WalMart can help by offering inexpensive pharmaceuticals. I don't know if they can help overcome a larger problem. The problem seems to be that health care providers do not compete on value delivered. Until we effectively measure value (long term benefit divided by cost) delivered and compare it across providers we will have no way to use the market to stimulate improvement.
Right now we don't measure long term benefits and decisions are insulated from costs.
"... WalMart can help by offering inexpensive pharmaceuticals. ..."
Inexpensive yes, effective maybe, probably no. Walmart works by dictating the price a supplier sells. This is how it gets things so cheap, screw the other guy hard. So the question is "do you want the cheapest drug or the most effective?". By effective I mean, "it does what it claims". There are huge quality problems in outsourcing pharma-products to China, India and other non-first world states. If you want to Walmart exerting it's control on drug price, the likely result is cheaper but an inferior outsourced product.
Seems like there a couple of interacting problems but no one size fits all. It does seem like WalMart would be useful for high frequency low severity (adjusting for risk of some high severity situations lurking in the intake). Trauma needs a trauma center, chronic progressive conditions benefit from Kaiser's approach (and have proven amenable to pharmaceuticals in many cases). It's not clear where to put cancer, if we can't screen and catch it early we don't seem to have a good answer. Stroke and heart attack may benefit from early intervention that's one time plus physical therapy follow up. There may be some more categories.
Trauma (e.g. automobile accident, gunshot, explosion) => trauma center
High Frequency Low Risk (for most: cough, cold, flu) => WalMart
Chronic (heart disease, diabetes, high blood pressure, gout, glaucoma, cystic fibrosis) => pharmaceuticals / Kaiser pro-active healthcare
Low Frequency High Risk (cancer, heart attack, stroke, appendicitis) => medical center / surgery
Getting fewer people to smoke would have a huge impact.
You also need to distinguish between an intervention that gives a 1 year old another 60-80 years of life and a 72 yr old another six months, they may cost the same but the first has a much stronger impact on society. I am not saying deprive anyone of medical care, but understand there may be an enormous cost for medical care in the last year of life. Good health is dying more slowly: good medical care doesn't save your life, it lets you die of something else a little (or a lot) later.
"The goal, everyone agrees, is to maximize coverage, heighten competition and cut costs. Good goals, all."
No, the goal is to save lives and provide EVERY American with health care in order to improve the quality of their life. This isn't about being "cost effective," it's about doing what is right,
>This isn't about being "cost effective," it's about doing what is right.
There are a finite number of resources in this world and an infinite number of wants and needs. It is ALWAYS about being "cost effective". Money used on health care cannot be used on other things, such as education, transportation, or investment in a company that provides jobs and useful services.
How much medical care should everybody get? Should we be willing to spend $1 million to extend an elderly citizen's life for a year? Should EVERYONE have access to that quality of medical care? These are important questions. Cost and benefit must be weighed in health care, just like anywhere else.
Life is more complex than leftist soundbites, my friend. If spending $1 trillion extra on medicine would save a thousand lives, I would contest that it would not be worth it. The question is, how much of a reduction in the quality of life in America are you willing to accept for an improvement in the average quality of health care?
I understand that there are limits and finite resources. If you're asking where to get the money from how about a little less on weapons development and a little more on medical research.
"How much medical care should everybody get?"
Well -any at all- would be a start for the millions without it. A lot of the questions you posed (who gets what and how much) have been answered in one way or another by the dozens of countries who already employ a universal health care system. We should be looking to them as a template and applying their to a new system.
Sorry, but I get a bit heated about UHC. People tend to say things like "Where is the money going to come from?" or "The government is too incompetent to manage such a system" which are cop-outs, imo.
"The question is, how much of a reduction in the quality of life in America are you willing to accept for an improvement in the average quality of health care?"
I'm willing to give up a lot more of my money for health care than for weapons and war funding.
> "The government is too incompetent to manage such a system" which are cop-outs, imo.
It's reality. Wishes aren't horses.
UHC advocates claim that the US would spend 10% with UHC. Let's see what that would mean.
