The Great Healthcare Dilemma: Who lives—Who Dies

( - promoted by Bob)

One girl’s hope, a nation’s dilemma

A Cambridge firm’s drug worked wonders, but was hugely costly – more than Costa Rica thought it could spend on one child among so many

Every two weeks, Tania Gonzalez receives a two-hour treatment with a drug called Cerezyme in a San Jose hospital. (Tito Herrera for The Boston Globe)

By Stephen Heuser

Globe Staff / June 14, 2009

Costa Rica – At the time, he had no way to know it would trigger a high-stakes controversy that reached all the way to Boston, but Jose Antonio Gonzalez remembers clearly the day he first heard that there might be a drug to help his little daughter.



To Jose, it sounded like a miracle. As a toddler, Tania had been a bright girl with a vivid smile and a penchant for dancing. But by age 8 she was in a strange and frightening decline. She struggled on frail limbs to carry her swollen abdomen. As other children rode their bikes on the tiny fishing village’s dirt roads, Tania lay on the sofa in her orange cinderblock house, inert.

No one understood what was wrong. Specialists had run tests on Tania to rule out common diseases, then unusual ones. When Jose’s phone finally rang with an answer, the doctor told him Tania had a genetic defect so rare that it strikes only a tiny scattering of people around the world.

“The first thing he said was, she could die,” said Jose, a somber and powerfully built man. “The strength I was supposed to carry with me just vanished.”

But the doctor had another piece of news. There was a drug that might halt Tania’s suffering and perhaps even reverse the toll of her disease. The drug was called Cerezyme.

For Jose and his family, it was as though a hand had reached down to answer their prayers. But in that moment, something else had happened as well: The Cambridge drug company Genzyme had just found its first potential patient in Costa Rica. And now that it had found one, it would supply the drug to Tania, but at an astonishing cost – $160,000 a year, possibly for the rest of her life.

This was far more money than the Costa Rican government had ever paid for a drug, and Genzyme would not bend on the price. The country’s health officials were forced to weigh the prospect of a healing gift for one girl against the needs of a nation struggling to care for millions.

Should Tania get the drug?

What unfolded in that village was a dramatic example of the hard choices often forced by the inventions and ambitions of the biotechnology industry, an increasingly important part of global healthcare and a critical growth sector for Massachusetts. Its high-priced cures are creating both great wealth and great moral dilemmas, one new drug, one new patient at a time.…

The greatest dilemma of universal healthcare, with a single payer: the federal government

will result in political intervention for affected individuals. We have already witnessed Barney Frank pick up the phone and threaten the new CEO of GM. The politically connected with whomever is in power will get preferential treatment. Do you really want to go down this road. Please don’t offer the rationale that it won’t happen. It already does.

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135 Comments . Leave a comment below.
  1. A quick question

    Your assumptions are completely wrong, but I'll play along by asking this: why is it preferable to have decisions based on commercial intervention and private business/wealth connections than political ones?

    sabutai   @   Tue 4 Dec 7:00 PM
    • Response:

      I will frame my response this way:  Considering that I have worked in medicine in every facet except intensive care and surgery for fifteen years and to my knowledge and belief you have no experience in healthcare, you're immediate retort, while not unexpected is disappointing. Hospitals and large specialist medical groups have ethics panels that make these decisions viz a vis who ponied up the most cash to a hack, which hack (someone like Murtha and that crooked republican in CA) is taking bribes, or a hack pol who is willing to trade healthcare for votes (we saw Barney just stick his nose into GM  located in his district) Not only is this a moral and ethical issue, but it has the propensity to further the expanding diviseness engulfing this country.

      I do not want some hack making the decision on whether a family member, someone who I love dearly, will receive or not receive  medical attention, or a med, or a particular medical practioner because of my party affiliation, failure to grease his/her palm or the pol/federal bureaucrat is saving it for one of their own. I could live with a disinterested group of medical ethicists making this decision. Conversely---I could be provoked.

