Ten Key Questions Framing the Health Care Debate

by Doug Iliff, M.D. on September 25, 2009 · 60 comments <span>Print this article</span> Print this article

in Economics & Empire,Politics & Power

Operation how to downsize medicare

Operation how to downsize medicare

“The burqa is not welcome in French territory,” French President Nicolas Sarkozy said in a June 22nd speech at Versailles.  He was referring to the head-to-toe garment worn by some Muslim women which covers their faces.  It is banned in French schools.

What does that have to do with health care reform?  Well, maybe a lot.

Can you imagine any form of dress being banned in America?  Think of President Obama in the Rose Garden announcing that “sagging pants are not welcome in America.”

If you tell an 87 year old Frenchman that he’s going to have to live with a 98% blockage of his left anterior descending coronary artery, he’s going to shrug and say “C’est la vie.”

Say that to an American, and he’ll say “The hell I am.”  And if he’s had a stroke, and can’t talk, his solicitous California relative, who hasn’t visited Pops in a decade, will say “The hell he will.”

And yet if we don’t change the medical entitlements of aging Americans, we’re almost certainly going to bankrupt Medicare within a decade–long before we bankrupt Social Security.

This is not just my opinion.  It is the stated opinion of Mr. Obama, the Congressional Budget Office, Rush Limbaugh, John McCain, Nancy Pelosi, The New Yorker, the New York Times, and The Wall Street Journal.

Here are the ten most important question to ask about health care in America:

1. Is American health care among the best or the worst of the First World?

It’s the best in the world if you have decent insurance, and among the best if you don’t.  Nobody is denied care in America.  Show up in the emergency room uninsured or undocumented, having just wrapped yourself around a light pole while operating a motorcycle drunk and exercising your constitutional right not to wear a helmet, and you’re in line for a million bucks of state-of-the-art free care paid for by the shrinking number of citizens still paying taxes.  Nobody denies that.  What they point to is a mediocre life expectancy, and a relatively high infant mortality.  The first is due to slovenly lifestyles (36% of our Medicare costs, and 48% of Medicaid, are directed to the treatment and complications of obesity), and the second to a decadent underclass which refuses to act responsibly in the face of pregnancy.  By the way, don’t forget that the vast majority of technological and pharmaceutical innovations in the world are provided and paid for by Americans.  See Nobel, Alfred, Prize thereof.  Don’t forget, either, that there are few queues in this country, except for organ transplants.

2. Why do most Americans say they want health care reform?

Because we are a truly empathetic people, and we feel sorry for responsible people with hard-earned assets who lose their insurance with their job and can’t afford to replace it.  Or even for people who are healthy, choose to not purchase coverage, get sick, and are denied coverage.  We can put ourselves in their shoes, and it worries us.

3. Why do most Americans fear health care reform?

Because despite all the weeping and wailing in the media, we’re pretty happy with our own coverage.  It’s like with politics: people hate Congress, but love their congressperson.  We know and trust our personal physician, we worship with the nurses from the local hospital, we play softball with insurance company employees who are decent people.  It could be worse, and we’re afraid it will be.  So we can be spooked easily by demagogues on both ends of the philosophical and political spectrum.

4. Is a crisis coming?

Almost certainly.  Theodore Dalrymple observes that financial collapse has been threatened since Medicare was first introduced, and it hasn’t happened yet.  Nevertheless, the graph plotting percentage of GDP consumed by health care rises inexorably, excepting the mid-1990s (more about that later).  Health care inflation far exceeds salary inflation, and with the Baby Boomers just entering Medicare it is hard to avoid the conclusion that we are facing a demographic apocalypse.  If it doesn’t bankrupt the country, it certainly will sap our competitiveness vis-à-vis the lean and hungry barbarians in the East.

5. So– how do we reduce costs?

There‘s the rub.  Let’s break it down.  Who has the authority to reduce costs, how do they do it, and how do we like it when they do?  There are four options: government, doctors, insurance companies, and patients (that is, us).

5a.  How does the government reduce costs?

Who knows?  They’ve never done it.  Medicare is under complete control of the government, and Medicare inflation has been galloping right toward the edge of a cliff.  Furthermore, virtually all private insurance now hitches the stagecoach of physician reimbursement to Medicare-determined Relative Value Units.  Those passengers are headed toward the same cliff.  Furthermore, those RVU decisions have so inflated the salaries of procedural specialists relative to generalists over the past 15 years that medical students won’t choose primary care, which means there aren’t enough internists and family physicians to care for those 47 million uninsured Americans.  Furthermore, every year at the stroke of midnight Congress caves under pressure and authorizes additional Medicare expenditures.  Furthermore, Medicare is already cost-shifting a large percentage of its real expenditures onto private insurers and citizens, who make up for the share of hospital operating costs which Medicare won’t pay.  Oh–and those taxpaying citizens, from janitors to rocket scientists, pay 2.9% of every dollar they earn to support Medicare.  That’s the government record to date.  What do you think?  Want more of the same?  Do you believe in miracles?

5b. How do private insurers reduce costs?

Who knows?  They’ve never done it.  When they try to squeeze physician reimbursement, the best physicians won’t sign contracts; they can afford to be selective, because they‘ve got more patients than they need already.  So cut-rate insurers end up with the dregs of the medical profession, and that doesn’t turn out to be a sustainable business model.  They can attempt to fix prices with other insurers, but that risks antitrust prosecution.  They can sell policies which honestly exclude certain expensive conditions or treatments, and patients will scream to the politically appointed or elected insurance commissioner when those conditions hit; that results in embarrassing publicity.  They can “reinterpret” contract provisions to the detriment of patients, expand pre-existing conditions, drop coverage when the disease gets expensive, refuse to cover “experimental” treatments, or cherry-pick healthy patients–more public black eyes.

5c. How do physicians reduce costs?

At least this is not a theoretical question.  Those disappearing primary care physicians brought health care inflation to a halt in the 1990s.  It was called “managed care,” and the physicians were called “gatekeepers.”  They were guarding the gate to the Money Tree through mandatory referrals for procedures, consultations, hospitalizations, and lab tests, and had incentives to do a good job.  The strongest incentive was called “full capitation.”  The insurer gave the gatekeeper all the premium money, less administrative fees; withheld a percentage from the gatekeeper’s reimbursement; and if the gatekeeper didn’t spend it all he got his “withhold” back at the end of the year, plus a cut of the leftovers.  Pretty soon lawyers figured this out, and began making this arrangement known to malpractice juries.  That stopped that.  Then the insurers tried a weaker, more subtle incentive: bonus payments based on total managed expenditures, with the payments partially disguised by percentile groupings and “quality” measures to confuse the juries.  Ultimately, though, when patients realized that the interests of their physician diverged from the interests of themselves, this arrangement was doomed.  Massachusetts, faced with bankruptcy due to its heroic experiment insuring all citizens, is flirting with the resurrection of full capitation.  This time they think it will work, because electronic medical records will enable high-school graduates working for the state to monitor the daily medical decisions of physicians.  It’s like, you know, the triumph of hope over experience.

5d. How do patients reduce costs?

This hasn’t been tried for a long, long time–since payment for medical services switched to Other Peoples’ Money in the 1940s–so we have no recent data to help us.  Proponents of Health Savings Accounts believe that if every American were given money to manage, they would make medical purchasing decisions as shrewdly as they make automobile purchasing decisions.  Opponents of HSAs point to the complexity of those decisions, the lack of pricing information, and the impossibility of deliberate choice at the point of sale in an emergency.  Proponents respond that insurance policies could be simplified and standardized, sold across state lines to increase price competition, and that the vast majority of medical decisions, anyway, are made under non-emergency conditions.  And those glowing reports of great primary care in every other industrialized nation?  Well, you could buy all of my services as a family physician– including obstetrics, office lab and x-rays, laceration repair and skin biopsies, physicals, treadmills, and 24/7 on-call coverage–for a family of six for $100 per month.   I’d make more money than I do now, because my billing cost would drop to zero.  (With the Democrats controlling the government, this option is not on the table; and we don’t have enough primary care physicians, anyway, having converted them into colonoscopists.)

6. What about rationing?

Yes, the issue is rationing– and it’s about time we started this national discussion.  It has started badly, with the New York Times trotting out Dr. Peter Singer to examine the topic from the view of a secular utililitarian.  He really did an excellent job of presenting the choices; alas, his comments elsewhere regarding the advisability of terminating human defectives age two or less, and pulling the plug on Granny, instantly set conservatives on the scent at full bay.  Mr. Obama, having risked a personal example in the form of his centenarian grandmother (who received a hip replacement while dying of cancer) was immediately equated with the Butcher of Baghdad, if not Nero reincarnate.  It is in fact possible (see 4 above) that at some point we may, as a society, be forced to make our present sub rosa system of rationing explicit.  This might be in the form of Wise Latina Women making decisions about how much we can afford to pay for Quality Adjusted Life Years, as in Great Britain, or some other system applying medical evidence to the budget.  Whatever we do, it is not going to involve wise people like Mengele or Eichmann.  That is a statement of faith on my part, but I’d bet my income on it.  Most people are unaware that these sorts of judgments have been applied for a long time.  I remember when mammography was developing in the 1970s, the question among physicians was how much it would cost to save a life through early detection.  The answer was, “little enough that we can afford it,” and the point is that we were not Nazis in the 1970s, and we are not Nazis now.  But we do live in a world of finite resources, and at some point choices have to be made between what is possible and what is the best use of available dollars until the Money Tree is rediscovered.  This conversation should be rational, as opposed to emotional.  Can we afford quadruple bypass surgery on 89 year old citizens?  Can we afford chemotherapy which, on average, offers two months of extended life for $80,000?  It’s a hard conversation, but necessary.

