The Long Fix

Solving America's Health Care Crisis with Strategies that Work for Everyone

[Amazon Link]

Every so often, I get it in my head to read a book about the American health care sector. (Also to beat my head against a concrete wall for a few hours, but that's not important right now.)

By the way: calling it a health care "system" is something I will try to avoid. The very language seems to presume something that's the result of design, instead of (more accurately) a sector that's been kludged over decades by powerful forces operating under the wrong incentives.

Also a "system" implies something that actually works well.

And the author, Doctor Vivian Lee, contends otherwise. She has some facts on her side. For example, US Covid-19 deaths just passed 200K. In comparison, Johns Hopkins researchers estimate the body count for medical errors at around 250K. That's per year, every year. Eek.

I wish I liked the book better. It's written in what I've come to think of as USAToday-ese: short paragraphs, heavy on anecdotes, short on statistics, punchy-cute section headings (E.g., "Rebate and Switch" on pharmaceutical manufacturers offering rebates to pharmaceutical benefit managers.) This comes off as condescending.

Worse, Dr. Lee seems to rely on slogans instead of concrete policy proposals. She advocates moving away from a "fee-for-service" pricing model, toward a "pay-for-results" model. I'm still not sure what that means. No charge if the patient ends up dead? There might be a good idea there, but I think it's buried in all the salesmanship. The numerous anecdotes point to successful programs spearheaded by talented and devoted reformers, but Dr. Lee seems to not be skeptical of whether these reforms can scale when the keys are tossed to the less talented and devoted.

Each chapter tackles a different topic (drug costs, mistakes, health records,…) and closes with a set of action-recommendations for patients, doctors, and payers. And ends with "And most importantly, all of us need to elect leaders who will…". And what follows is some vague prescription that assumes government can top-down regulate/mandate/subsidize our way to medical nirvana.

A specific gripe: It's a clichéd observation that the US devotes a huge amount of its economy to the health-care sector, with mediocre results. Geez, why can't we be like those other countries, at least as far as spending goes?

I've noted in the past that one way other countries save money is pretty simple: paying lower salaries to the folks in the medical field. Doctor Lee seems to reinforce that:

Many health care professionals are highly paid (especially doctors, dentists, and administrators). Analysis of 2016 data showed the average generalist physician in the United States made $218,173 a year, double the average of generalists in ten other high-income countries (including the Netherlands, UK, Canada, Australia, and Germany). Specialists averaged $316,000, also higher than in any of those nations. US nurses also make more than their international peers, averaging more than $74,000 per year comparied to $42,000-$65.000.

(Reference to a JAMA article described here.)

But then Dr Lee sticks a pin in this balloon:

While high salaries undoubtedly worsen the US health care crisis, the impact on the economics is not that big. Health care economist Uwe Reinhardt showed in 2007 that higher salaries added about 2% to total national health care spending.

I've even heard of Uwe, so case closed, right? Well… the reference here is not to a peer-reviewed medical economics journal, but to a 250-word LTE Reinhardt wrote to the NYT back then, in response to an earlier column by Alex Berenson.

In “Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.

Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.

Notice one thing right off the bat: Uwe is only talking about physician salaries; if you've (God help you) been in a medical building recently, you'll have noticed there are a lot more people running around than the doctors. So Dr. Lee's wrong in claiming that Uwe "showed" that "higher salaries" were a 2% effect on the total health care bill; Uwe's not counting all those other folks, not to mention the paper-pushers behind the closed doors, in insurance company offices, in regulatory agencies….

I'm also unconvinced by Uwe's argument on its face, which seems to be a lot of handwaving. And, at least in part, it really seems to amount to: "We gotta pay doctors high salaries, or they'll kill even more of us." (See above.)

Last Modified 2022-09-30 12:30 PM EDT

The Phony Campaign

2020-09-27 Update

[Amazon Link, See Disclaimer]

Another good week for Wheezy Joe, who eked out another small net gain (0.3 percentage points) in winning-probability from the wagerers. Is this despite or because of his habit of "calling a lid" on a day's campaigning at (for example) 8:34 am yesterday?

I'd be OK with all the politicians calling an immediate lid on campaigning for (say) the next month or so. Hey, a dude can dream. Guys, you can turn it back on a week or so before election day; that's plenty of time to make your case.

But instead, Pun Salad will be on the job chronicling the parade of phoniness.

Candidate WinProb Change
Donald Trump 43.5% -0.1% 1,540,000 -500,000
Joe Biden 53.9% +0.2% 569,000 -163,000
Jo Jorgensen 0.0% unch 126,000 +6,000
Howie Hawkins 0.0% unch 21,300 -3,400

Warning: Google result counts are bogus.

  • The Atlantic's Edward-Isaac Dovere has a scoop for those voters who might have confused the two: The Green Party's Howie Hawkins Is No Kanye West. It's an interview where Howie's interviewer spends time on what really matters: whether lefties voting for Howie instead of Wheezy will cause states to tip to President Bone Spurs.