      As you have already seen, the pushback is beginning in congress, the medical community and across America.  

      • What crap

        How is it better to have that decision made by a private insurer? What really is the difference? If you really have all that much experience in the healthcare system, you have to know that insurers regularly deny expensive coverage for no good reason other than to save money.

        • Easy for you to say $quot;what crap.$quot;

          Have you ever lived in a country with socialized medicine and seen how it really works? There is always a two-system result even under socialized medicine:  those with the money and connections get to stay in the best hospitals and have the best doctors and care.  To think otherwise shows total naivete on your part about human nature.   I will agree that Medicare seems to work fairly for people over 65;  perhaps a universal system run that way would work.  And I have to say from personal experience that the socialized system does work in France--probably because of some differing cultural attitudes towards doctors and medicine--I really don't know for sure. In any event, what MCRD has written is not crap.

          • Is that necessarily bad?

            If people with money want to pay for better services, that's fine with me.  The point is to give everybody access to something.  It's just like education.  If your family has the money to send you to Phillips that's perfectly fine, but everybody has access to your community's public schools.

            • Yes, but sometimes it is a question of receiving or not receiving

              the same general benefit.  If one cannot afford Milton Academcy, one can still get a  good education in the Milton or Sharon public schools.  And I agree that with that as long as everyone has access to the good brain surgeons and not just the Kennedy's or Bush's.

            • Exactly----look at our public school systems

              viz a vis parochial schools, charter schools and private schools. You made my point.

              • Not sure what the point is.

                Given your leanings I assume you're implying the public system isn't that great.  That is of course a gross overgeneralization, but unsupported assertions are par for the course for you.  Right now too many Americans (47 million if I remember correctly) have NO health insurance and this will give them some coverage.  We already do this.  Just merge Medicare, Medicaid, and SCHIP and then expand it to plug the holes.  If families or employers want to pay for more, that's fine.  We of course need to have a discussion about what gets covered as basic, what is subject to copay and which does not get covered.

              • No, not really.

                Just as you have seen how health care works from the inside, I have seen education from the inside, having taught in both public and private schools.  I have news for you: the public schools in Newton, Brookline, Weston, Sharon, Duxbury, Norwell ( I know that I am only citing some of the best) are at least the equal of most of the so-called elite schools. And they are far, far superior to the parochial schools in Massachusetts.  So the residents of those communities have real choices.  Unfortunately, the residents of poorer middle class suburbs don't have that equality.  And they probably won't have that equality in medical treatment either. (though you could make a good argument that they don't now, anyway.)

          • Dang!

            Good thing we don't have any stinking "two-system result[s]" here.

          • From personal experience---medicine delivery in Ireland and England works so that everyone gets the same mediocre care

            Except for the well heeled.

            • There is no proposal anywhere

              ... suggesting we adopt a British system.    

              • I'm not sure.

                I'd be OK with a British-style National Health Service.  They don't seem to be anxious to dump it.

                • I wouldn't have...

                  ... too much of a problem with actual socialized medicine like they have (and we have with the VA).  My sister's been there for years... while she's here she does actually miss it.

                  Yglesias actually had an interesting idea last week that you could make a "...very strong case on the merits for a limited form of socialized medicine."

                  The idea would be " identify a list of preventive health services where it's not desirable for people to be economizing and then we'd bring the services to the people directly as a public service."  Then for "...the government to directly provide a certain class of relatively cheap, not-very-interesting preventive services."

                  It would not provide comprehensive care, but would have a " mission to provide basic preventive care.", like "... vaccinations, regular tooth cleaning, prostate exams, etc."

                  This would be an interesting hybrid of a German and British system.  The German's provide a public plan for insurance that the vast majority of people opt into.  Private plans 'compete', but for the most part they wind up providing 'niche' services.  The option above would be a socialized medicine version of what Germany does with socialized insurance.

