Monday, August 27, 2018

Post-Apocalyptic Health Care

Post-apocalyptic life in American health care is a fantastic blog post on the state of American health care and insurance. (HT Marginal Revolution)

Bottom line:
American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.
The formal systems of health care are  broken under [my interpretation, to follow] the weight of regulation. By "formal systems" I mean the normal bureaucratic procedures by which large organizations run and interact: a set of rules, forms, records, and so forth. "Bureaucratic" here is not a pejorative. Bureaucracy is what allows large organizations to work.

This isn't about technology -- for centuries large organizations worked well using the technology of paper, writing, forms, and files. Electronic records just make those structures work more efficiently.

But when the rules and formal systems grow immense, vague, contradictory, and unworkable, human networks form in their place. Then things happen only by networks of personal connections, informal structures working around the dead elephant in the room to get anything accomplished. The latter, at great inefficiency, of course. Large bureaucratic organizations, allowing people to cooperate anonymously, are vital to an advanced society.

Later in the post,
It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.
Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.
Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.
To be specific, follow the author through a detailed personal story. The story takes a while, and it's one story, but the granularity of a story makes the case vivid.

My mother [also with dementia] went into the hospital a month ago with severe pain in her hip. (It’s still undiagnosed.) After two days, she was medically ready for discharge from the hospital: whatever the pain was, it wasn’t one they could help with. Instead, she should be sent to a “skilled nursing facility” (SNF) where she’d get “physical therapy,” i.e. leg exercises.
Most health care policy debate is about who will pay, as if the good to be determined, treatment for a specific condition, were known and well priced. Of course that's not even vaguely true. As we all know from experience, diagnosis, running from doctor to doctor and specialist to specialist, is a catastrophe today. It's often impossible when buying insurance to figure out if a given doctor is in network, or even when getting care whether it will be covered.

But this story is about something much simpler than the usual treatment snafus:
For a SNF to agree to take her, they had to get confirmation from an insurance company that insurance would cover her stay. She has two kinds of health insurance, Medicare plus coverage through a private insurer (Anthem). Which would cover her? Or both, or neither?
This seems simple enough, no?
SNFs have admissions officers, whose full-time job is to answer this question. Two different SNFs started working on the problem. I talked with the admissions people every day. Both claimed to be working on it more-or-less full-time. The hospital wanted to free up my mother’s bed, so their insurance person was also working on it. 
Days passed. The hospital doctor on rounds said “Well, this is typical, especially with Anthem. It’s costing them several thousand dollars a day to keep her here, versus a few hundred dollars a day in a SNF, but it might take a week for them to figure out which local SNF they cover. Don’t worry, they’ll sort it out eventually.” 
Meanwhile, I learned that Anthem and Medicare were confused about their relationship... Medicare believed that my mother (who retired in 1997) is employed and therefore ineligible. Her Anthem coverage is through her former employer. 
I talked with her ex-employer’s benefits person (whose full-time job is understanding insurance, pretty much). She looked into it and said she couldn’t understand what was going on. She called the company’s outside insurance consultant. He couldn’t understand what was going on. He called people he knew at Medicare and Anthem. He said that they couldn’t understand it either, but that multiple people in both organizations were working on straightening it out. 
A week later, I called Medicare to verify that it worked. The surprisingly competent customer service person looked up my mother’s info and said: “This is really weird… I don’t know what’s going on… there was a record that said Anthem is primary. And then on November 16th, there’s a note that said it’s deleted, and Medicare is primary. But then there’s an update on the 18th that says Anthem is primary. But obviously since your mother is 84 she’s not employed, so Medicare should be primary… I’ll delete the record again…” 
After three days of trying, one of the SNFs gave up. I talked to the admissions dude there. I’ll call him Paul. He was smart and friendly, and he was willing to explain: 
"My full-time job for ten years has been understanding how to get insurance to pay us, and I have no idea how the system works. Even if I somehow learned how it works, it changes completely every year, [my emphasis] and I would have to start over. But at most of the insurance companies I know people who can sometimes make things happen, so I call them up, and then they try to figure out how it works. But Anthem… I spent hours and hours on hold, and in phone trees, getting transferred from one department to another, and eventually back to where I started. The most clueful-sounding person I could find sent me to a web site that just says ‘This program is not implemented yet.’ Does ‘program’ mean software, or does it mean some project they haven’t got going?"
In sum,
at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed
This isn't about health, where logic usually departs in health care discussions. It's about money, something that large bureaucratic private organizations usually handle well. You don't need to call the bank a hundred times to find out your account balance.  Notice that this is a fight between a large regulated insurance company and Medicare, the government program, not a pathology of free markets.

