The Obama Phenomenon and the 2008 Presidential Campaign

[anthriel]

I have a Master's Degree in Public Health. And believe me, the rationing of health care was the numero uno topic thread that ran through all my courses.

The problem is... the problem ALWAYS is... who is to ration the care? In the US, it is often the insurance companies. Yes, even people WITH insurance cannot always get coverage for the newest and shiniest procedures.

But proving that access to these highest levels of care makes a population healthier is problematic. It's difficult to measure "health", really; the study I saw based "health" on cholestrol levels, heart stress tests, infant mortality rates, infectious diease rates, things like that. It turned out that "unlimited" access to health care had about the same effect on health as the average periodic care does.

What DID make a big difference, biggest bang for the buck sort of thing, was providing minimum health care for those who had none. Providing prenatal care to uninsured mothers made a measurable difference in the overall health of mother and child. And vaccinating those children caused another huge bump upwards in overall health.


I think that Bill and Melissa Gates have it right. Their money goes to very basic health care in places without it. I wonder how many lives they have saved?

[Faramond]

I wonder if Obama is as vulnerable on Wright as people are thinking.

I think it's clear that random Democrats aren't vulnerable on Wright at all. And why would they be? Helllooo, RNC. Transitivity isn't working out for you. Wright = Obama = "some random local Dem candidate" isn't working. The Republicans deserve to lose these seats.

[River]

Access to health care isn't always as immediate and quick in the US as people like to think it is. My parents are insured through a spectacular carrier (seriously, when my brother pulled his groin Mom's insurance paid for him to get acupuncture). However, in 2004 my dad developed a cyst on his back. He got a referral from his GP but couldn't get a surgeon to see him for three months. In that time, Mom, Dad, middle sis and brother and I all went to Bolivia. Well, the cyst got infected on the trek so when we returned to La Paz we found an English speaking doctor who took care of it that very evening and did the follow up the next day, even though it was Bolivia's national day. Dad canceled his appointment on return to the US and then sent his GP and his would-be surgeon pictures of the whole lot of us sitting in the wait area in a Bolivian clinic, sipping the tea the nurse served us.

A family friend waited weeks for care after dislocating his shoulder. He's insured.

When I broke my nose I had so much bureaucratic fun I think the next time I get hurt I'm just going to do what my dog used to do and crawl under the porch and lick my wounds. Except noses are hard to lick and I really, really needed my airway opened back up. Getting a doctor was fine. I got a referral, waited until the appointment opened up, scheduled the surgery, and then went through a massive hassle because no one, not even the person hired by Student Death to navigate this stuff, knew the rules and my carrier got really squirrely about covering a procedure anyone who looked at me would agree I needed. The reason why? Right doctor, but I had my initial appointment in his office at the hospital the next town over, as opposed to in his office at the hospital in Boulder. And why did that happen? Because his Boulder office was booked solid but the other one wasn't. Same doctor, same staff...just different location.

[yovargas]

(I was thinking of starting a new thread to ask this question but since it's directly stemming from the posts in this thread's last page or two, I didn't want to do that. Maybe a thread split is in order?)


A question.
Would you prefer a system that:

1) provides great, top-notch healthcare to most people and really great, cutting-edge medical care to the fairly wealthy but leaves out a whole lot of the lower classes who can't afford it

OR

2) provides healthcare to everyone but has mediocre standards of care and doesn't generally provide good access to a lot of the higher-level, more expensive or cutting-edge medical care?

Note: I am NOT saying that these are our real-world options (I wouldn't know). I am also NOT trying to compare merits of the US vs the UK (I wouldn't know). I'm just trying to get a feel for what people's priorities are along with understand the complicated issues involved a bit better.

[axordil]

But the US private insurance companies are worse, the bureaucracies are just as bad and the client is helpless in the face of capricious rules.

The bureaucracy of an average group health insurance provider and of a government health insurance provider are functionally equivalent, save that the former is expected to make enough money to keep shareholders happy, whereas the latter just has to break even. I say this as someone intimately familiar with the software that said insurance companies use. The software reflects the bureaucracy it serves.

One obvious point of savings would be the lack of need for supporting sales and marketing. I can tell you roughly 20% of the code we put out is for commissions, direct marketing support, and the like. That doesn't necessarily translate precisely into dollar savings, but there is a connection, obviously.