The US spends about 15% of GDP on healthcare. Of that 15%, about half is spent by govt while the other half is private. Curiously enough, the govt covers about the same number of people as private spending.
For argument's sake, let's say that the govt currently spends 7% of gdp on health care. If govt is only going to spend 10% to cover just the people who currently have health care, that means that it will only spend 3% to cover the folks that are currently in the private system. (Yes, I'm ignoring the uninsured, but they just make the numbers worse.)
I'll repeat that - UHC folk are promising that the govt will cover the people it doesn't cover now for less than half what it pays to cover the people it covers today.
If you want to argue that UNC can do health care for 10% of gdp, start by fixing govt health care so it only spends 5% of gdp to cover the people it covers today.
You can kill private health care by simply opening up govt health care at cost if it's actually cheaper and better. However, as long as it isn't.....
Until govt health care is actually cheaper than private, it's absurd to argue that it will be. Govt health care isn't cheaper or more effective than private in the US.
>I understand that there are limits and finite resources. If you're asking where to get the money from how about a little less on weapons development and a little more on medical research.
Sounds great. Only one problem: money is an illusion. The issue isn't money, it is supply of medical care as measured in units of doctor-hours.
The only way you can get doctor-hours for person X is to take them from person Y. Doctors already work far more than full time and are unlikey to work more. Getting more doctors will be tough, since medical schools are all full.
The issue is that medical care is a very scarce commodity. And you can't legislate scarcity away. Any proposed solution that doesn't create new doctor-hours (or find a substitute good for doctor-hours, such as nurse-hours) is a fraud.
"The issue isn't money, it is supply of medical care as measured in units of doctor-hours"
Except it isn't. The cost of the supplies necessary for treatment (drugs, medical equipment) is at least as big of an issue.
Also, wages for doctors are trending downwards thanks to HMO's. I'm not saying that's an inherently bad thing, but it's definitely not what you would expect if doctor-hours were the scarcest resource in the system.
Sounds great. Only one problem: money is an illusion. The issue isn't money, it is supply of medical care as measured in units of doctor-hours
That is wrong.
What you are saying is that a doctors hours in 1940 are translatable to a doctors hours in 2008. This is obviously false; the limiting reagent is not the number of hours but the increase in effectiveness of those hours due to the 68 intervening years of medical research.
A single doctor with today's knowledge and technology could have prevented the 1918 influenza epidemic, polio, the Black Plague, etc.
Technically it is medical schools that are kept in short supply. Most medical schools operated at full capacity, and about 2/3 of qualified applicants are turned away.
This is certainly fixable, though the time horizon (medical school construction/expansion time + doctor training time = 10-15 years) is longer than most politicians like.
From a resource perspective basic medical care is cheep and effective. EX: The cost benefit ratio of free vaccinations is varying positive. We can efficiently have basic universal healthcare without spending huge piles of cash on every patent. The problem is we obligate institutions to treat everyone without funding them to do so which destroys the free market. We don't have huge efficient hospital chains because it's not profitable to create them. I say we use the Japanese approach of basic universal insurance and private medical system for the best of both worlds.
PS: Would you rather the government pay ~50$ per MRI in Japan or your private insurance pay ~1500$ in the US for the same procedure?
Are you saying that people in the US don't get vaccinated already with or without "health insurance"?
BTW, the reason that someone can't sell a $20/month insurance policy that gets you the kind of basics you're talking about is b/c it's illegal. By law health insurance plans have to abide by all kinds of rules, one of which is that they must insure against the possibility that you develop a drug problem and all kinds of improbable things. The end result is that even the cheapest health insurance is quite expensive.
The problem is that government is already regulating the private market significantly. Add to that the tax loophole that lets employer-provided plan fees be taken from pre-tax income, and you have a set of incentives that have resulted in the mess we're in.
Also, top notch care at a level that was very elite in 1990 is now significantly cheaper than it was in 1990. The problem is that the average person wants cutting edge 2007 medicine, which is a lot more expensive.