Notice also the "changes completely every year." One thing large bureaucratic organizations do not do is to change the rules completely every year! People need to get to know the rules, and to know the channels by which an organization works. This does not happen if the rules change every year.

But why are rules changing every year? Life insurance, car insurance, home insurance rules don't change every year! This is an artifact of our current regulation, especially the ACA, which has destroyed long-term insurance. What policies are offered, how much they cost, who is in and who is out of network -- all of that changes every year, and companies need to renegotiate the whole package with state regulators every year. The market does not produce this pathology.
Hospitals are bad places that make you ill; you don’t want to spend any more time there than you have to. On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.” Their admissions person was reasonably confident that either Anthem or Medicare would pay, even though neither was willing to say either yes or no ahead of time. 
The SNF called me to tell me they needed my mother’s records from the hospital. Well, what do you want me to do about that? We need you to call the hospital and ask them to fax us the records. “Fax”? Why not send clay tablets in wicker baskets on the back of a donkey?
The venerable fax machine. Again, the author is good on story and less on why. Why must medical records be faxed around? Why can't hospital 1 get records from hospital 2? The answer there is clear as a bell: HIPPA, the extensive privacy regulations surrounding medical records. 

Their result is ludicrous beyond fax machines. We long ago should have had medical records stored in our Iphones or fitbits, and take them with us where needed. This isn't a technology problem, it's a legal problem. 

It's most hilarious every time I go to a hospital or doctor's office. You've been there too. You sit down with pen and paper, and you are asked to fill in your medical history. 

Are you kidding? I'm 60. My medical history, that I can remember of it might start with "Chicken pox, age 7. Asthma, age 10. Broken leg, Age 12." and go on like that for page after page. I don't bother of course -- nobody does. More hilarious, half of this stuff was treated at the very hospital where I am now sitting. The thought must have occurred to many of you: If my memory on this form is important -- if anything life saving is important to disclose here, why in the world are you trusting my memory on this? Does a bank, when you apply for an account, ask "write down the history of every check you've received or paid." 

The author starts to sniff where the trouble lies: 
I was trying to get my mother into a SNF—but all I could do was talk to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to talk to people at Anthem, who couldn’t say yes or no. Was that their fault?
Just speculating, I imagine they are supposed to apply 1600 pages of rules for what’s covered in what situation. 
Actually, that's off by at least an order of magnitude. The ACA itself is longer than that. Between ACA, HIPAA, subsidiary HHS rules, state and local regulations, and interpretations of those, add at least another zero
And the rules are vague and conflicting and change constantly, and who can read 1600 pages of rules anyway? So eventually someone has to make up a yes-or-no answer on the basis of what seems more-or-less reasonable. Whoever it is could get blamed if someone higher up later decides that was “wrong” based on their interpretation of the rules, so it’s better to pass the buck.
Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.
I imagine people working in legislative offices and regulatory agencies find themselves in a similar position.
In this maze, even competent people with good intentions cannot act systematically. Their work depends on coordinating with other institutions that have no systematic interface.
I don't think it's really the "interface" that is broken. The internal workings are so broken that no interface is possible.

Back to the post-apocalyptic vision; people standing around among aqueducts that no longer work and they don't know how to fix:
Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” 
I know my left of center friends are chomping at the bit here -- "single payer will solve it all. The problem here is a pointless fight about who will pay." But that is a bit like people who trash their own houses, which finally burn, and then demand the government build them new ones because we all saw how awful the houses were.  Single payer systems also often quickly devolve into dysfunctional bureaucracies, and getting care depends on networks of personal connections to work the system.