[Primula Baggins]

I wonder if Obama is as vulnerable on Wright as people are thinking.

I think it's clear that random Democrats aren't vulnerable on Wright at all. And why would they be? Helllooo, RNC. Transitivity isn't working out for you. Wright = Obama = "some random local Dem candidate" isn't working. The Republicans deserve to lose these seats.

They also sent Dick Cheney down to campaign for the guy. Hello? Someone who has lower approval ratings than Bush?

[solicitr]

Prim, it's essential to keep straight a basic distinction which seems to have got lost in here:

Healthcare delivery and healthcare finance are two different things

In virtually all the Western world except the US (Canada, France, Germany, Japan etc etc etc) the latter, healthcare finance or insurance, is delivered or guaranteed by the State. However, only in Britain and (I believe) a few ex-Eastbloc countries does the State presume to run the hospitals and employ the doctors- a recipe for mediocrity at best.

How bizarre! Which planet are you on Soli?

One where not buying a Mercedes every month is a proof of fiscal prudence and an example to those who can't afford weekly groceries.

A cheap shot, Frelga, but increasingly common from the Left, which constantly blames everything on, dumps everything on, and taxes everything out of the Undeserving Rich (usually defined as anyone who drives a nicer car than you do). I in fact drive a very ordinary car, much older than a month, and take a certain I think deserved satisfaction in being free of credit-card debt and holding a responsible fixed-rate mortgage for much less than the value of my very ordinary house. This is result not of pennies from heaven but hard work, thrift, and above all doing without. I suppose this makes me an Enemy of the People.

Soli, it's lovely that the system works for you, but not everyone is like you.

It's true that I belong to the fortunate seven-eighths of the US population. I would like to see my good fortune extended to the remainder: the present system of US healthcare finance is a mess, with all the problems of access, portability and burdensome bureaucracy mentioned by several above. I have in fact been there: for my first few years in solo practice I couldn't find an affordable policy, and I wouldn't recommend it to anyone. This is *not* an acceptable situation, and I wish some folks would read more carefully (as Far and Yo have) rather than ascribing to me blanket praise of the status quo.

But this should not be corrected at the cost of what's good, indeed excellent, about American medicine.

Why is this acceptable and waiting a couple of weeks for a non-urgent procedure is not?

It's not merely what you casually dismiss as 'waiting a few weeks' and 'non-urgent.' Tell that to those confined for monnths or years to a walker or wheelchair waiting for a hip replacement, or the many Canadians streaming south to American hospitals to avail themselves of non-rationed care. However

Sure, if I have some rare complaint and I want to pay big money for a top specialist, I might well take advantage of the ridiculously expensive American consultants and surgeons, but on an average day, with a broken leg or in need of a stitch? Give me the NHS anyday.

This is where the rubber hits the road, my good man: but for access to an eminent eye surgeon at Johns Hopkins and a procedure available nowhere else in the world, my mother today would be totally blind. What urgency-value would you apply to that?

If all one needs is a stitch, the local Doc-in-the-Box will do it for fifty or seventy-five bucks. It's the major procedures that consume the overwhelming bulk of the US healthcare dollar.

It's not even that great of a system any more. The United States has a higher infant mortality rate than.....

Ah, the joys of metastatistics!* Does this somehow diminish American standards of cardiac surgery or cancer-survival rates? Besides, while access is indubitably a factor in infant mortality, it is by no means the only one: pre-and post-natal lifestyle choices carry enormous weight, and no health-insurance program is going to affect the number of neglected infants or crack babies.

*this happens also to be a very skewed and deceptive statistic: details on request.

[Cerin]

Here's one Brit's view of British v American health care. It's taken from a longer article, sorry about the formatting and not having a link.

Evening Standard
Tuesday, April 15, 2008
LIZ HOGGARD

When actress Helen McCrory had her second child, she opted to give
birth near where husband Damian Lewis was filming — in LA's smartest
hospital. Now, as her own new film opens, she reveals the appalling
standard of care she received

<snip>

Of course, if Damian was to be present at Gulliver's birth it meant
McCrory faced the prospect of having her baby in a foreign country.
But she wasn't worried about giving birth in America. After all, she
was booked into the Cedars-Sinai Medical Center, the cream of Los
Angeles hospitals. Admittedly she'd had a tricky time with Manon: the
baby was breech and dangerously high so her doctors at St Mary's
Hospital, Paddington, couldn't risk a spontaneous labour. Manon was
born by Caesarean, weighing a healthy 7lb. But with Gulliver McCrory
was hoping to have a natural birth. British doctors agreed it was
safe. What McCrory hadn't reckoned on was the intransigence of the
American medical system. When she went into Cedars-Sinai, for an
initial consultation, doctors were adamant she would have to have
another C-section.