Think about it this way, the more effective healthcare is, the more people will spend on it (not less). As procedures have a higher chance of succeeding, more people will decide to get them (who in the past would have gone to hospice).
Yes, some people don't get vaccinated due to cost issues. (It's a small group for many diseases but they are out there.)
What I am saying is the real cost of treating a broken leg is less than what people with or without insurance pay in the US. When you seek treatment the hospital / doctors office does a quick "what are my chances of being paid back" and then they charge you Total Cost of Treatment * Profit / (pay back%). So someone with insurance might pay 500$ * 1.2 / .8 = 750$. But someone without insurance might pay 500$ * 1.2 / .5 = 1200$.
Now if relative to the rest of the world our system was cheaper or more effective then I would say stick with it but it's not. At the most basic level Insurance does not lower costs because it does not prevent coverage.
"If spending $1 trillion extra on medicine would save a thousand lives"
"Medicine" is too vague of a term. You'll be spending your trillion dollars on Ducatis and BMWs of drug sales reps and medical equipment middlemen, plus thousand of other parasites that make several times more of what an average engineer can dream of, by milking the system we have in place.
I know a little bit about how the "sausage is made" and it makes me sick, what an irony...
- Free glasses for those who don't have 20/20 vision.
- Why not give free glasses for those who don't have 20/30 vision?
- What about free contact lenses?
- Wait, why not make daily disposables a right?
- While we're at it, what about nutritional counseling?
- Or what about a Federally funded delivery service for fresh organic produce?
My point is that if you are willing to define a "right" then you also have the burden of having to define "healthcare". What if person A would rather spend $10K of personal income on a motorcycle or home theater, but person B would rather spend it on extra long doctor visits? What if person C would settle for inferior healthcare b/c she practices some form of alternative medicine?
Bottom line is that if you are thinking of it as right and wrong then you haven't thought about the ramifications of the issue very deeply.
Glasses are horribly, horribly overpriced in North America. They only really cost $15 dollars max to get a decent looking frame with anti-reflective & anti-scratch coating with a prescription as high as -8. (zennioptical.com)
One problem is that there's no such thing as 'health care'. It's like saying everyone should have 'transportation'. Does that cover bicycles? A Ford Focus? A Rolls Royce? To 'do what is right', 'transportation' should include air travel, too, right? So, free coach? First class? A Gulfstream? And so it goes with 'health care'.
The many products under the umbrella term 'health care' are scarce goods. Long experience shows that in virtually every respect the best way to allocate scarce goods is on a market. All systems (including the present one) used to distribute 'health care' that ignore or distort markets are doomed to frustration and failure.
Alas, creating a truly free market in health care is on no mainstream politician's agenda. I don't expect our situation to improve much soon.
To save lives and improve the quality of life, you'd be better off providing EVERY American with access to a gym.
Exercise adds 15 years to your life. It's pretty difficult to show statistically that marginal medical treatments (medical treatments that people purchase if they are cheap, but not if they are expensive) do anything.
Early healthcare tends to reap huge benefits. AKA prevent someone dieing at birth and you add ~70 years. Older patents and random accidents reduce the possible gains. The second cheapest group to save is emergency room patents where minimal treatment can have dramatic effects. Exercise falls into the next group where huge investments in time reap huge long term benefits. (Someone making 50$/hour * 3 hours a week * 50 weeks a year = 7500$ / year.)
A 5$ per month medicine is a lot cheaper than exercise so it's long term benefits don't need to be on the same magnitude to be vary worthwhile.
Well first, the link I provided discusses marginal medicine, or medicine people choose not to buy if it will cost THEM lots of money. Emergency care tends not to be marginal.
As for the opportunity cost of exercise, it is only $2850 (average wage is about $38,000/year, http://www.ssa.gov/OACT/COLA/AWI.html) if people substitute exercise for productive work. It's not obvious that that is what would happen.
I suspect most people would substitute exercise for TV. Lots of people watch 3 hours of TV per day. Squeezing out 3 hours/week would be easy. For gods sake, 9.9 million people sit on their asses watching The Biggest Loser (a weight loss game show). People can exercise more.