The author seems to think that health insurance is just the vanguard of a trend taking over our society in general:
I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.
Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies. 
Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.
I disagree, and the blog post shows why. The author rightly notices that health care is pathological, and that other, private, large organizations work well.
To ship a package by FedEx, you don’t need to call someone who knows someone who knows someone. You go to a web site, put in some numbers, it gives you back some numbers, you put them on the envelope, drop it in a box, and it appears at a farmhouse on an island in Lapland the next day.
If Amazon sends you the wrong type of cable adapter, you don’t have to call them up and try to act pathetic and virtuous in order to convince someone that you need and deserve a refund because your poor mother is so ill. You go to a web site and push a button.
Many other large systems of bureaucracies still are functional. Banks and airlines work. If the websites fails, you can call and get things fixed. You don't need a fixer who knows the special phone number of a guy or gal who can decide if your flight change is reasonable. Facebook, Google, Uber, and so forth operate really with no people -- you can't call anyone, and don't need to. The interface is simple and excellent.

Even much government continues to work. The DMV works as a bureaucracy. I had to register an imported trailer recently. The lady at the Redwood City DMV actually knew which channels to take and which pieces of paper needed to be filled out, or at least could quickly access that information. Yes, it was slow, yes, it was almost charming to visit a bureaucracy functioning with 1970s technology with stacks of physical pieces of paper going around. But it works, I didn't need a fixer.

Where are large bureaucracies falling apart in this way, that webs of personal connections are necessary to keep things going, and where are they not falling apart? Health insurance is the poster child, but the highly regulated or government organizations stand out. Taxes. Estates. Real estate zoning permitting is headed that way. Large businesses dealing with regulatory agencies all have to work this way more and more. Increasingly, retirement finance is heading this way. I had a lovely conversation at a B and B recently with a very nice woman whose job it is to help teachers with retirement options. Many have government loans. She started to explain the myriad programs to help them with complex filing requirements, various forgiveness rules and so on. A finance professor, me, was completely lost by the second cup of coffee. Public school teachers facing retirement with some student debt now need a fixer too.

The blog's bottom line:
For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.
Perhaps the market will respond, with a supply of professional fixers, like my breakfast companion. For rich people, it's concierge medicine, where the doctor really serves to navigate the same mess of health care, not insurance.


  1. It's all to be expected given the divide between government and private payers. And in this case the private payers are not individuals they are employers who are buying healthcare on behalf of employees who have a median tenure of 4.6 years with any given company.

    Instead of going to single payer, I feel we need to look at the Swiss model as a possible compromise. Swiss health insurance is sold to individuals (required to buy). These insurers compete on service and you can buy upgraded policies if you wish. The minimum services covered are regulated. There's a lot more transparency and efficiency in the system but the drawback is that the government is playing a role in pricing of services/drugs etc.

    The bottom line is that the per capita cost of hc in Switzerland is roughly 30% less than U.S. while achieving 100% coverage. Interestingly, about 27% of Swiss receive premium subsidies for old age or lack of income. Probably most importantly, 58% of Swiss think only minor changes are needed to their system. In the U.S. surveys show that figure to be about 4%, with most believing our system needs major changes (

    If I had to design a healthcare system it wouldn't be the Swiss but hoping for a tabula rasa type opportunity is highly unrealistic in my opinion. Transitioning to a Swiss type system would be quite painful but I think more likely to get bipartisan action than single payer or GOP solutions from the past 12 months.

    In true Swiss form, most people in Switzerland really could care less if we adopt their system. Unlike the English and Canadians they don't rub their system in front of our faces here in the U.S. and cite as an example of how "uncaring" or "wild west" we are. Yet if I had to pick a hospital, I'd most certainly take one in Switzerland over U.K. or Canada, especially non-private.

    Oh and three other things: 1) Swiss doctors are super well paid 2) Switzerland (for the most part) has tax rates that are lower than in the U.S. - ranking higher on economic freedom and liberty reports from Cato/Heritage.

    If we were paying much less than Switzerland or even the same, I'd struggle to recommend switching. By adopting their system we are adding a government benefit probably forever. Yet if the Swiss can do it (Singapore too) perhaps it's worth the risk.