7. Didn’t the Democrats try to slip euthanasia counseling into the mix in the dark of night?

I really hate to defend Democrats.  I really do.  It causes me heartburn.  But they were carrying water for my colleagues, who weren’t getting paid to spend time talking with old folks about their choices at the end of life.  So they tried to make sure they didn’t do it gratis. Politically, in hindsight, it was stupid.  However, a number of my decisions, in hindsight, have also looked stupid, though they seemed like a good idea at the time.  So I’m inclined to give them a pass.  Could we have an adult conversation about this, too?  As a Christian, I am dead-set opposed to abortion, infanticide, and euthanasia.  For me, and St. Paul, “to live is Christ, and to die is gain.”  I want to fight the good fight, to finish the race.  I’m so radical on this subject that I consider retirement to be an un-Christian accommodation to a secular culture—one which should be abandoned.  I want to be useful, in some fashion, to my last breath; to die, so to speak, with my boots on.  For those of you in the audience who don’t share my religious views, I would assert that among every other tradition, including that of atheists, there can be found advocates of a similar conviction.  When I get to the point where I can’t spoon my own soup, God spare me a relative who advocates another round of chemotherapy.  I don’t consider that a species of euthanasia.

8. Is there a systemic way to discourage sloth and gluttony?

There is good evidence that carefully structured incentives and disincentives can nudge people toward healthier choices.  HSAs are the easy way to do it; the effects of diet and exercise save money for the person doing the work.  Moreover, such a system would derail a coming, and ugly, scenario in which overweight people will be persecuted like smokers are now.  But smokers have it easy–after all, they aren’t smoking all the time, whereas fat people are fat 24 hours a day.  When government or insurance companies are paying, it takes a Rube Goldberg arrangement to get the goads in the right place.  But it can be done, as Safeway and Whole Foods have demonstrated recently.

9. President Obama says that electronic medical records will save a lot of money.  Is that true?

There is no evidence to back up this assertion, and plenty to refute it.  EMRs have some value in the delivery of efficient medical care, at some risk to our privacy.  But they won’t save any money, and may reduce productivity.  However, there is one certainty: searchable electronic records will make it easier for Big Government or Big Insurance to decide whether you need the care your physician is prescribing.  Whether this is a good deal depends on your view of 1984 or Brave New World.  That’s heaven for some people, hell for others.

10. What are the unintended consequences of proposed reforms?

Aside from cost explosion and civil war, let’s consider what would happen if the government immediately or eventually takes over responsibility for our health.  I’m going to ignore the status quo (government + insurers), a return to physician control, or the advent of HSAs, which appears remote.  I’m also going to stipulate that Death Panels are not in our future.  OK– the government has to control costs, and the choices are:

10a. Eliminate all profits from Big Pharma by dictating prices, like the Europeans do.  This will save 2% of the national health bill the first year (from 10% to 8% for drugs), and more later, as all pharmaceuticals eventually go generic.  Of course, there would be no more new drugs, so that’s the unintended but inevitable consequence.  Maybe the National Institutes of Health could do the research, as well as fund it; and maybe the executive branch can run General Motors, too.

10b. Nationalize the doctors, and put them on salary.  This would almost certainly reduce costs, because as Mr. Obama has pointed out, if a surgeon isn’t paid more to cut off your foot, he might not.  It would also increase waiting lists, because if the surgeons aren’t paid more to cut off good feet, they also aren’t paid more to cut off bad feet, and so you can bet they’ll be figuring out how to spend more time on the golf course and less in the foot clinic.

10c. Set up the American equivalent of the NICE commission to decide which treatments are cost-effective, and which aren’t.  This is not a bad idea, because some treatments really aren’t cost-effective.  Two problems: first, we don’t know for sure which are and which aren’t (in medical school I was taught that half the stuff I was memorizing was wrong, but the professors didn’t know which half); and second, having decided that drug XYZ is not cost effective for glycogen storage disease type 75b, sure as God made little green apples Senator Blowhard’s daughter will be stricken with– you guessed it, 75b.  Now we’re asking the Senator to number himself among the angels, and avoid interfering in the funding or operations of the Very NICE commission.  Chances?

10d.  I spent five pretty happy years working on salary for the world’s largest HMO, the US Army.  We didn’t have enough resources to do everything we needed, so we practiced “triage by attrition”.  When I arrived for a 6 p.m. shift in the emergency room, 75 people would be waiting.  If I worked hard, I might be able to see 50 in 12 hours, but 50 more would show up by 11 pm.  Nevertheless, by 4 a.m. I could usually take a nap.  What happened?  By ones and twos, the less sick drifted out as the evening wore on.  That’s the way the rest of the world works.  It’s not so bad.  Some people die unnecessarily, but some people die in our country now because they can’t afford care.  The main effect is wasted time and prolonged pain.  And that brings me to:

10e. My mother ran the business office at St. Luke’s Hospital in Kansas City for many years.  As the reputation of the Mid-America Heart Institute grew, more and more business came from wealthy foreigners who decided to jump the queue in their countries by flying to America.  What would happen if America became one of them?  A recent survey by Russia’s Ministry of the Interior found, without irony or outrage, that the average bribe had tripled in the past year.  That’s one way to jump the queue, well known in queue-tolerant nations.  The rich, the well-connected, the governmental employees who set up the system–they’d get their surgeries, one way or another.  And the rest of us?  I mean, the rest of you–I’m setting up an ambulatory surgery center in the Caymens.  No lines.  Cash on the barrelhead.  Round-trip airfare from Miami included.

See why I prefer patients to make the choices with HSAs?

I have two porches on the log cabin I built with my own two hands.  As a Republican sitting on either, I see my beloved Kansas woods, where one day my ashes will be scattered.  I work hard every day, doing my honest best to do a good job, contribute constructively to the betterment of my neighbors, and return home to my beloved wife, my beloved dogs, and a cat which I could probably do without.  I think every American wants, and deserves, competent and compassionate health care from a physician who knows them and, in his or her own way, loves them.  I do not think every American deserves, or perhaps even wants, every test, procedure, and intervention which could possibly, under even the extremes of age or disability, be applied to the life left in their vessel of clay.  For those who do: you have my pity, but not my agreement.

How we handle this disagreement, as a nation, is critical.  Sarah Palin (“Obama Death Squads”) and her fellow-travelers have so whipped up the pack that even conservatives are feeling hot breath at town halls.  Writing to physicians several years ago, I predicted that any attempt to impose rationing from above would produce blood in the streets.  We’re getting close, now.  To my mind, only self-rationing– in the form of HSAs, or something similar– could fix health care in a way that acknowledges the unique American character and experience.  Here’s to you, President Sarkozy.

{ 56 comments… read them below or add one }

avatar Albert September 25, 2009 at 10:58 am

Dr. Iliff, thanks for this informative essay.

I still think it is odd to say that when I pay for shoes, the shoe store is “rationing” the shoes to me. Same feeling goes for the idea of “self-rationing.” Such a notion of “rationing” seems to gloss over the issues of freedom and justice inherent in a personal relation of giving and receiving, i.e. in an economic transaction, such that it no longer matters that an unknown bureaucrat is decisively and impersonally interfering with a just relation.

While I agree that we need to acknowledge that some sort of distribution mechanism is needed, I’m not sure the best way to do that is by calling all distribution mechanisms forms of “rationing”; at that level, I don’t think–like many progressive folks do–that folks getting upset over “rationing” are being ignorant of “what really goes on.” I think there is actually a substantive difference there we intuit, even as they find it hard to express why “rationing” is illegitimate.

avatar Doug Iliff September 25, 2009 at 11:29 am

Albert, I think the reason why “rationing” sounds tinny in the context of normal exchanges is that your Uncle Sam or your next door neighbor is not paying for your shoes through the funding of an intermediary agency. If they were, and for every pair of “free” shoes there were a couple of buyers, rationing would be an apt description. It is wrenching to consider that the typical American consumer thinks nothing of spending $20,000 for a car, but is shocked– shocked!– at the thought of plunking down $100 for a trip to the doctor. There is nothing in our experience which compares to an “insurance” scheme which covers normal everyday expenditures.

avatar M.Z. September 25, 2009 at 1:22 pm

This is mostly ideologically driven nonsense. Rather disappointing.

avatar John Cisternino September 25, 2009 at 1:48 pm

Dr. Iliff,

I must take exception to a claim that marred discussion of an important topic.

You assert that our high infant mortality rate is due to “a decadent underclass which refuses to act responsibly in the face of pregnancy.”

I find this assertion very disappointing and it evinces rearguard prejudices that too often applied by outsiders to the localist movement as a whole. Do you really think that America’s poor are lazier, or more entitled feeling than the poor in the rest of the developed world? Even though we’re by most measures the most hard working and productive country in the world? Even though the social welfare system (which I’m guessing is what you’d blame for decadence) is much smaller here than across the rest of the developing world? I’d like to believe that you’ve got an argument behind your assertion, but you haven’t made one here. And having studied the social science on this issue, I think you vastly underestimate the importance of situational factors including the health care delivery systems in contemporary America for our nation’s disgraceful record of inability to bring infants into the world healthily. The slam of the “decadent underclass” strikes me as a latent prejudice, not an informed contribution to the debate.