          • all I can say is that

            Our private system gives far worse care, at far greater cost, than that "socialized" France. It's not even close. Their health care system is top 10 in the world, our's isn't even top 50. Meanwhile, the "socialized" medicare system is far more popular inside this country, as well as more efficient, than the private system. On top of that all, the single payer systems of France and dozens upon dozens of other countries not only provide far superior care at a far smaller cost, they manage to cover every single last person in those countries. It's easy to see which systems are the superior.

            • Rye, have you lived in and been sick in any of these countries?

              • Can't speak for Ryan

                I, however, have witnessed European healthcare secondhand (in that it happened to a traveling companion rather than to me directly).  I was in Bruges, Belgium with a class a few years ago.  One of my classmates took ill (nothing too serious, a bug of some sort).  She was able to make an appointment for the next day (so much for the waiting myth) and paid the equivalent of USD20 each for the appointment and the medicine she was prescribed.  She's not even a Belgian/European taxpayer and she was still taken care of - no questions asked.  That is where we need to get to!  There are plenty of comments I've read to the effect that people have experienced our health delivery and France's and much prefer France's.

                • Yes. I agree. I have had first-hand treatment in France and also

                  in a former French colony (Niger). Most of the negatives seem to be about Canada and England--perhaps lessons to be learned.

                  • I can't speak for Canada, but a spent a year living in London

                    I found the health care excellent.  Much better the HMO I was enrolled in prior to going overseas.

                    • My cousin John had a rather simple pulmonary issue

                      Handed back and forth and up and down amongst physicians. never the proper test, X-ray, or MRI. He died at 64 as the direct result of an incompetent, disorganized, and ponderous medical system.

                      Daughters, father in law in Ireland, again pulmonary issue (is it the rain?) came close to dying. Same drill. Wait two weeks for an Appt. Poor follow up. Poor coordination with specialist--paperwork missing. Just missed death by a whisker over a nickel dime medical issue exacerbated by a crappy system.

                      Why do Canadians come to USA for treatment ? Speaks for itself.

                    • Ever tried to get a referral from an HMO?

                      I'm assuming you realize that Ireland and the UK are different countries and that I said nothing about Canada.  

                      I still have no interest in anecdotal smears, unless you can somehow tie it to systematic problems.  There are equal horror stories about the American medical system... people getting the wrong leg amputated, people being given the wrong drugs, misdiagnoses, etc.

                      The point you seem to be deliberately avoiding in that our system there are huge numbers of people with no coverage at all.  Also that our system is far more bracketed than the e.g. the UK system.  Wealthy people get better care here, period.  

                      In fact, due to the prevalence of capitation in our health care system, you're far more likely to get denied service here than in the UK. Unless you have the money to pay for it, of course.

                    • Really?

                      Why do Canadians, even self-described conservatives, give high marks to their healthcare system?  Any system designed my people will have its quirks and negatives, but from what I've learned I'll take Canada's system over ours without hesitation.

                    • the problem of a sample set of one...

                      These anecdotes don't prove anything, for or against the British or Canadian system (which are different, Canada has national insurance the UK has a national health system).  I'm sorry this happened, but it's not evidence of a failed system, it's evidence of a system with failures.  The exact same thing happens in the US all the time - incompetent, disorganized, and ponderous all describe our system.  

                      I can point to stories of my friend's father who had an aneurysm in Australia, and because of the swift action of their socialized medical system, he's alive today without having to pay anymore than his taxes.  Given his job and situation, if he were in the US, he'd likely be bankrupt now if he were alive at all, all because of an incompetent, disorganized and ponderous medical system.  

                      Present some evidence - higher rates of death due to lack of treatment, chronic conditions that are routinely ignored or become worse due to a bureaucracy that is failing.  Show some results backed up with solid data, or all your personal experience isn't worth a dime.  

                    • What percentage of Australias population are on the dole and what percentage of their population are illegal aliens?

                    • More Americans

                      travel abroad as medical tourists than any other nation. Speaks for itself.

                    • Ya---speak to the folks that went to India and were maimed or died!

                    • Is this where you get your info?

                      Speaking to the dead? Suddenly it all became clear!!