    1. I'm Swiss and I'm not so sure I would recommend our system. While it seems to function better than the US system right now, the direction we are heading is not good. Over the past 20 years, the price of the basic insurance has gone up by about 4% per year - which is way above inflation. One cost driver of course is the aging of the population: about half of the total health costs of a Swiss occurs during the last two years of his life! Since the basic insurance is structured such that the insurances cannot do age discrimination (insurances with many young clients have to do transfer payments to those with the old clients), these costs are not very visible and the whole system transfers a lot of wealth from the young to the old (in my opinion, it would be better to transfer the wealth from the rich old to the poor old).

      One interesting economic question here is: would you be willing to sacrifice the last two years of your life if you get a lasting 50% rebate on your health insurance?

    2. "One interesting economic question here is: would you be willing to sacrifice the last two years of your life if you get a lasting 50% rebate on your health insurance?"

      Hell yes. The last two years are the worst. Let me have the extra capital now.

  2. Actually I'm not a left-winger, in fact I believe in free markets.

    But everybody believes in free markets, except for…

    In the case of healthcare I am for single-payer, a gigantic VA for everybody limited to 15% of GDP.

    1. And someday, you or someone you love will be diagnosed with a difficult cancer. And the single payer will say, "sorry, we are limiting costs to 15% of GDP. What kind of flowers would you like at the funeral?" And you will say, "wait, I have money. I worked hard and saved hard, and what's money for if not to buy a life-saving treatment. But no, the bureaucrat will answer, "sorry, we are a single payer system, and single means single. You're out of luck."

    2. Possibly---but then there should be limits spent on health care for the aged and terminally ill. From what I read, this is a well-known problem.

      Keeping people alive past the expiration date is very expensive.

      I suppose we could have a big VA, and then people who wanted to could pay for their own healthcare outside the system. Out of their own pocket.

      For example, perhaps some people believe in an unproven medical treatment.

      But even if we went to purely free-markets, we would have effective euthanasia. "We can keep Aunt Gertrude alive, but it will cost $3,793 a day."

      Time to put Aunt Gertrude into a hospice.

      I am not being flip or insensitive. We can go to free markets or a big VA.

      I have reservations about not treating a medical malady in someone under age 70, because they have no money. Yes, they may have been a wastrel. Never bought insurance, etc. Boozed it up. And that's just in my family.

      I concede a big VA would have its own problems. But perhaps the nightmare you described in this post, which I have heard various variations of for decades could be avoided.

    3. I appreciate that Benjamin used the VA as the (second tier, but may be affordable) model, and not the pie in the sky Medicare for all model. He won't get elected, but at least he is realistic.

      His solution is uninspiring, but not "gratuitously draconian." For example, in response to your challenge, he could say: "At that point I will use my personal savings (which I would hope exceed the allocated 15% of GDP) to seek this care (if I choose to). Clearly, his VA model can not seek to coerce rationing even outside the system, which some single payer systems do.

    4. How about single payer where folks are allowed to buy into "Cadillac Plans" which allow 100 year old geezers to get facelifts if they pay the premiums out of their own pockets?

    5. Or perhaps it will be more like K-12 schools: if the life-saving treatment will cost more than 15% of GDP, Mr. Cole & his doctor will never know of its existence in the first place (or it will never be invented, or he'll be preconditioned to just accept the results as "how things have always been," or whatever).

      I'm not sure that's such a terrible solution. Sure it's awful and dystopian, but so is our existing system. And neither party has made any real progress towards consensus on a proposal that would reform the existing system for the better... if anything we seem to be trending the other way.

      So yeah, maybe we ought to live in a world where medical care is just sort of frozen at a point in time, and property values rise & fall based upon the quality of the local government run health care complex. It's sad we cannot do better than that, but we have been at healthcare reform for 25 years now and are further from a solution than when we started. At some point maybe we need to just accept the inevitable.

    6. The VA is an excellent solution. I can't think of a better way to thin the herd of the old and sick than to put them in a VA hospital. It also avoids the nasty star chamber GDP-limited decision-making process that worries John.

    7. My standard response to people advocating for single payer is simple: Go ahead! Get together with a group of friends, agree to split the bill for all your personal health expenditures, and enjoy the ride. But, please don't force the rest of us to participate.