To save lives and improve the quality of life, you'd be better off providing EVERY American with access to a gym.
I whole heartedly disagree. Why then do you suppose that people who live in the Third World (where I grew up) tend to die younger and die of easily curable/preventable diseases? Is it because they got more exercise working in the sugar cane fields swinging a machete for 16 hours?
I've read other studies that show that if you exercise 1-2 hours, 3 times a week, you end up living 5-7 years longer, but then, the extra 5-7 years that you live, you've spent in the gym exercising.
The article you quoted has a fundamental flaw in that it assumes that we can simply reduce an ICU stay at the end of life by 1-2 days. When a person is in the ICU, it's not quite so clear that a person is only going to live 1-2 days and then die. People want their family in ICU, because they want that person to have any and every chance at living.
Certainly he raises some good points about cost effective health care. No on would disagree that a bunch of low cost primary health clinics are going to be a much cheaper way to treat people than an ER or ICU. But, dismissing ER or ICU treatment as unnecessary is absurd.
Yeah-- I gotta disagree here too. As a guy who weighed 300 lbs and smoked two packs a day two years ago, and a guy who weighs 220 and runs marathons now, I spend more time (and money) paying for my healthcare now than I ever did when I was living a far less healthy lifestyle.
I just broke my fibula and dislocated my ankle in an accident. Fortunately I have health insurance, fortunately I have sick days at work, and fortunately I have enough money where I can pay the $3000 out of pocket it's going to cost me, even with the insurance, for the surgery I can have to walk (and hopefully run) again.
But somebody without insurance, making it so that they could get back into stable condition could lead them into bankruptcy and making them a burden on society. Quite frankly, I'd rather be paying to the burden of keeping that person well and making sure they can stay in the workforce than I am paying for their unemployment and bankruptcy because they can't get well because they can't afford to.
Universal Healthcare just makes sense and it is embarrassing that we're the only western country without it.
>Why then do you suppose that people who live in the Third World (where I grew up) tend to die younger and die of easily curable/preventable diseases?
The vast majority of those diseases are prevented in the developed world by non-medical means. A doctor didn't prevent me from dying of malaria, DDT eliminated malaria in the US before I was born. Doctors didn't cure my cholera, other people flushing preventing me from being exposed to it. The NY/NJ water utilities prevented me from being exposed to water-born diseases and my refrigerator/consistent food supply protected me from spoiled food.
>The article you quoted has a fundamental flaw in that it assumes that we can simply reduce an ICU stay at the end of life by 1-2 days. When a person is in the ICU, it's not quite so clear that a person is only going to live 1-2 days and then die. People want their family in ICU, because they want that person to have any and every chance at living.
True, which is why the ICU study alone isn't conclusive.
However, the RAND health insurance experiment (discussed in the article) doesn't have that flaw. Randomly chosen people consumed different levels of health care, and few statistically significant differences were observed.
The vast majority of those diseases are prevented in the developed world by non-medical means. A doctor didn't prevent me from dying of malaria, DDT eliminated malaria in the US before I was born. Doctors didn't cure my cholera, other people flushing preventing me from being exposed to it. The NY/NJ water utilities prevented me from being exposed to water-born diseases and my refrigerator/consistent food supply protected me from spoiled food.
Malaria is still one of the top killers of people world wide, which is why the Gates foundation is funding vaccine research. There are 300 million people world wide infected with malaria, and 1.5 million people die from malaria each year. How's that DDT working for them?
I'm an ER nurse by trade, and I pick up old medical textbooks in antique shops whenever I can. There are usually entire chapters on Polio, Tetanus, Tularemia etc... These are diseases that we just don't see any more. Why? Because of vaccines and antibiotics.
My uncle, (now a surgeon) almost died in the 40's from a ruptured appendix. Know what saved his life? The new miracle drug that had just come on the market: Sulfa antibiotics. I haven't seen a person die from a ruptured appendix in years. Why? Because of antibiotics and surgery.
People used to die from infectious diseases all the time, and they do in the Third World as well. Yes, prevention and basic sanitation help a lot, but that's not the only answer.