If localism is to work, it will be because we are better at creating environments that produce human flourishing at the local level than at larger levels of social collaboration – because we are more responsive to more of the texture of our world, and this makes our communities more humane and more ethical. If localism means socially turning our backs from those less fortunate than us, or tarring the poor (of all people!) as decadent, I fear it will harden our hearts, not open them. And that would be regress, not progress.

What I love about Front Porch Republic is the spirit of reclaiming knowledge by paying attention to kinds of information that get lost in most national discussions of policy, where good is measured in statistics, and the dignity of work gets reduced to dollar signs. Your remarks on the poor don’t live up to the high standard I’ve seen here.

That said, I think there should be a lot of room for localism in the health care. I think we agree that “rationing” of care by some mechanism or other will be necessary to keep health care affordable for the country. One big question I have is whether it might make sense to have nationally funded health care (for equity and efficiency reasons) where care priority decisions are made at the local (town, neighborhood) level. Maybe talking to our neighbors about what kinds of care matter most to us and why would help us make better decisions, and decisions that we could respect because we’d been a part of them. I’m not sure, but this is the sort of direction that seems promising. I’ve got a gut feeling that in a conversation like that (as opposed to an anonymous national poll), more people would agree with you about the kind of care they want to collectively provide than would disagree. I certainly would.

Sincerely,
John Cisternino

avatar Jeremy Beer September 25, 2009 at 1:49 pm

Dr. Iliff — This is one of the best pieces we’ve ever posted here on FPR. You’ve done a wonderful job of describing the landscape and laying out the options–or lack thereof. Thanks for writing this. I hope it is widely linked to and read.

avatar Doug Iliff September 25, 2009 at 2:28 pm

John,

I regret the use of the word “decadent”, which is more judgmental than I intended. Would “dispirited” be more acceptable? If we could agree on that, then we can argue about the substance of my point. Is it disputable that an underclass where 70% of babies are born out of wedlock is too stressed, dysfunctional, obese, and/or addicted to responsibly participate in a cooperative medical relationship such as prenatal care? I have read of experiments where public health authorities take prenatal care to the poor in Louisiana with good results; but these are heroic and expensive, and they are the norm in many First World countries with which we are compared. My point is simply that societal and cultural breakdown is not a failure of the medical profession, and will not be affected in the least by any current proposals for health care reform. On a personal and more positive note: I believe that HSAs would be a force for positive change even among the dispirited underclass, because I have cared for many members of this group over time and I find them to be just as rational as I am. But they have a very, very hard time following through with the best of intentions.

avatar John Médaille September 25, 2009 at 5:24 pm

As much as I would like to like this article, there is much that is problematic, to say the least. The problem with HSA’s is that only a small fraction of the population can take advantage of them, and even in that case there is little evidence that it actually works to make people better consumers. HSA’s function as a subsidy to savers, and the higher your income the higher the subsidy. In other words, the biggest subsidies go to the people who need them the least.

Here are some of my questions.

1. Is this really the best system? Even if you have insurance, there is no guarantee that you will have it when you need it. True, everybody can get some medical care, simply by going to the emergency room on the 5-5-5 plan: wait five hours to see a doctor for five minutes for five dollars. How much actual care they can get from this is another matter. Even the fact that people come here for medical treatment is less persuasive than it might seem, since people often leave this country for the same reason; medical tourism is in fact a large and growing business. IN any case, the actual statistics do not bear out this claim, and explanations like a “decadent underclass” sound unconvincing at best, especially since the more obvious problem is a decadent overclass.

2 & 3. I don’t know that it is empathy for the poor so much as fear of the current system. You don’t know if you have insurance until you need it. Then you may or may not. People are afraid of their own insurance providers.

6. All scarce goods are rationed. Price systems are rationing systems. The question is not whether such goods are rationed, but how. Is the free market the best way for a “common good” like medicine? Maybe, but that’s a discussion we need to have. And the question is never whether we ration but how.

7. What euthanasia counseling?

10. Cost controls seem to work in Europe just fine. Why? Because so many of the medicines are monopoly products; that is, the gov’t restricts the market. In such cases, price controls are perfectly valid even under “free market” ideologies. Even at controlled prices the profits are enormous. It won’t (it hasn’t) limited research (40% of which is funded by non-profits anyway). Further, the biggest expense is neither profits nor research, but marketing, which runs twice what research runs.

The problem is that we do not have a free market, but a series of overlapping gov’t markets guaranteed by patents and licenses. Doctors don’t want to give up their license privileges, which limits competition. This may be a good thing or a bad thing, but the economic consequences are constantly rising prices, and this cannot be denied. Further, to too many in the profession, this is not a profession at all, but a business, and every surgery counts as a sale, every test a profit center. My own most recent experience was being told I needed immediate neck surgery, no time to waste. After a second opinion, it turned out that getting computer glasses cured the problem. Doctors complain about defensive medicine, and then it turns out that they own the lab, the MRI, etc. They are just forced to make more and more money.

But there is another problem: the professionalization of medicine, and everything else. Mothers are considered to too incompetent to be primary care givers, and every aspect of our lives are in the hands of some “professional” who turns out to have a pecuniary interest in his own advice. Our food is manufactured (but has 100% of our Minimum Daily Requirement of some chemical or other.) We tell people they are too stupid to take care of themselves, and then we complain about their dependency.

One closing story. A doctor acquaintance of mine once told me that “of course he prescribes pills to everybody, even those who don’t need them. When people go to the doctor, they expect to be “treated,” and the sign of that treatment is a prescription.”

I wonder why costs are so high.

avatar Russell Arben Fox September 25, 2009 at 5:38 pm

Caleb was kind enough to share Dr. Iliff’s thoughts with me sometime back in August, and I’m pleased to see them here. This is a fine, broad and balanced consideration of many problems which plague our system(s) of health care coverage and addressing the costs of such. However, I have some of the same questions now which I had then. John wisely brings up one of them in regard to Health Savings Accounts; while their capacity to refocus the issue of costs on the lifestyle choices which many of us unthinking make (or don’t make), how would it be that such a program wouldn’t in effect become a kind of subsidy to exactly those people who currently aren’t the ones who most desperately need some kind of reform?

Given our country’s roughly egalitarian/Christian aspirations (evn if not called that), wouldn’t some sort of basic minimum guarantees be necessary before a sufficient number of people could be persuaded to leave their private insurance and their payment plans, and set up such accounts? It seems to me that until you had sufficient numbers express a willingness to do so, then you’ll see corporations and insurance companies fighting tooth and nail to undermine the reach of payments coming out of said Accounts, pressuring doctors’ associations and hospitals to decline to accept said payments, for fear that too much of that would collapse the appeal of the arrangements different employers had set up for their employees through Blue Cross or whatever. (As before, Dr. Iliff, if I’m completely misconstruing your point, feel free to correct me!)

avatar Albert September 25, 2009 at 9:07 pm

If they were, and for every pair of “free” shoes there were a couple of buyers, rationing would be an apt description.

In that situation, the language of rationing would make sense.

It is wrenching to consider that the typical American consumer thinks nothing of spending $20,000 for a car, but is shocked– shocked!– at the thought of plunking down $100 for a trip to the doctor. There is nothing in our experience which compares to an “insurance” scheme which covers normal everyday expenditures.

That last point seems especially important and somewhat of a paradox. We don’t have any other insurance that covers normal, everyday expenditures, and if one points that out to people, they would pause in reflection and then agree that it’s odd. And yet, we don’t have reference points with which to judge alternatives in health care, and so the oddness is dismissed as something that’s perhaps intrinsic to health care or somehow better.

Perhaps the analogies to car insurance, as imperfect as it is, would at least help to communicate why it might be better to limit insurance to covering catastrophic events and acclimate folks to paying $100 for a visit. I pay $300 every six months for my car insurance and, because I have reference points in the premiums of my friends, am quite comfortable with paying that…

avatar cecelia September 26, 2009 at 12:29 am

The article is misleading on several points.

First, decadent underclass is what causes high infant mortality? What a leap of logic. I did not know babies died from their parents moral decadence. Infantmortality is caused by a lack of pre natal care to the mother and by a lack of post natal care to the infant. Low birth weight contributes to infant mortality, as does pregnant women working at manual labor during the last trimester. I fail to see how any of these lead to a conclusion of moral decadence.

Second, the notion that you can arrive in an emergency room and receive care regardless of ability to pay and this equals health care for all is silly. Health care is a great deal more than critical care. It includes preventive care, ongoing routine care which uncovers things like high blood pressure and gets one sent for mammograms and colon cancer checkups. That isn’t happening in emergency rooms. Emergency rooms may be free at point of service delivery – but do you really think hospitals do not vigorously attempt to recover those costs? There is a growing business of law firms whos pecilaize in collecting debts incurred by the uninsured at emergency rooms.

avatar Russell Arben Fox September 26, 2009 at 7:48 am

Incidentally I forgot to mention before that the following passage from John Cisternino’s comment was about as fine and as moral a description of the localist ethos as I’ve ever read:

If localism is to work, it will be because we are better at creating environments that produce human flourishing at the local level than at larger levels of social collaboration–because we are more responsive to more of the texture of our world, and this makes our communities more humane and more ethical. If localism means socially turning our backs from those less fortunate than us, or tarring the poor (of all people!) as decadent, I fear it will harden our hearts, not open them. And that would be regress, not progress.

“Creating environments that produce human flourishing”–yes, exactly. I would like to believe (and I still hold at hope) that one could insert “populism” into the above passage, and have it read the same way. Enabling people to exercise real democratic and economic sovereignty in their places, because it is in those places that communities can do their most human and ethical work…for me, anyway, that’s pretty much what it’s all about.