But surely British film stars get the best treatment in the States,
where you can expect to pay upwards of $15,000 for a Caesarean birth?
Not so, says McCrory. "Oh my God, I was really shocked at the level of
care, it's appalling. Because you're paying, you think you'll be
getting a superior form of private medicine."

It was, she says, a bit like being in Paris: where only rudeness gets
results. "And that's not how I work in life, because I think it's
unnecessary. But actually, I realised, when people were barking down
this corridor with million-dollar diamond rings on each finger,
everybody was running. Someone like me who sits and says [she adopts a
demure tone], `When you have time could you possibly get me a
painkiller, I've just passed out', you don't get anything."

Things didn't improve when it came to pain management: "They couldn't
recommend me a drug because, of course, it's all private." Everyone is
terrified of being sued? "Yes, so you're supposed to know everything
about your own drugs."

EVEN after the birth: "I sat in the hospital for five-and-a-half hours
before they had enough nurses on duty that my child could be brought
to me. Then, when Gulliver didn't breastfeed immediately they were
insistent: "No, we're just going to bottle-feed him, we are taking
this child away.' We were told, `God wants him to feed on the bottle.' "

Childbirth was not the only experience that put McCrory off
healthcare, American-style. During the early part of their stay in LA,
older daughter Manon developed a fever. "Damian was working 18 hours a day," says McCrory, "and she was so hot she was 105F for five days.
I'd sit with this huge pregnant stomach in lukewarm water, take her
out, put her in again. For five days I didn't sleep. They won't even
do a home call. And when you take children to the doctor's, they will
do one test that takes seven days to come back, and charge you $350
for a urine sample. And this was Cedars-Sinai."

It has given her a renewed passion for British hospitals. "Can you
please make the title of the piece `God save the National Health'?"
she says, suddenly solemn. "People are literally dying in America
because they can't afford to live. You hear, `Oh the Americans are so
vain, this is why they are so health-conscious.' No it isn't: they
can't afford to be ill. If you have the wrong insurance, they will not
put you in the ambulance. I think you judge a society by how they
treat their poor and old."

In contrast, after she had Manon in London, the health worker came to
her house four times: weighed the baby, checked her hips and her eyes,
and talked to McCrory to check for signs of postnatal depression. "In
the States you have to have a paediatric report that costs you $1,000.
You're not allowed to leave the hospital without it. It takes two
minutes, and the doctor is only doing exactly what our nurses do for
free. And that's it, you don't see a doctor again, unless you pay."

British nurses and doctors are just far more caring, she insists. "You
know it's a vocation. Gulliver had his jabs and his temperature went
up to 104F — so they took him to the Whittington Hospital and got a
consultant on a motorcycle over from Guy's. He was there in 45
minutes. We had a lumbar puncture, a urinary tract test, lungs,
everything, on the NHS, all by 3.30pm the same afternoon that we'd
taken him in at 11am. And then the next day, the doctor phoned us at
home and gave us his mobile number as it was his day off and said if
there were any problems to call him."

[Primula Baggins]

Soli, if you have

unfettered access to the finest doctors and hospitals on earth

you are better off than most insured people, let alone the uninsured.

[solicitr]

The bureaucracy of an average group health insurance provider and of a government health insurance provider are functionally equivalent, save that the former is expected to make enough money to keep shareholders happy, whereas the latter just has to break even.

Ax, you're being astonishingly optimistic about the efficiency of the public sector. Government bureaucracies positively hemhorrage money, as why should they not? There's no incentive towards efficiency, indeed the opposite: from personal experience I can testify that the typical gov't dept spends the end of the fiscal year blowing every last penny of the budget so as to ensure an increased appropriation. The burden of InsCo paperwork and red tape is indeed appalling, you'll get no argument from me there- but the notion that you're going to do better or even as well in the home of the $600 hammer strikes me as rather naive.

[vison]

Neglected infants and crack babies? If that's all they were, then who gives a rat's ass, eh?