Pneumonia used to be a major killer. It's not anymore. Why? Antibiotics and oxygen.
I was born with a cleft lip. I had two surgeries on my lip before I was 1 month old. My parents took me down to Honduras where they worked in a rural village running a school. People in the village were shocked that there was something that could actually fix cleft lips. There were a number of people in that village and surrounding countryside who lived decades with a cleft lip, not knowing that a surgeon could change their lives.
To say that medicine doesn't help people is absolutely absurd.
It would probably work if it were permitted and available. That isn't happening, due to pressure from the various third parties (US/EU governments, donor agencies) who care more about keeping rich environmentalists happy than about saving children's lives.
The fact is, flushing, soap, clean water and food have saved vastly more lives than medicine ever has or will. That's the difference between developed and undeveloped countries; medicine is a distant second.
By the way, my claim is not that medicine doesn't help, that we hit the point of diminishing returns a long time ago and a marginal change in medicine available does not affect health levels.
The title is misleading. Wal-Mart can't fix US healthcare. But Wal-Mart can make big inroads into fixing prescription drug access. But there are so many problems in healthcare that Wal-Mart isn't positioned at all to fix. Tens of millions of Americans need health insurance (though the 47 million number that is thrown around includes many who are young and don't want insurance, and many people in between jobs and temporarily uninsured). If Wal-Mart can't insure it's own employees, I don't think they'll become the health insurance provider for underserved Americans.
That said, here is another problem that Wal-Mart can "fix": It's too hard, and too expensive to see a doctor for a minor illness. CVS' MinuteClinic and related offerings by Wal-Mart are trying to exploit this niche.
But basically, there is too much wrong with healthcare for any one entity (incl the gov't) to "fix" it. As an administration official said (privately): "The great thing about health policy, is that your education & training is still useful. The issues we're facing now are the same ones we were facing 30 years ago!"
I don't think the title is misleading. The author claims that Wal-Mart can lower health care costs and increase access to more people. Do you have any specific argument against that?
> If Wal-Mart can't insure it's own employees, I don't think they'll become the health insurance provider for underserved Americans.
Nobody said that they would, including the author. However, if Wal-Mart can work their magic on basic health care, then it becomes much easier to get by on a high-deductible catastrophe plan for most people.
Well, healthcare != drugs. Yes, better medications are a part of providing better health care, and Wal-Mart can help a lot with that. But there is much more to providing quality healthcare.
I'm not criticising Wal-Mart - they're doing a great job lowering barriers to access. I'm just saying we should recognize the limitations and not call it a panacea for American healthcare.
What you're really saying is: there's no money. Insurance is basically a means of pooling together money then someone has to assign to fix the people that need it.
That's not what's wrong with healthcare. What's wrong with healthcare is that the lower middle to middle class don't have much money to be taxed with or to contribute to healthcare.
At the end of the day what needs to be done is someone needs to figure out how to get money and spend it wisely. Both the government and businesses do a shitty job with this.
Not just that. Healthcare has so many players that all need to be pleased to make anything happen. It's complicated because the payer and customer are different, unlike most other industries.
If YUM wants to switch its core competency from serving fast food to automobile servicing... why not?
Snark aside, there's a current trend in "retail healthcare" that I think is really interesting. Drug stores like RiteAid and Walgreens experimented with posting a doctor at each store to provide basic diagnosis for approachable prices on a 9 to 5 scale. That combined with cheap generic prescription drugs, it's become a very good health service for people that don't have jobs that provide medical care.
Will this scale to other more advanced medical treatments? Maybe. That's what the article is talking about.
Maybe I should have expanded a bit. I think the WalMart healthcare system would be about as good as the WalMart-branded clothing. Not good.
If Taco Bell started to service your car while you were in the drive through, some men in business suits might say it's a good synergistic initiative. I mean, your car is already there in the drive through.
But really, Taco Bell makes horrifically shitty tacos. Is that even meat they use? It's embedded deeply in the corporate culture to make shitty tacos, and I am positive the same philosophies they use in building their tacos would go into the quality of their in-drive-through-car-repair.