One big question I have is whether it might make sense to have nationally funded health care (for equity and efficiency reasons) where care priority decisions are made at the local (town, neighborhood) level. Maybe talking to our neighbors about what kinds of care matter most to us and why would help us make better decisions, and decisions that we could respect because we’d been a part of them.

John, my post from last summer touches on this question (among others), and considers a couple of reforms that might make it more likely. (In some ways, Dr. Iliff’s comments are a bit of a response to mine.) Be sure to read the comment thread following the post, it was one of the most edifying and education discussions I’ve ever been a part of online.

avatar Hudson September 26, 2009 at 12:09 pm

Dr. Iliff:

Thanks for writing this piece. I didn’t quite catch your point in 5d. about lowering health care costs by allowing people to purchase health insurance across state lines. Would legislation permitting persons in one state to purchase a better health package in another state lower costs significantly, or not? Would that legislation, in your opinion, create new, more affordable basic plans across state lines, or not–assuming the present government would drop some of its fancier provisions mandated in a basic package?

Also, unless I missed it, you don’t discuss tort reform. Wouldn’t real tort reform significantly lower health premiums and insurance costs that doctors like yourself must pay–assuming, of course, the politicians/lawyers can be found to enact tort reform?

It seems to me that the simple way to lower medical costs is to take money out of the system instead of pumping more and more money into it. Tort reform and lower insurance costs would do that. There’s an old saying: The more bread crumbs you scatter on the grass, the more pigeons will come. What we want is fewer bread crumbs and fewer pigeons.

avatar M.Z. September 26, 2009 at 9:02 pm

Purchasing across state lines is about making health insurance like the credit card industry. Health insurers will shop for the state with the weakest regulations and states will have a conflicting interest of attracting industry or protecting consumers.

As for malpractice, all malpractice spending makes up less than 3% of health care expenditures. That is all malpractice spending.

As for HSAs, they are typical libertarian talking points devoid of experience. We have used co-insurance, co-pays, high deductibles paired with HRAs, and now high deductibles paired with HSAs in attempts to extract efficiencies from consumers. They have only managed to shift costs socially to individuals. What has worked is states doing things like regulating the construction of hospitals and the addition of hospitals beds. Those not ideologically poisoned recognize that the largest savings in health care are on the supply side. Production of these savings is usually best done through granting a monopoly. Utilities are a classic example of this.

avatar Doug Iliff September 26, 2009 at 9:23 pm

Let me backtrack with responses from the bottom up.

Hudson: I tried to stick to things I know, and since Kansas has already experienced tort reform (it did save some money, but not as much as people think), and I haven’t surveyed other states, I ignored the topic. Good question. The issue of trans-state policies would give people the freedom to tailor their protection to their needs and desires. Some states mandate chiropractic treatment, others don’t. It would certainly increase competition and lower costs, but might increase confusion, too.

Fox: I’m with you, heart and soul, on localism. Personally, I think localism will find better soil when the choices belong to individuals rather than national authorities. And don’t forget human nature; when push comes to shove financially, class warfare is less likely to erupt when everyone knows that their neighbor is bearing some personal responsibility for their health. I really, really, fear a backlash toward fat people.

Cecelia: You’re clueless. We’re doing drug screens on all neonates now. Any idea why? Visitation by the amphetamine fairy?

Fox: Health Savings Accounts would indeed be a reward (not a subsidy: the healthy will subsidize the unhealthy under any conceivable scheme) to those who chose a healthy lifestyle, like automobile insurance rewards safe drivers or life insurance rewards non-smokers. My hope is that refundable tax credits for low-income folks would fund their HSAs, give them skin in the game, and boost them toward healthier choices on the margin. Indiana recently offered HSAs to all state employees, and something like half the workforce signed up. Don’t worry about doctors taking the money of HSA account holders. We are indiscriminate.

Medaille: 1. I think Canadians and Germans have the best “system”; Now if only I can get Americans to think like Canadians and Germans. With regard to technical expertise, ours is indisputably the best system. 2&3. You are basing your opinion on what you read, and limited personal experience. I don’t blame you. But my patients do not fear their insurers, though their are occasional hassles and inconveniences. 6. Agreed. 7. There never was a proposal for “euthanasia counselling”; that was my point, perhaps too obliquely. 10. Bring on the cost controls. We have good enough drugs for the vast majority of problems already. I’m no cheerleader for Big Pharma. And as for your last paragraphs, I have worse stories about physicians than you do! We have our outright scoundrels, and the entrepreneurial spirit sometimes goes too far.

avatar John Médaille September 26, 2009 at 10:13 pm

Dr. Iliff. Having been around politics for a very long time, I have never seen a situation where the recipient of a subsidy didn’t call it a “reward for efficiency.” But subsidy or reward, the amount increases with the marginal tax rate. Higher income persons get a higher subsidy–oops, I mean reward–then lower income ones. Of course, subsidies are always the opposite of efficient. If the gov’t “rewarded” everybody who claims an efficiency, the deficit would be about twice as large as it is. Make that three times. HSA’s have been around a long time. It’s now an empirical question: they have been tested without any appreciable effect.

The problem is not that you have scoundrels in the profession; every profession has that. The problem is that the current system rewards the scoundrels as a matter of course. The sale of surgeries, procedures, pills, and tests to a captive and undereducated public is almost too easy. And indeed, the high costs of training and practice almost forces the doctors to be less professional and more “entrepreneurial” (as you call it.)

Choices cannot belong to individuals unless both knowledge and the means to choose (money) belongs to them. But the medical professions, along with the corporations that serve them, have spent 100 years convincing the public that they are far too stupid to attend to their own health, to be their own primary care. And the prices are far too high for people to make their own choices.

We agree that the problem of monopoly profits must be addressed. As things stand, none of the bills on the table addresses this problem, nor do any who oppose the bills have any solution. In fact, all of the solutions, right or left, merely fuel the current problem, shoveling more money into monopolistic markets. We cannot stay where we are without ruin, but we cannot see the way forward.

avatar Albert September 27, 2009 at 1:06 pm

I don’t have a problem with people paying lower health insurance premiums for not doing things that put their health at risk. That makes sense. Does anyone?

Mr. Medaille seems to be adamant about the fact that HSAs subsidize those with higher incomes. By that, I take him to be referring to the tax deduction/exemption from the funds deposited into the HSA; the higher one’s income, the higher the marginal tax rate that will be avoided by the static deduction ($3,000-$5,950).

I’d like to be a bit more clear on whether it is the subsidy aspect of the HSA that Mr. Medialle opposes, rather than the principle that those who don’t hurt themselves should be paying less on insurance premiums. I think it is the former rather than the latter, such that if health insurance were not subsidized at all for anyone, that would allow people to more accurately “count the cost” and thereby lower health care spending overall, and yet still allow for companies to offer lower premiums to people who, for example, don’t hurt themselves.

avatar John Médaille September 27, 2009 at 1:41 pm

Albert, I simply do not see the connection you appear to be making between using HSA’a and taking better care of oneself. HSAs have been in existence for a long time, yet seem to have no appreciable effect on each health care outcomes or the price of health care. This is what one would expect under monopoly conditions: any funds added to the system would only serve to raise the price without necessarily increasing the supply. This is economics 101.

The decision to use HSAs are largely a tax decision made mainly by those families that can afford to save $6,000/year in addition to their other savings. At the lower income levels, where the taxes are mainly the social taxes, it doesn’t even apply. If the high deductible policies implied by HSAs are significantly cheaper, then that alone is sufficient incentive to buy them and put aside funds for the deductibles. But if the advantage is solely from the tax laws (as seems to be the case) then the whole thing really only applies to a small percentage of the population and applies as a subsidy, not as a saving.

avatar Doug Iliff September 27, 2009 at 5:43 pm

John and Albert: I understand the points you are making. Could we duck the issues of subsidies for a moment? Let’s talk about behavior. If you review my arguments, I think you’ll see that I’m looking for something that works: not a win for the Republican or Democrats, or the liberals or libertarians or conservatives. I outlined several approaches which have failed. M.Z. (see previous comment) brought up one which I forgot: restriction of hospital beds in a direct attempt at rationing. That effort (called “certificate of need” regulation) failed in the 1980s. Now, John, you say that HSAs have failed empirically. I didn’t know that was a fact; if so, then there’s one more scalp, and your statement that “We cannot stay where we are without ruin, but we cannot see the way forward” would be pretty much the last word.

However, we have to do something about a very complicated problem. As a family physician, I know two things: we must change the mindset that everything must be done to delay the end of life, because we’re spending an enormous amount of money on the last 30 days of existence. And we must change the behavior of enough overweight, underexercised Americans to avoid bankrupting ourselves from the complications of lifestyle choices.

You can see why I support the approach of Front Porch Republic, which would give us bike lanes, a revitalized urban core, mixed-use suburbs, and so forth. I was appointed to our county planning commission for a couple of years in hopes of helping the planning director, a kindred spirit, to move us in that direction. No luck. My wife and I saved 80 acres of virgin prairie and woods from the bulldozers of the developers, and have turned them into a restoration project and walking trails for the public at our private expense (http://doctoriliff.com/commons.html). That has been a gratifying, but small-scale, success.

The Holy Grail is a way to incentivize individuals to enjoy the subtle pleasures of good food and regular exercise. So you can also see the appeal of HSAs to me. Now, if they don’t work, that would be a big disappointment. But I would be hesitant to throw in the towel prematurely, because Americans, of all peoples, respond to monetary incentives. We haven’t changed much in the 175 years since Tocqueville called us out.