    8. The VA as a model?
      'Shirley, you jest.'

  3. Right now employers ration care by taking on the services of Pharmacy Benefit Managers. These companies (such as Express Scripts) have exclusions of drugs (not on formulary). They also use tactics such as "Prior Authorization" that requires significant time and effort by the physician to fill out the forms to get approval (some Rx don't make it). They also use "Step Therapy" which may cause other delays or abandonment. My point is this: If your employer doesn't cover the drug your doctor selected, you need to pay out of pocket for it in this country in 2018. It doesn't happen too often but it does happen.

    Also, CVS a PBM announced they were moving towards European style QALYs in some plans, so rationing isn't limited to single payer.

    Today, either my employer or the government is the one choosing this policy of coverage. Under a modified Swiss system, individuals could be empowered to select plans that match their desired level of coverage. Why should I have to subsidize people who think each additional year of life is worth $1M in cost? I may choose to be a part of a plan that has a limit. And yes, I'm aware of the adverse selection risks.

    Again, I'm not saying we adopt the Swiss system exactly as they have implemented. I'm saying that for mostly political reasons, it solves a problem. Adopting a U.K., Canadian, French, or German type model would be a much worse mistake. I don't know how many times a bureaucrat in Switzerland says to a patient they are out of luck. It's an interesting question.

    I can say that after almost 2 years of GOP controlled WH and Congress, I see no meaningful progress on reducing the cost of healthcare to Americans (as a % of GDP). We're headed to 20% of GDP in the next few years then towards 25% probably in early 2030s. Fun times if/when any technology starts to replace jobs that come with healthcare.

    1. Except that paying out of pocket is basically impossible, with ridiculous sticker prices only used as bargaining points for the unwary.

    2. Today that's largely true. If your employer won't pay for your drug, you either take the alternative or pay out of pocket. With expensive single-manufacturer brand Rx the out-pocket price isn't that much different that what the government or third party payer actually pays. Some people go to Mexico or abroad for treatments (or self-import from Canada). This is rare for complex diseases (cancer, HIV, MS etc).

      You did get me thinking about an interesting question. In Switzerland, a company is free to set whatever price they want if they want to sell the product for cash. If the drug company wants it paid for by insurance companies, they must agree to sell at some price in line with other countries - Swiss version of a reference price.

      Again, I'm not sure this isn't such a bad idea compared to our current system. If a drug company refused to take the price negotiated by the government, they could basically sell as a pure cash product. They would do the math of evaluating what they could achieve in sales versus taking that government price. This is not dissimilar to what happens in many second and third world countries that lack any form of insurance or coverage. This is why the price of Harvoni in India is a few hundred dollars vs $80,000 in the U.S. I'm not saying it would be that cheap but let's compare this scenario to our current system:

      - Government payor (about half of spending) doesn't set prices for drugs, relying on prices established by pharma in light of purchasing interest from PBMs
      - PBMs are hired by employers to negotiate reimbursements but are not functioning in a fiduciary role, benefitting by higher prices (and rebates)
      - They are denying some drugs but not necessarily on the basis of value to the patient but rather often times, their own economic interest.
      - Due to the conflicts from PBMs, taxpayers surely overpay for Medicare Part D and Medicaid drugs
      - Individuals can't choose plans based upon coverage or value - the employers do

      Given this mess of the third party system, to me it is a real question of whether or not a Swiss type model wouldn't be just cheaper, but more transparent, and efficient. From all my research to date, the Swiss deny very few drugs (if any).

      If the U.S. took this approach it would no doubt impact innovation. However, I'd argue that major breakthrough drugs always have the potential for a positive ROI for investors. It's the "next best drugs" that come out a few years later and have marginally better results at twice the price that become hard to sell (or invest in).

      I'm just not certain that given where we are headed that a modified Swiss approach wouldn't be much better on many dimensions. Sure the free market is always the best solution but can we afford to go from bad to worse? I'd handicap that at a 90% likelihood at this point.

  4. Price controls and bureaucratic displacement. Milton Friedman is rolling over in his grave.

  5. Once again, people don't understand how the system works - or rather, doesn't work. I've been going through the same experience with a good friend of mine whose father has terminal cancer. He's a federally licensed lawyer with power of attorney for his father and couldn't make the system work. I tried to tell him 6 weeks ago when the saga began that it wouldn't work. I tried to warn him about what was coming - the frustrations, the run-arounds, the bureaucracy that would torture his father to death with useless interventions. My friend is extremely insightful. he's a brilliant lawyer. He has an emotional blind spot with his father.