WalMart, similarly, does everything cheaply and fucks with entire markets by using their power to demand certain prices or functionality. WalMart effectively morphs some companies into Wal*Mart-like companies. I think it would be stupid to assume they wouldn't do the exact same thing to healthcare professionals.
Can you imagine having the same person who negotiated the price of a toilet bowl brush down from $1.99 to $0.99 by demanding the toilet brush company use half as much plastic as being the same person negotiating with the doctor to delay your xray a few days?
Before swallowing this tripe, one must first believe the "government is your enemy, the market our savior" mantra.
Government is a tool that can be wielded effectively or ineffectively. Though Americans haven't quite learned how to do anything with this tool (or rather, have forgotten over the last few decades), other people have and they enjoy the benefits, one of which is affordable, effective health care for everyone. Americans too can enjoy these benefits, however too many of them would rather repeat the mantra and eat their tripe, than learn from reality.
What amazes me is that progressives simultaneously believe that 1) the U.S. government is controlled by special interests ( insurance companies, the AMA, drug companies ) and 2) we should give the government more power to regulate healthcare. If you believe 1), then doing 2) means giving even more power to the special interests.
Anybody who wants the US healthcare system to look more like Europe's, must also come up with a realistic way of 1) replacing our Congressional system with a Parliamentary system, and 2) curbing the power of the lobbies. Otherwise, any plan to use government to make healthcare better will be co-opted by the special interests and end up making the healthcare worse.
Yes. All institutions are governed by incentives. The Government is not run by angels, but men. Furthermore, being the largest organization of any sort in the entire world, it has a particularly byzantine, inefficient, and wasteful web of contradictory incentives that govern it.
It amazes me that people use such sloppy thinking when it comes to politics. "We'll should use the government to do X" is not the end of the conversation. We must ask how likely it is to carry out the goals given it, how much it will cost to do so compared to alternative solutions, etc.
Edit: In Economics this line of reasoning is called "Public Choice Theory"
Well, we'd like to curb the influence of special interests before giving the government more power. And while I'm at it, a moon base would be pretty cool, too.
collectivists are always cheerful until they meet people who don't agree with them. why do you think socialism works so well for several small european countries? homogeneity.
Government is not a tool, neither is "the market". People solve problems by creating organizations to address specific needs. If something comes from the government, you get one try (like doing an experiment with one petri dish). If the government does not offer a top-down approach, then often many people will try (so you get many petri dishes and a better experiment).
The same argument can be used in favor of healthcare policy at the state level rather than at the Federal level.
The idea that the Federal government offers the ideal approach to solving broad problems is fraught with a fundamental misunderstanding of science and the idea of any policy being at its core an experiment.
Sadly, those who advocate a single attempt at a solution are very far from thinking of the optimal solution as the result of experimental trial and error. In fact, they go so far as to claim that "free" healthcare (whatever that means) is a "right".
The market is not the savior, it's the scientific method!
"If something comes from the government, you get one try"
I tend to be skeptical of "progressive" political thinking, but must admit I was impressed by a quote I just heard in a documentary about Franklin Roosevelt. When someone asked of one of his policies, "Well, what if it doesn't work?" FDR's response was "Well, then we'll need to try something else."
I don't hear that from either left or right. The only correct answer for a politician today is whatever their ideology dictates. Obama comes closest to escaping this box, occasionally, but even he has to pander to his base at times, I think.
More so than any one particular gaffe, I think that Bush's biggest shortcoming has been his total unwillingness to "try something else."
I don't think one needs to subscribe to a particular mantra to make healthcare effective. It doesn't matter if it's a government official or a business that getting a doctor to see you, tell you what's wrong, and fix you up, the point is that we ant something like that to happen.
What's being argued continuously is how do we get that to happen given the clear disproportionate amount of doctors and resources to people.
Right now we don't measure long term benefits and decisions are insulated from costs.
(Yeah, I drink the Kool aid: http://www.amazon.com/Redefining-Health-Care-Value-Based-Com...)