That’s why I’d like to talk about the effect of health systems on behavioral change, in the context of FPR values. Can any readers come up with ideas (from whatever political or philosophical direction) which would enable a system of health care to help people like me push people like you in the direction we all agree we need to go?

avatar Kevin J Jones September 27, 2009 at 7:47 pm

I am surprised tort reform isn’t playing a larger role in the opposition to the Democrats’ plan, since it’s a prime area for the GOP to score points against the stereotypical greedy lawyers.

Has anyone studied the financial impact of pharmaceutical advertisements? When the FCC (FDA?) lifted the ban on such commercials, that surely altered the economics of health care. Would health care be more or less expensive if companies couldn’t market to prospective patients directly?

“a relatively high infant mortality.. due to a decadent underclass which refuses to act responsibly in the face of pregnancy.”

While this sentence attracted criticism from commenters, I found it a blunt reminder of how the world really is. Child neglect sometimes begins in the womb, and it’s no good providing free prenatal care if irresponsible pregnant women are indifferent towards it.

I want to note that the high infant mortality rate in the US relative to other countries is also affected by our differing definitions of a stillbirth vs. a live birth. Also, I’ve heard greater use of fertility treatments in the US may result in more sickly newborns who otherwise would not have been conceived.

avatar M.Z. September 27, 2009 at 7:49 pm

I’m not sure why local is a priority. Let’s implement the French system or most any other system, even the NHS. We have a good idea what the costs will be.

More practically, a concerted effort toward reducing accounting/billing costs would do wonders. Take a basic office visit. Is the physician even seeing 30 cents on the dollar at this point? One of the few compliments I’ve heard about Medicare on the business side is that at least you know you will get paid and you know what you will get paid for. With HSAs, clinics and hospitals are having major receivables issues. There is no good reason they need to have these issues. Cost is just being added by having these issues. (To the person above that claimed people need to understand $100 physician charges, do understand that exceeds what many people make in a day of work.)

On the facilities side, what a mess. With hospitals, we seem to have chosen the most expensive way possible to account for charges. Billing for aspirin? On the hospital side, it should be possible to reduce billing codes down to a half dozen to dozen billable codes. I would advocate public ownership or the equivalent for most facilities.

avatar John Médaille September 27, 2009 at 8:02 pm

Dr. Iliff, I certainly agree that “lifestyle choices” are a big part of the equation, but this is something far beyond the reach of any health care reform legislation. A society addicted to subsidized corn syrup diets, non-stop entertainment, and the automobile is likely to have a different health profile than a society that eats real food, does real work, and walks someplace now and again.

As far as HSAs go, everybody has an “HSA” to the extent that they have a deductible. The only question is whether the insurance deductible is also tax deductible. For those who structure their payments in a certain way, it is, and for those who don’t it isn’t. Your efforts to provide conservation and walking trails are more than commendable; every such step, no matter how small, is still a step in the right direction.

avatar Doug Iliff September 27, 2009 at 9:48 pm

John: I’m still reluctant to give up on HSAs. I’ve only had mine for three years, and it has upwards of $5000 in it. Imagine a young mechanic who started contributing to an HSA at age 19. By my age (60) he might have $100,000 to pay deductibles, home health nurses, or care at a quality nursing home. So over time, HSAs produce serious money– far exceeding the cost of deductibles, which provide only trivial incentive to make wise choices. I don’t think it would take very long before ordinary Americans started to read the tea leaves.

M.Z. 30 cents on the dollar is just about what I take home. But it’s not administrative expenses accounting for the other 70 cents– it’s rent, nurses, equipment, supplies, and drugs. Administrative expenses, as you are thinking of them (something which would be eliminated by Medicare or some other single-payer plan) are only a few pennies.

Now we’re cooking, readers. Keep the comments coming. Maybe we’ll come up with something revolutionary which I can take to the American Academy of Family Physicians in mid-October (I’m on the board of their management journal, and write their practice managagement blog).

avatar M.Z. September 27, 2009 at 10:18 pm

When NHS in Britain went to copays, they found it cost as much to administer them as they gained in revenue. It also didn’t reduce “unnecessary care”. 31 cents of every dollar go to administration.

Imagine a young mechanic who started contributing to an HSA at age 19. By my age (60) he might have $100,000

This is derogatorily called Chinese math. If people commonly held a multiple of their deductible in a heath savings account, changes would be made to plans to be capture these dollars. Regardless, we are at this point violating principles of insurances. Insurance is not a guess of how one person will fair. Insurance is the principle that if we aggregate enough people, we can approach certainty of our costs over a certain time period.

avatar D.W. Sabin September 28, 2009 at 8:56 am

Whatever sure to be cockeyed plan is developed, it might be wise to actually include incentives for reduced costs extended to those people who have both a low incidence of care history and prudent preventative lifestyles. The current system operates on the opposite principle with those of good health subsidizing those of poor health and as we know, many …though obviously not all…. of the poor health individuals are willful in their pursuit of extravagantly unhealthy lifestyles. Sure, lifetime runners drop dead of heart attacks at age 60 and children get cancer but one wonders if these are not statistical aberrations.

I am put in mind of one of Twain’s acerbic quotes to the effect that he liked his riverboat-styled house in Hartford , where Samuel Colt made guns next to the aborning nationwide insurance business because it was the “only place in America I can take out an insurance policy after breakfast and blow my brains out before lunch”. Extending this thought, we can recall Twain’s heir Ed Abbey and his statement that “they should reinstitute dueling, it might improve manners around here” and then we might consider those Death Panels to be the silver lining in all our problems….as long as I can choose the panelists. then again, i have a bad attitude.

avatar Doug Iliff September 28, 2009 at 1:05 pm

MZ: I won’t argue that a single-payer system would reduce costs of billing, collecting, profits, and exhorbitant executive pay, but that is closer to 15%. The rest is administrative expenses tied to compliance, which are worse with Medicare than any other program. That’s not to say it wouldn’t be good to save 15%, on a one-time basis; but compared to the costs of medical inflation, it’s trivial over the long term. If the problem is restraining costs through retraining behavior, this won’t do it.

I don’t know if politicians would raid HSA accounts. It’s possible, but I think unlikely. Patients would quickly equate this to their 401K accounts, and would raise holy hell. Again: we’ve got to have behavior change, and tinkering with payment mechanisms won’t get us there. As I said in my article, either it has to be dictated from on high (overt central rationing), or incentivized from below (by individual choice). I’m not wedded to HSAs. I just haven’t heard any other ideas to put the difficult choices at the local level, and it’s a leap of faith to think a single payer plan will fix the problem.

avatar Albert September 28, 2009 at 4:15 pm

Mr. Medaille, you keep writing HSAs have been around for a “long time” and haven’t worked. Am I mistaken to believe HSAs have been around since 2003, i.e. for six years, or do you really think 6 years constitutes a “long time”?

Regarding the connection between HSAs and taking better care of oneself, I’m simply pointing out that having a separate account for health care purchases under a high deductible plan give folks a clearer picture of their health care budget and thereby motivate people to take better care of themselves so that their account does not shrink, rather than using current comprehensive insurance schemes which obfuscate and thereby increase costs. Perhaps that is clearer, if not persuasive.

In the end, it’s not the tax benefits but the use of health care budgets, use of high deductible plans more akin to catastrophic insurance, and the rejection of “comprehensive” coverage that are the main benefits of HSAs. While HSAs aren’t a panacea, they seem to be beneficial; the problem is not that they aren’t helpful, but that they are not being adopted because most people are okay with their current insurance schemes since they do not emotionally own public debt used to subsidize the status quo.

Regardless, we are at this point violating principles of insurances. Insurance is not a guess of how one person will fair. Insurance is the principle that if we aggregate enough people, we can approach certainty of our costs over a certain time period.

M.Z., HSAs do not replace insurance. They reduce the comprehensiveness of insurance, which is a good thing.

avatar M.Z. September 28, 2009 at 4:24 pm

I never claimed HSAs were insurance. The idea that reducing the comprehensiveness of insurance is good is an assertion in search of an argument.

Tell you what. We’re creating a new health care system. This system gives each person a savings account. At birth $500,000 is placed in the account that can be used on medically related item. Why is this a bad plan? Why does it become a better plan if we instead add $5000 to the account yearly but start with zero in the account?

avatar John Médaille September 28, 2009 at 4:25 pm

How long should it take? HSA’s are an extension of MSAs, which started in 1996.

avatar Doug Iliff September 29, 2009 at 9:07 am

MZ: There is no plan to put $500K in an account; the plan is to continue the status quo, only more of it. That is, you get whatever you need/want (an eye of the beholder issue), with no incentive to lift a finger to reduce your present needs/wants for health care consumption. What in the world are you talking about? Again: the goal is to devise a system with SOME incentives to self-preservation.

John: You’re right about the timing. But HSAs/MSAs have never achieved a significant market penetration, and therefore never avoided the selection bias which makes evaluation of effectiveness impossible. And that is for the reason Albert gave, which is that they can’t compete with standard policies, which ask nothing of patients except to continue eating potato chips on the couch, and carelessly consume their health care. This is the old rental/ownership issue, which goes back to Aristotle’s rebuke of Plant’s Repubic: that which is common to all is cared for by none. Patients need to have some ownership in their health. You would think that imagination would be enough: “If I don’t stop smoking or gaining weight, I’m going to suffer some time in the future.” But it’s not. And I need some help, because they’re not listening to my lectures (or those of any other primary care physician).

avatar M.Z. September 29, 2009 at 9:57 am

…with no incentive to lift a finger to reduce your present needs/wants for health care consumption.