Jeez, solictr. I think we should maybe take Dr. Johnson's idea and run with it!!! A protein shortage solved, mucho quicko.

Simple, ordinary, common cheap public health care interventions in pregnancies - things as silly and socialist as an orange a day for pregnant women, milk fortified with folic acid, you know, that kind of communism? Those things make a enormous difference. They cost pennies per woman per day. Pennies. Free prenatal clinics, where an orange and a glass or two of milk go along with a nurse who does routine prenatal care - healthier, heavier babies are the result. Nothing fancy is needed. No foetal heart monitors, no ultrasounds, just a nurse and a refrigerator, and a room to put them in. But, sadly enough, no one is willing to pay for it.

The US doesn't have good health care. US health care sucks the big one. What the US has is sick care and if you can afford it, it's splendid.

Cuba, that sad, sorry little nation off your shores, has quite good health care. Astonishingly good. Likewise, Cuba is a world leader in organic farming, also astonishingly good. The USSR gets credit for that by pulling out, and the US as well, the embargo has forced the Cubans to look after themselves, rather in pioneer fashion. I'm not a fan of Cuba in general, but they do some things very well indeed.

[solicitr]

Here's one Brit's view of British v American health care....

Oh, dear: one anecdotal bad experience. I can assure you that the births of my children were nothing like what she describes. And from some of her comments it does rather sound like she has quite a chip on her shoulder, as well.

[axordil]

I can testify that the typical gov't dept spends the end of the fiscal year blowing every last penny of the budget so as to ensure an increased appropriation.

This happens in business settings too, end of every fiscal year. Any unused funds are seen as a place where the budget can be squeezed next year, ergo, no one leaves a penny unspent.

[solicitr]

Cuba is a world leader in organic farming, also astonishingly good. The USSR gets credit for that by pulling out, and the US as well, the embargo has forced the Cubans to look after themselves, rather in pioneer fashion

Which is why Cuba's leading source of food is.....wait for it..... the United States, so-called 'embargo' notwithstanding.

It is an admission that Cubans cannot even produce what grows very easily on Cuban soil. If one lists the food products that have been rationed since 1962, it becomes evident that almost all of them were in abundance before the 1959 revolution and were produced domestically. --Alvarez, Overview of Cuba's Food Rationing System, U. Fla. 2004

Here is what Cuba's 'leadership in organic farming' and 'looking out for themselves' has brought them to:

Monthly Cuban food ration:

5 lb rice
6-9 oz fish
3 oz chicken
3 lb sugar/ household
no milk except to children under 4
No meat
No bread or flour


Now here is an interesting comparison: from Thomas Jefferson's farm book, the food ration his slaves received at Monticello:

1 lb meat
12 herrings
1 qt molasses
8 qts cornmeal or flour....

.....per week!.

[halplm]

Has anyone seen my straw? I was going to build a man, but it seems to have been all used up...

[solicitr]

This happens in business settings too, end of every fiscal year. Any unused funds are seen as a place where the budget can be squeezed next year

An odd and (I assume) heavily bureaucratized business. My wife's annual bonus is calculated in part as a function of how far under budget she brings in the books.

[Primula Baggins]

Most people don't get bonuses of any kind, so that motivational source isn't available except to execs—who seem to get bonuses no matter how things are going.

[axordil]

An odd and (I assume) heavily bureaucratized business.

Yeah, IBM is certainly a rogue company.

Small health insurance companies are dying or being bought out at an astounding rate. All that's left are medium-to-large-to-huge companies at this point, which means yes, large and somewhat bureaucratic.

I'm not saying public agencies don't have inefficiencies. I'm saying it's a matter of choosing which inefficiencies you want to tackle, those of the public sector or those of the large private sector. Having to make an artificially high profit is a private sector inefficiency when it comes to providing a necessary service. So is paying salespeople commission. So is marketing.

[solicitr]

Most people don't get bonuses of any kind, so that motivational source isn't available except to execs—who seem to get bonuses no matter how things are going.

Oh come on, Prim. I would think you would know better than this sort of 'people vs. the moneybags' rhetoric. Susan is a middle manager and her compensation package is not remotely unusual.

[solicitr]

Yeah, IBM is certainly a rogue company.

No, but certainly heavily bureaucratized and hidebound- which is (in part) why outfits like Microsoft and HP have beaten up on it so.