    The first thing you need to do is dig up a copy of Time magazine from a few years back that had the article "How doctors die". Sure, many of us clutch our chests and drop dead on the spot, but those of us with terminal illness don't die like the rest of you.

    That's because we know that when the machine says "Tilt" we understand the game is over. We understand that no matter how much you pull the launching knob or hit the flippers, you're wasting your time and energy.

    There are two problems here and part of it is the bureaucracy and the rest is human behavior. The bureaucracy is infuriating as documented above. My friend was told his dad was going to SNF (skilled nursing facility), then LTAC (long term acute care), then home hospice, then around and around we went. Meanwhile, specialists worked on trying to save him. It was like watching monkeys trying to hump a football.

    It got to the point where I took a morning off from my practice and drove over to the hospital where my friend and I waited at his father's bedside until the doctors came by on rounds (they had stopped returning his calls - something I highly don't recommend you do with a federal lawyer with POA).

    I was able to speak to them doctor to doctor, which means I was able to say "You know and I know that this guy is toast. You're prolonging death, not life. You need to have a frank discussion with Mr. Jones about his father" .

    That's problem #1 with the human angle - we don't want to give bad news. We don't want to take away hope. The second problem is getting people to believe that it really is game over. I've seen people whose insurance denied chemotherapy for a terminally ill loved one go out and spend thousands of dollars to buy it themselves, only to have the patient die before they could receive the first dose.

    Fortunately, I was able to get the two parties together and agree on a plan. Now, how much do you think it would cost to have an ombudsman who speaks both languages (patient-speak and doctor-speak) and understands the situation (I was co-director of the surgical ICU at Duke for 8 years and watched a lot of people linger for months) do what I did? How many doctors do you think would take my call or return my call if I tried to be an ombudsman for a living?

    Our pets die better than we do. Most of you will not have a doctor involved on a personal level like this and if you're terminally ill, I'd suggest you dress up as a large dog and go to the vet for euthanasia.

    As usual, the problem is far more complicated than policy wonks realize. You have to be there, at the margin, watching how these decisions are made - how the parties think and interact. If you don't understand the problem, you can't come up with a solution.

    1. "Most of you will not have a doctor involved on a personal level like this and if you're terminally ill, I'd suggest you dress up as a large dog and go to the vet for euthanasia."--Michael Gorback.

      I have a certain brother-in-law for whom this might work.

      Excellent comments.

      My friend's ex-wife, age 68-ish, recently got a double lung transplant and died less than a year later.

      I hope I die gardening, while strong enough to engage in such activity. Just make it quick.

  6. We need death insurance...say, allow the sick to choose terminal care, and the savings from anticipated health care costs, to go to his family.

  7. The comments above somewhat support Richard Fogoros's Grand Unified Theory of American Health Care: That all the complexity and inefficiency is caused by "covert rationing." Third-party payment requires someone to say "no" to things, but we do not tolerate that. So we end up saying "no" de facto, somewhat randomly, and inefficiently.

  8. What about addressing the underlying cost structure? There's many levels of markup. Big pharma is one producer that might get upset along with insurance companies in the private market.

    Also, exactly why is an MRI or CATSCAN thousands of dollars? Why is the tech ans service so expensive? Is it really to recover sunk costs, hmm?

    This is all pertinent to me because without insurance my insulin would be $1000 a month out of pocket. No insulin, no life so my demand is pretty inelastic for insulin. There's no substitutes. I'm not the only diabetic who has to face this reality.

  9. The episode in question here involved a form of long term custodial care.....
    and these episodes will be contentious and complex for a long time to come. The underlying reason is that long term and curative care for the elderly is just frighteningly expensive.

    Say that 1 million additional elders should really be in a nursing home, at a minimum of $50,000 each. that is $50 billion a year for 3-5 years.

    Say that we invent a cure for Alzheimers at $100,000 per cure. That is at least $100 billion more.

    For most of human history, most persons died young and the rich elderly were cared for by servants.

    Whether we can democratize old age, and pay wages to caregivers, is up for question.


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