This has been the assumption with every American reform. The British have no consumer orientation to their health care system, but Brits are not fatter than Americans. In fact, they are significantly thinner than Americans. At some point we need to recognize that our assumption is invalid.

avatar John September 29, 2009 at 2:06 pm

The US ranks 19th out of 19 industrialized countries in virtually every measurement of health care. Canada, with universal health care, is 10th, far superior to the 19th place US. Busloads of Americans go to Canada for both treatment (superior in quality and far less epensive) and prescriptions because the health care system in the US is both way over-priced and of poor quality for most people compared the the Canadian system.

There are 50 Americans who cross the border into Canada for every Canadian who goes the other way. American navel gazers actually think the have a health care system, what you have is an insurance run and rationed system. Insurance company bureaucrats prescribe and decide treatment for patients, physicians do not. In Canada if a physician decides a treatment, you get it, without outside interference.

Without reform, you continue to have an insurance run system, and all the Baucus bill does is enhance insurance company profits, and has no cost controls.

avatar CitizenMom3 September 29, 2009 at 2:25 pm

Another positive for HSAs is the ability to use the accrued savings account portion to actually pay for insurance premiums in certain situations. I had an HSA in the past and was able to help pay for my spouse’s COBRA coverage while he was unemployed. You can also use it to pay for tax-qualified LTC insurance which might (way in the future) reduce the dependence on government nursing home/long term care programs.

Having used a HDHP with an HSA in the past, I can say that there are a lot better plans these days including reduced out of pocket expenses on preventative care and vaccinations that did not exist when I had my plan. If their use was more widespread, I’m sure competition would drive the improvement of these plans further.

avatar Albert September 29, 2009 at 3:38 pm

I never claimed HSAs were insurance.

Not to split hairs, but I never claimed that you claimed HSAs were insurance. But I do claim that you said HSAs violate the principle of insurance, which would only be a sensible criticism if you thought HSAs were meant to replace insurance. But since HSAs are not meant to replace insurance (nor are they insurance), it doesn’t matter that they violate the principle of insurance.

The idea that reducing the comprehensiveness of insurance is good is an assertion in search of an argument.

Indeed it is. But that’s because I wasn’t trying to make an argument in favor of reducing the comprehensiveness of insurance. I was only correcting you on the point of what HSAs do and what they are, versus what they not (they are not intended to preserve your principle of insurance).

Tell you what. We’re creating a new health care system. This system gives each person a savings account. At birth $500,000 is placed in the account that can be used on medically related item. Why is this a bad plan? Why does it become a better plan if we instead add $5000 to the account yearly but start with zero in the account?

It’s a bad idea because how the system got a hold of half a million to give each person is undefined. … I’m afraid I’m a bit too dull to understand your point here!

Mr. Medaille, I’d give it five years after Congress removes tax subsidies for employer-based insurance.

avatar Doug Iliff September 29, 2009 at 5:59 pm

M.Z. and John: Where do you get this stuff? No health reform prior to MSAs/HSAs had the slightest pretense of changing lifestyle behavior. And 50 Americans cross to Canada for every Canadian crossing to America for health care? Geeeesh.

Here’s a fact to counterpose your fictions: The World Health Organization ranks the US 37th in the world in quality, mainly because we lack universal coverage and care is a financial burden for many Americans. Fair enough, and I agree that’s a problem. However…. we’re 1st in the world in “responsiveness”, which has two components: respect for persons (including dignity, confidentiality, and autonomy of individuals and families to make decisions about their own care); and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities, and choice of provider).

Which brings me back to what I keep saying: Americans are exceptional, and they prize individual autonomy and liberty over government authority and control. Which is why ObamaCare or ClintonCare always provokes a revolution. Now: as believers in localism and liberty, where do you stand?

avatar pb September 29, 2009 at 6:23 pm

The British have no consumer orientation to their health care system, but Brits are not fatter than Americans.

Maybe not yet, but obesity is on the rise in the UK.

avatar M.Z. September 29, 2009 at 8:33 pm

Maybe not yet, but obesity is on the rise in the UK.
And that is likely explained by greater adoption of American food habits. I realize meta analysis breaks the whole individualism thing so it should be automatically rejected.

No health reform prior to MSAs/HSAs had the slightest pretense of changing lifestyle behavior.
That is simply wrong. Everything from co-insurance to copays. Nevermind this though. Good heath and living are goods in their own right, and the argument that they need financial incentives to be desirable is pushing something that should be more than just asserted.

avatar pb September 30, 2009 at 1:52 am

And that is likely explained by greater adoption of American food habits.

And the response would be that this is voluntary behavior. So what is the UK gov’t/NHS going to do to cut down on expenses associated with obesity?

avatar pb September 30, 2009 at 2:07 am

Good heath and living are goods in their own right, and the argument that they need financial incentives to be desirable is pushing something that should be more than just asserted.

Dr. Iliff has already explained why financial incentives may promote greater individual responsibility for maintaining health. Just because a good is desirable in itself does not mean that people cannot choose something else in preference to it. So how are they to be led to do what is necessary to take care of their health? Through law or by being financially responsible for the consequences of bad behavior?

avatar Doug Iliff September 30, 2009 at 8:53 am

M.Z.: Copays and deductibles were never intended by any stretch of imagination to change behavior. They were only attempts to make patients think twice before seeking care. As such, they were a (very mild) stimulus toward self-rationing, but not lifestyle self-control.

avatar Septeus7 October 1, 2009 at 1:44 am

Quote: “It’s the best in the world if you have decent insurance, and among the best if you don’t. Nobody is denied care in America.”

You are insane to think having insurance will get you good care. People are denied care all the time through insurance company policies and people in rural area are denied care by the fact they often have drive more than 100 miles for a proper hospital. Why do you think RAM is now spending so much time in the United States?

For the amount of money we pay for health care we get crap medicine and anyone denying that frankly doesn’t know what he is talking about.

Quote: “Because we are a truly empathetic people, and we feel sorry for responsible people with hard-earned assets who lose their insurance with their job and can’t afford to replace it.”

Wrong! We want “reform” because we are tired of being ripped off by the HMOs and insurance companies and having needed public hospitals shut down while we pay more and more for less and less.

Quote: “Because despite all the weeping and wailing in the media, we’re pretty happy with our own coverage. It’s like with politics: people hate Congress, but love their congressperson.”

Are you crazy? Apparently, you where asleep for the entire month of August where folks ready to lynch the traitors both democrats and republicans and don’t give me the crap about how everyone one of thousands of people where personally hired by Dick Army. Most American so disgusted by politicians that most of us don’t vote for either party and stay home.

Most Americans that are happy with their coverage because they aren’t sick and don’t to really on it as soon as they have to rely on it they quickly start to hate the system and that’s not count the 40+ million uninsured and underinsured (myself included).

Quote: So– how do we reduce costs?

That’s not the issue. The issue is how do we get our money’s worth because we should have twice as good health care in America considering how we have paid for over the last 30 years yet we keep hearing how we have to ration even though we are getting less and less for more and more of our money.

The proper question is who is leeching off the sick and stealing the country’s investments in healthcare?

The only people who would try and build a healthcare system by asking the question “how do we reduce costs”? are Fascists and yes that includes Nixon whose fascist tendencies where well know.

Quote 5: “How does the government reduce costs?
Who knows? They’ve never done it. “

Wrong. Under the Hill-Burton System the rates of disease and indeed elimination of various diseases such Whopping Cough, Small Pox, Polio and other result in the great cost saving in health care the world has even seen. Public investment in cures reduces costs. Investment in for-profit medicine eliminate the desires for cure and turns medicine from curing to keeping people sick in order to loot them. A non-profit system would return medicine to it proper basis of healing rather being collection of money.

Quote 5: How do private insurers reduce costs?

That is very simple task. We do what Swiss did and make them non-profits because we you get the profit motive out of the way people start focusing on actually doing something worthwhile like providing people with access to health care and building up your physical capital rather trying to drive stock value by keeping your your customers sick which is the current model.

Quote: “Yes, the issue is rationing– and it’s about time we started this national discussion. It has started badly, with the New York Times trotting out Dr. Peter Singer to examine the topic from the view of a secular utililitarian. He really did an excellent job of presenting the choices; alas, his comments elsewhere regarding the advisability of terminating human defectives age two or less, and pulling the plug on Granny, instantly set conservatives on the scent at full bay… The answer was, “little enough that we can afford it,” and the point is that we were not Nazis in the 1970s, and we are not Nazis now. But we do live in a world of finite resources, and at some point choices have to be made between what is possible and what is the best use of available dollars until the Money Tree is rediscovered. This conversation should be rational, as opposed to emotional. Can we afford quadruple bypass surgery on 89 year old citizens?”

This is crazy Nazi stuff and totally irrational and insane. I suggest you folk here read Dr. Leo Alexander on how the Nazi system started with these very assumptions and how if we weren’t careful we would find ourselves where the Germans where during the depression talking about “Quality Adjusted Life Years” err “lives unworthy of life”.

You do not build anything by asking an accountant how to cut cost before you’ve hired the architect. The question should not be can we afford quadruple bypass of 89 year olds but can we cure heart disease so that we don’t have to do bypasses anymore but if you assume any system of rationing you are assuming a fixed state of medical science and have thus eliminated the potential cost reductions.

