of passengers who used the newly-built railway network.
Independence in 1960 helped the virus to “break out” from small groups of infected people into the wider population, including immigrant workers from Haiti who then carried their infection back home from where it would eventually be transmitted to visitors from the US.

The Right to Health Care

The country is beginning to descend into the morass known as the Affordable Care Act. This program insincerely purports to be a health care program when, in fact, it is an effort to control health care costs. It grandly presents itself as the achievement of a long neglected right, the right to health care. There have, of late, been a growth of rights around the world, whether realized or not. The Universal Declaration of Rights, created by the U.N., is instructive and here are a few examples:

Article:
16. to marry and found a family
22. free development of his personality.
25  adequate standard of living.
26. free education
27. enjoy the arts. (The same article has a rider: The right of copyright.)

All of these rights have in common the inability of the individual to exercise them without significant help and contribution from others. Free education must be funded and those funds must come from somewhere. One, to marry and found a family, must have a willing volunteer as a partner and...AND... that partner must be fertile; infertility would be an abridgement of the partner's rights. What about "free development of his personality?" Some of life's difficulties would be illegal if they cramped someone's development. And the "enjoy the arts" is a real zinger; what if the citizen doesn't like current styles or fashions. What if some guy in Nigeria can't see the Russian ballet?

Rights as principles have certain obvious characteristics. Life, Liberty, Pursuit of Happiness are inherently abstract notions that can be approached and fulfilled only by the active effort of the individual and careful distance by the state. But as goals, they get confused. Equality other than that by nature before God is clearly impossible. Fraternity is a bit whimsical; one cannot guarantee community on either end of the bargain. And promising such "rights" must be dangerous to the society; unfulfilled devotees certainly would reconsider the sincerity of the promise.

 

The real question here is medical care as a right. How is such a right seen? Is the medical care of the average New Yorker the same care as Shepherdstown, West Virginia? Doesn't the Shepherdstown citizen have a right to New York medical care? Certainly, if not identical, it should be comparable. And what about the physician; is he harnessed to the patient's right? Can he decline to care for someone or is his freedom limited by the patient's right to care? How does that infringement on his freedom work?

The problem here is that rights are inborn, inherent to the individual by his very nature. They are not goals. Nor are they products. They are not time sensitive--one cannot have rights that appear with a new technology  Most importantly, they are not a function of another's efforts, nor, especially, of another's freedom.

Redistributing Health Care

The State of New York's decision to limit the number of patients' medical office visits is a clever take on redistribution: Medical care will now be available to people who do not need it, an under-served subset. It will free up medical offices to see more people who are healthy--and they are a lot less expensive to care for.

The only more effective plan would be to shoot the ill when they show up for their appointment.

The Real Conflict for the Church

The Catholic Church has over the years been cornered in a debate that was once theoretical and became, through technological advances, deadly practical: The notion of the beginning of life. Over time they have been backed into the position of defending the notion that life begins at conception and, along a different path, the idea that contraception is against "Natural Law." This position has some sizable philosophical holes but enough ambiguity that their preference for a safe position, like "do no harm," has become their stance. The result has been an alienation of a large percentage of their following and new problems that arise with every scientific advance.

Now the Affordable Care Act.

Under current insurance law the Church will be forced to participate in programs that violate the very essence of their positions over the last two centuries. They have filled a blizzard of law suits in an effort to protect themselves from these contradictions under the umbrella of "religious freedom." They lost their first case last week.

If they find no protection, their only alternative is to withdraw from participation in any service that is not specifically limited to their own congregation; this would force them to exclude others like non-Catholic patients in their huge hospital system, non-Catholic poor in their charities, non-Catholic students in their schools, and so on. Legally correct but morally offensive.

So, if they do not win their case, who will they be true to? There will certainly be a lot of outraged Catholics if the hierarchy surrenders this point after all the misery they have been put through.

Watching the Injury Happen

This strange health care event continues on. Like a plane that has lost its air pressure it flies on, a death ship, everyone watching silently, everyone knowing the lifeless thing must at some point come to earth and be dealt with. The press worries about process, about precedent and protocol. The politicians have become distracted and speak strangely. The citizens watch with awe and horror. There is debate over a bill that hasn't been written; there is speculation over the effects of unknown causes. Most noticeable, there is this weird urgency, this rush to achieve this unknown thing. This elephant must deliver this malignant mouse.

This is still a different land, different from others. It still does not accept organization over independence, security over possibility. And they have no faith, no confidence in the self proclaimed experts and leaders. Something remains of that spirit and energy that created itself in Philadelphia, that expressed itself in the settling of the West, that prepared itself for the challenges of the twentieth century in the crucible of the Civil War. But how much is left? Will a courageous, noble people boil up or will we be left with just an angry, bitter distillate?

The relationship between the public and their rulers has been incrementally changing over the years. This awkward political event may reset how the people see their government--but only if it changes how they see themselves.