    Howie has no problem seeing this problem from the other side:

    Dovere: Kanye West is also running, saying he’s the candidate of the Birthday Party—though he doesn’t seem to have a clear platform for why he’s running or a clear rationale for it. Should he be on the ballot?

    Hawkins: I think Kanye West is a Republican dirty trick. If Roger Stone didn’t think of it, he wished he had. The Birthday Party? I mean, come on. There has to be some criteria for getting on the ballot. Anybody with money can hire petitioners and get on the ballot. There should be some threshold for recognizing parties—a level of organization, so there’s really a base there, and they should be allowed to make their nominations by convention.

    Howie doesn't seem to realize that stricter "thresholds" and "criteria" would be designed by Rs and Ds. How likely is that to work out the way he expects?

  • Leslie Eastman of Legal Insurrection counts up Four Biden Brain Freezes That Should Chill Democrats' Hearts.

    For example, during a speech in Philadelphia, Biden said 200 million people have died of coronavirus infections.

    2020 Democratic presidential candidate Joe Biden had another gaffe on Sunday when he said an estimated 200 million people have already died from the coronavirus, even though the number of American casualties is closer to 200,000.

    “If Donald Trump has his way, the complications from COVID-19, which are well beyond what they should be — it’s estimated that 200 million people have died — probably by the time I finish this talk,” he said during a campaign speech.

    As the population of the US is about 330 million, the former Vice President’s statement would mean that 2/3rds of Americans have died.  And while it is simply likely that Biden meant to say 200 thousand, there might have been a reason for Biden’s Freudian slip over the extreme number of cases. Everyone knows the dead vote Democrat.

    Which reminds me of a joke:

    The renowned cosmogonist Professor Bignumska, lecturing on the future of the universe, had just stated that in about a billion years, according to her calculations, the earth would fall into the sun in a fiery death. In the back of the auditorium a tremulous voice piped up: "Excuse me, Professor, but h-h-how long did you say it would be?" Professor Bignumska calmly replied, "About a billion years." A sigh of relief was heard "Whew! For a minute there, I thought you'd said a million years."

    I've flogged this dead horse before, but wouldn't it be neat if candidates would take a few basic tests including (in this case) numeracy?

    I should mention Leslie's other examples of Biden Brain Freeze:

    • Did Biden botch the Pledge of Allegiance? No.
    • Did Biden say he "lost that line" during a Telemundo interview, revealing that he was reading off a teleprompter? No.
    • Did Biden respond "Probably not" to a heckler who yelled, "You don't have a chance, Joe!". Eh. I looked at the video and it's unclear if who he actually said that to.

    It probably clear that Legal Insurrection will be in of pro-Trump, anti-Biden propaganda mode until (at least) November.

  • Of course, the Babylon Bee has the real story. Biden: 'It's Ridiculous To Say I Use A Teleprompter And Your PC Ran Into A Problem And Needs To Restart'.

    There have been some suggestions that presidential candidate Joe Biden has been using a teleprompter when he’s supposed to be spontaneously answering questions. The campaign has vigorously denied this, but the charge has resurfaced because of an unusual answer Biden gave recently at a video townhall.

    When Biden was asked about whether or not he uses a teleprompter, he answered, “It's ridiculous to say I use a teleprompter and your PC ran into a problem and needs to restart. We're just collecting some error info, and then we'll restart for you.” Biden then softened his tone a bit. “C’mon, man. Initiating TeleMatic boot sequence. Beginning demo mode. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua.”

    Some say this blog is written by an AI, but I say to them: Microsoft Windows XP has encountered a problem and needs to close. We are sorry for the inconvenience.

  • Ann Althouse analyzes the headlines: President Trump won't commit to a peaceful transfer of power after the election!. And finds that the question was a lot more problematic than Trump's answer.

    Let's break it down:

    Will you commit here today for a peaceful transfer of power after the election... Will you commit to making sure that there is a peaceful transferral of power after the election?

    First of all — "making sure." I have a tag for that. It's an insidious phrase, used by politicians to gloss over how they will achieve whatever the end is. Add "commit" to that, and you're deeper into fantasy land — "commit to making sure." Who can do that?! Where is this lack of peace coming from? How could Trump know in advance? It could be a crazy tantrum by people who hate him and who are saying we'll only stop if you resist litigating about voting fraud. Trump needs to reserve his right — and responsibility — to ensure that we get a fair and accurate vote count. He can't be at the mercy of the protesters and rioters. The question is quite obviously a trap, and Trump calmly stakes out appropriate ground […]

    I'm with Ann here. Note the questioner specifies a "peaceful transfer of power", which asks Trump to assume he's going to lose. Why should he respond to that at all?

    Well, because he doesn't know how to respond coherently to such garbage questions. Take a lesson from Bryce Harper, bro.

Last Modified 2022-10-18 6:05 AM EDT