The idea that the Money Tree is monetarism that assumes money is what allows us to treat people. People treat People and the Money Tree could be discovered and that wouldn’t treat a single person.
The question how do better improve the physical capacity to delivery care given and then organize the financial side of national economy after we have figured out what kind of medical improvements we want. That’s how you solve the health care crisis. Rationing always makes things worse because it always starts with false apriori assumptions that disallow the possibility of creative solutions. If you mandate rationing procedures then you outlaw the clever ways people can figure out how to solve problems as the problems arise by forcing everyone onto determinist mode of decision making that denies them Liberty.

You no doubt you’ll try and give examples and playing the moral dilemma game but just like philosophy professor you will fail because I’d figured out a way to save both lives in every situation given enough technology and energy.

Now you mentioned the British system as somehow a model of ration and not being Nazis when we all know the King’s Fund which current runs the NHS forced euthanasia policy and has promoted eugenics since the 1907 and during the 1930’s the Brit set up the Voluntary Euthanasia Society to help Hitler look good because until Hitler signed the pact with Stalin the Brits loved the Nazis.
And if you haven’t paying attention the Britain today is pretty much a Fascist Orwellian Police State with post-modern PC values complete in with pre-crime and in-home with speakers that shout order from Big Brother. And no this not a joke it is the UK tday. See http://www.telegraph.co.uk/science/6222938/Artificially-Intelligent-CCTV-could-prevent-crimes-before-they-happen.html and http://www.wired.com/gadgetlab/2009/08/britain-to-put-cctv-cameras-inside-private-homes/.

avatar Doug Iliff, MD October 1, 2009 at 9:46 am

Dear Septeus7:

For your chronic dyspepsia, I would recommend over-the-counter ranitidine, 150mg twice daily. It is cheap, and effective.

avatar outsider October 2, 2009 at 9:36 pm

Doug–
I’d like to see a serious response to Septeus 7 and Cecelia (# 26 September 2009 at 12:29 am ).

avatar Doug Iliff October 4, 2009 at 5:46 pm

Outsider:

Dang. I attempted a semi-serious answer to both, bumped my keyboard, and the whole thing erased. Here’s the gist: Septeus is ranting, and it’s hard to answer rants about “crap” medicine from someone who considers me “insane” to hold my views. I have 4000 active patients who will disagree with him about the quality of their health care. I’m sorry he’s so disgruntled, but I attempted a serious argument, and this is not a reasoned response. End of reply.

Cecelia apparently thinks that bad prenatal care is the result of society or the health care system. That is sometimes the case, but (as I said on 29 September) amphetamine abuse plays a role, too. So does personal irresponsibility in the form of missed visits, smoking, obesity, etc. Then there’s the way we keep extreme premies alive long enough to count in statistics, which isn’t done in other countries.

Her point about health care being more than emergency care is valid, but when you get to preventative care (my specialty of 23 years, after 6 years in the ER), personal irresponsibility is just as striking. I know that some people believe that personal responsibility is a fiction, but I’m not one of them, and that colors my views of American health care.

avatar Zac October 5, 2009 at 10:27 am

Thank you, Dr. Iliff! Your article was very informative and well-written, and I find myself agreeing with many of your conclusions. I share your views on personal responsibility and appreciate the solutions you propose, but I’m wondering if you could speak to Septeus7′s question about profit motives driving medical practice. Perhaps it’s the liberal streak in my anarchist beliefs, or maybe cynicism, but I find it hard to believe that a system motivated by profit could truly be effective when it comes to treating and preventing the very health problems that are the source of said system’s success. It’s the reason so many of us distrust the pharmaceutical industry.

avatar Doug Iliff October 8, 2009 at 9:10 am

Zac and anyone else stumbling into this blog late:

Here’s the answer to your question in the best article I have ever read on the economics of health care (from the September Atlantic). Absolutely every point the author makes rings clear and true from my experience:

“How American Health Care Killed My Father” http://www.theatlantic.com/doc/200909/health-care/1

avatar John Cisternino November 6, 2009 at 7:29 am

Dr. Iliff,

Thanks for your response. I think “dispirited” is a fairer word, though I don’t know that I’d single out one particular class of American society for that appellation. Having had the blessing of growing up comfortably in a suburb of great wealth, I saw plenty of dispiritedness in the ranks of the successful. As I see the conversation unfold here, I’m more and more convinced that you’re aiming at truth, and I greatly appreciate that. I have some disagreements and confusions and am curious about how they’ll strike you.

First, as others have noted, HSA’s don’t seem likely to be able to achieve what you want them to. There is the problem that Mr. Medaille has pointed to, and also the problem that they are no help when medical problems get severe. If you get cancer, unless you’re really rich, you’ll go bankrupt even if you’ve socked away money in your HSA religiously if that’s the way you pay for things. But if you backstop HSAs with insurance, you’ll undermine the healthy-lifestyle incentive that seems the primary benefit of the HSAs as you describe them (which I think are probably existent, but I suspect they’d be much less powerful than other forms of behavior inducement – see below – I’d certainly be interested in experimental data though).

Second, even if we idealize away the problems mentioned about HSAs, I don’t think people will respond to the incentives as you hope they will. It’s not like people have no incentives to avoid obesity now. The potential long range medical costs of obesity don’t strike me as nearly as powerful motivators as the high social costs attached to obesity, especially among the young. And yet, more and more children are morbidly obese, in a culture that more and more fetishizes thinness, fitness, and muscularity. I don’t think the problem is one that reasonable incentives can fix. Much more plausible to me is the possibility that we live in localities that are perversely structured, and that we are lured toward bad habits through mediums of communication that are powerful enough to largely bypass our rational inclinations to cost-benefit analysis that respond to incentives. So while I am 100% in agreement with you that our lifestyle problem is if anything a far greater threat than our health insurance problem, I’m quite skeptical about both the prospects for rationally convincing people to live otherwise given the social status quo, and of the wisdom of pushing more individual responsibility instead of collective responsibility for health and for shaping our cultural and social situations more broadly.

I think localism is crucial to changing the situation, as the social bonds between people at extra-local levels of governance are probably too weak for the kinds of spontaneous normative organizing that Lin Ostrom explores in her Nobel Prize winning work to arise. But my hope is that there are possible positive kinds of social reorganization that would both increase local ties and increase cosmopolitan love for the rest of humanity.

Sorry I’ve taken so long to respond.

avatar Doug Iliff November 6, 2009 at 12:27 pm

Good to hear from you, John.

I think you may be confused about how HSAs work. They are ALWAYS tied to a catastrophic insurance plan. Mine is typical. There is a $2500 deductible, a 20% copay on the next $12,500 (for a maximum out of pocket of $5000), and then Blue Cross pays 100% up to $5 million. So my cancer will cost me $5,000 at most, and I have more than that in my HSA account, so I’m 100% covered.

HOWEVER– I have a powerful incentive to not waste money. An MRI of my knee cost my HSA account $850, so I dragged my feet until I saw the knee just wasn’t getting better. It’s that commonsense hesitancy– the money is there, but it isn’t Other Peoples Money– which HSAs produce.

Although HSAs have been very slow to catch on, there is good evidence that they restrain costs in the working insured population– see, for instance, the articles in the Wall Street Journal on the experience of Safeway and Whole Foods. What we need is a statewide trial of “refundable” HSAs in a Medicaid population, where patients are given the money to manage in their accounts.

The problems of the American lifestyle are so pronounced, and the health care delivery system so complex, that only a fool would consider any intervention a potential panacea. I’m old, but I’m no fool. I need every tool in a big bag of tricks to push my patients in the right direction. I think HSAs would help, sure– but so would bike lanes on Topeka roads, a $2.00 per gallon tax on gasoline, and a 5 cent per ounce tax on sugared soft drinks, to go along with my continual prodding, wheedling, shaming, and encouraging.

In the meantime, and after reading all the comments on this article and John’s, I still think there are only two alternatives for restraining health costs in America: a single-payer system with rationing by panels of experts, or HSAs with rationing by patient choice. As a believer in localism, only the latter appeals to me. Neither one is currently under consideration.

avatar John Médaille November 6, 2009 at 12:59 pm

Doug, there is a third option: end the patent regime and loosen up the licensing regime. These create monopolies, which always increase costs in proportion to the funds added to the market. HSA’s do not address this problem, and hence to the extent that they work, they fail; by adding more money, they add more cost, which requires more money, etc. What we see in the medical market is the typical monopoly cost curves. This is all just economics 101. The only way to have a free market in medicine is to free the market from monopolies.

HSAs address the needs of a portion of the middle class and the rich. They do not address the needs of those who cannot save the $5,000 in addition to the insurance costs. They do not address the needs of the unemployed (rather a large problem, at this moment), the poor, and indeed a large portion of the middle class. For those groups for whom it will work, it will likely work as you say. But these are the people who need the least help.

avatar Donald Green MD March 8, 2010 at 11:01 am

I stumbled across this blog and am impressed by the sincere efforts to solve the knot of the problem.

First of all, everyone is correct in what they have stated about American medicine. However everything proposed will not solve the problem. We all need to get closer to the ground and note some special characteristics of the “health care industry.” I would recommend no matter how tedious a short treatise by Kenneth Arrow entitled “Uncertainty And The Welfare Economics Of Medical Care.”

Some points I have learned.

An insurance pool must be large enough and reflective enough of the population to cover the unwanted risk of not having access to basic health care.

Health insurance as presently purchased has the peculiar property that if its subscriber has to cash in on what is covered it can produce what is being insured against. That is, it can produce bankruptcy or even death. How short to leave oneself is an economic question but usually made by those least able to protect themselves in a health crisis.

Getting professional help and establishing a desirable doctor-patient relationship is your best asset for personal care.

Individual care has become a human necessity since the 1960s when medical knowledge reached a critical mass to make it so. Careful studies have shown that being uninsured in this country produces 44,000 excess deaths per year. Care becomes so imperfect without routine access that many lives are put in jeopardy.

No one pays for their particular care but contributes to supporting the system itself. No one is keeping a separate account for you but the money is used to keep the health delivery in good shape. It should be that the largest portion of the insurance dollars were directed in this way. Overhead should be under 10% not the present 15 to 20%.

The sick and those with identifiable problems need help not vilification. If there are no sick for doctors to learn better care, it will not be available to you if you happen to fall into this category. Most of these problems involve intervention by practitioners but are probably more effective using public health tools. Smoking, vaccinations, unhealthy food recalls are examples to ponder to see if this holds water. Most of the frustration of individual providers is the lack of broader tools to intervene.

The government has passed footing 50% of the health care expense by default. Our present system is actually creating what is abhorred. Private insurers are pricing themselves out of the business and shrinking their pools to include the mostly healthy. The recent increase in California of some groups to 39% is Enron accounting. They put these souls into their own smaller risk pool when Wellpoint actually covers millions of lives and covering them would have made little difference in their bottom line. Their use of the worst free market principles will be their death knell.

It is incorrectly stated that Insurance Company profit is 2 to 3% since this only becomes true if you include the “medical loss ratio.” However the latter is to pay provider bills, not run the company. In fact, usually by law, they are required to hold money in reserve to cover payments but it is not touched or used. Their profit margin is therefore closer to 10 to 15%.

An American solution can be enacted but it must take insurance principles and the unique nature of the health care industry into account. Many models exist in the world including totally public(England), public/subscriber/insurer(Canada), HSA/insurance/public(Singapore), insurers/public(Germany), Insurers/Employers/Public(France). Without a doubt all comers want to see good care for all but we have to bark up the right tree.

avatar Michael Kinders October 10, 2010 at 9:40 am

Health Care + Politics = one really scary situation, should we be giving our ELECTED OFFICIALS the power to create ANOTHER monstrosity? Do you want government taking control of your medicare benefits?

Big pharmaceutical companies control drugs and money and government.

This is why you will get health care shoved right ware you don’t want it.

– Michael Kinders

avatar Auntiegrav May 12, 2012 at 9:56 pm

Not bad, Doc. I would agree more if you spent a little more time on the Army situation, or compared the Army to the Navy. Bottom line: if socialized medicine is good enough for the troops, it’s good enough for everyone else, too.
The VA has done some amazing things at reducing costs, by the way, so to say the government has never done so is not really true.
You might want to slip in some more “Christian” references, ’cause nobody ever gets tired of that crap. (sigh)
The one question, and the ONLY question, which neither Republicans nor Democrats want to ask is this:
“What are people FOR?”
All of the other questions become subsets of that answer. You either think people are contributing to the future (giving more than they take), or you believe that only you are Christian enough to be so wonderfully generous and everyone else is supposed to buy your services to support your habit.
Once we accept that people have been groomed to be wasteful, useless consumers and producers (not laborers…the loss of exercise is obvious), we can begin to work on how to change the grooming process toward them being useful contributors to future generations (other than contributing debt, that is). Humans survived for many many centuries without the “help” we are getting from this overblown hospital-building sick care system. Somewhere between no money and too much money, we have destroyed even the health of the lucky ones who have robust genes, under the guise of ‘saving’ everyone’s life and “growing the economy.”
We need to stop thinking about the money aspect and first understand real useful needs to be met. This is the basis of all morality, including God’s. Creating the universe from nothing is the epitome of being useful to the future. Humans don’t have to start with nothing, but they surely shouldn’t be working in the other direction to turn all of Creation back into random decay. It takes healthy people to build a future. We have to stop thinking of being healthy as a luxury only deserved by the ones who have accumulated (denied) resources from the work of the rest. The “self-made” myth needs to be reconsidered as the lucky random break that it is, not the basis of everyone’s right to health. Civilization IS socialism, and it isn’t a new idea to live in a cooperative manner with common needs and goals. We just let money beat it out of us.

avatar Jim Dooley July 1, 2012 at 12:09 pm

Dr. Iliff
I feel like I have been walking on the beach and have stumbled across a message in a bottle; and lo, it is a message well worth reading.
Like Antonin Scalia, I’m not about to read the monstrosity of bureaucratic log rolling that was just shoehorned onto Uncle Sam’s foot; I doubt any one ever has; I doubt any one ever will. I guess the future will tell how bad the limp will be.
Nevertheless, I surely would like to read from so one both so committed and coherent on the issue as yourself your diagnosis as to where we are now, a prognosis, and your thoughts on what all anyone can do about it now, or should be thinking about doing about it (if anything) (in light of this being an election year, and all.)
In other words, generally speaking, how bad is it on the substance and is the good, assuming there is some in there, going to outweigh all the damage from the politico-legal storm.
I hope this request finds its way to you.
Thanks

avatar Mrs. Reeves July 25, 2012 at 2:35 pm

Dr. Iliff,
What a wonderfully informative piece! Even 3 years and much debate later, it is still an excellent explanation of the status of our health payment system. (Let’s be realistic, the “Health Care” bill had absolutely nothing to do with actual care.)
I think that the biggest problem with health payments is that having any third party between the patient and the doctor removes the “sting” of paying for services. If I go to the shoe store to purchase shoes, I can discern if I really need the $50 pair of name brand or if I can save that money or if another alternative is available. Having the price of my shoes only known to my shoe-insurance agent removes from me the incentive to not spend willy-nilly. I’ll buy the $50 pair of shoes and take a shoe-scan to go with it, because, in a sense, I’m not paying for the shoes, my agent is.
HSA’s or the like, which proved a tax-sheltered pool of my own money to be used for my own health, are much more “real” than an insurance pool. I’m not going to trot down to the doctor’s office for every sniffle and bruise because that will cost me future dollars, MY future dollars. I will save those dollars now and use them later, when *I* need to do so.
However, Insurance is still, I think, a necessary thing for when I have a heart-attack or my husband falls off a roof, or there’s a car accident, or the results come back that it’s cancer. But wouldn’t saving my insurance to pay only for the big things ultimately drop the price? As I am not spending (or paying for some one else to spend) all the insurance money on sniffles and bruises?
PS: I would gladly sign up for your $100/month care-for-a-family-of-six plan, if only you would move to Central North Carolina…

avatar Darlene August 23, 2012 at 11:38 am

I agree with John Médaille.

Healthcare needs to move more toward price-controlled/nonprofit: Pharma, insurance, etc. Going from billions in profit to millions of drug profit will still attract someone facing a 50,000 management job somewhere to produce drugs…the beauty of capitalism is someone hungrier will step up.

Consumers need to be educated about necessary, nonnecessary, and selfcare options for better self rationing (and therefore better collective rationing), not just when we get old but throughout our lifetime. Options remain available to purchase privately and electively care deemed nonnecessary.

My HSA gives me about $500/year. That’s not going to get me much healthcare. Being poor but educated, I have learned self care, and even when covered by insurance, I stay out of healthcare systems as much as possible. Over prescribing and over proceduring often adds to medical problems, and letting the body heal itself the way it is designed in many cases, is healthier and more cost effective. I find it more prudent to use established, tried and true and cheaper drugs than the new, expensive and prone to safety recall meds being tested on the public. Stress management alone will reduce many healthcare costs. And yes, the underclass is dispirited and stressed and in a quagmire, not to mention without the funds for adequate prenatal and postnatal care. There are a couple of publications out by MacArthur Foundation on Socioeconomic Status and Health that are decent reads: Reaching for a Healthier Life and The Biology of Disadvantage.

It is projected that healthcare provider fraud accounts for 10% of healthcare costs, so closing down the opportunities here can be helpful.

We do need some cultural changes in our country about personal healthcare responsibility, more education for making better consumer choices, rationing with options for private purchase on electives, and get over this this notion of “other people’s money,” which is our money pooled in a cooperative fashion to obtain more affordable care for all of us, but only effective in a system that is managed with controls to keep the costs down (pharma, insurance/administrative simplification, tort law, etc)

We cannot ignore the stats of other countries: 50% more covered lives for 50% less costs. These people are not ignorant fools, their healthcare outcomes are better, and I am willing to say many will match our technical expertise.

Moving beyond profit mentality and politics protecting the same are going to be daunting but necessary.

avatar Nigeria Health Forum August 2, 2013 at 4:04 am

Thank you, Dr. Iliff! Your article was very informative and well-written, and I find myself agreeing with many of your conclusions. I share your views on personal responsibility and appreciate the solutions you propose, but I’m wondering if you could speak to Septeus7′s question about profit motives driving medical practice. Perhaps it’s the liberal streak in my anarchist beliefs, or maybe cynicism, but I find it hard to believe that a system motivated by profit could truly be effective when it comes to treating and preventing the very health problems that are the source of said system’s success. It’s the reason so many of us distrust the pharmaceutical industry.

avatar How To Nigeria August 2, 2013 at 4:07 am

Mr. Medaille, you keep writing HSAs have been around for a “long time” and haven’t worked. Am I mistaken to believe HSAs have been around since 2003, i.e. for six years, or do you really think 6 years constitutes a “long time”?

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