                      Naresh Trehan, who worked as a heart surgeon in Manhattan but returned to start Escorts hospital group in India, was quoted as saying that his hospital in Delhi completed 4,200 heart operations last year.

                      "That is more than anyone else in the world. The death rate for coronary bypass patients at Escorts is 0.8 per cent and the infection rate is 0.3 per cent. This is well below the first-world averages of 1.2 per cent for the death rate and 1 per cent for infections," he said.

                      With approximately 1.5 million Americans traveling abroad for health care this year, I'm having some difficulty finding all those stories of botched procedures in India.

                  • Agreed

                    There's more than one way to do government-run health care, or mixed-system.  After six years firsthand experience with Canadian care, I would say their way is the wrong way.

                    sabutai   @   Tue 4 Dec 7:00 PM
                    • Actually, before I'd say...

                      ... that the Canadian way is the wrong way, I'd assert the American way is the wrong way.

                    • I guess

                      I should have said among government-run systems, the Canadian system is the wrong way.  As for popular support of the system, I think there is confusion upthread.  The idea of "CanadaCare" is one of the precious few differentials between the US and English Canada, and is thus clung to by Canadians attempting to emulate patriotism.  However, when asked about the system in terms of outcomes and satisfaction, ratings are horrid.

                      sabutai   @   Tue 4 Dec 7:00 PM
                    • What does it say...

                      ... about what we have if their system is 'horrid' but is more dollar efficient, covers more people, and creates better outcomes.  By most data, it'd still be preferable to what we have for the vast vast majority of patients (as well as for those who are not patients, but should be - a condition our current system excels at cultivating).

                    • Really?

                      The data I saw said that the Canadian system gets better outcomes per dollar, but I'm not sure about better overall outcomes.  Also, I think that the majority of patients get better care via HMO in the US than what passes for a system in Canada.

                      sabutai   @   Tue 4 Dec 7:00 PM
                    • You have to take...

                      ... into consideration the 'outcomes' of all the uninsured in the US when you're comparing outcomes on a national scale.  You have to include the 'should be patients' in the sample.  Unless you're talking about merely extending our system to the uninsured without systemic change (massive subsidy? Isn't it expensive enough already?), leaving them out is an inapt comparison.  That's why the WHO includes overall mortality statistics in their data.  Of course there are individual categories of outcomes where the US does better, but I'm looking at the system overall.

                      Incidentally, how are you differentiating measuring 'outcomes per dollar' and 'outcomes overall'?  What exactly does that mean?

                    • and yet

                      much better than America

              • I got a stomach bug in germany

                and was told to drink some Jaegermeister.  It worked.  

              • I actually had a professor

                Who's specialty was the Portuguese government (UMASS Dartmouth has a very large Portuguese emphasis)... and he'd go and be a visiting professor at Portugal every summer, leading a group of UMASS Dartmouth students.

                Well, one day he rented a motorcycle and got in an accident. He broke one of his legs which, I'm sure, cost thousands of dollars. He received prompt care and, when he asked how much it would be, they looked at him with weird googley eyes. He asked where he should give his insurance information - and they wouldn't even take it. They wouldn't know what to do with it. So, some foreigner comes to the country, gets in a bad accident, offers insurance information and is refused... not only do they cover every citizen, but everyone - and they still spend far less per capita than the United States on health care costs. The care only gets better in many other countries in Europe, and no matter how you slice it, it costs much less than what we spend in the US, whilst covering far more.  

            • WHO?

              I submit, that the fiction that US health care is inferior is just that. A myth.

              US by the numbers, according to WHO.  Turns out the US is not the Dark Side of the Moon:

              Table 1: Kids 5, % underweight by age.  1.3%.  The US is as successful as any country.

              Table 2: Mortality rate 5.  US, at a probability of 8% per 1000, is behind Canada and Cuba in the Americas.  And seriously, Cuba?  Sorry, I simply can't accept any serious data out of that totalitarian fiction machine.   And US trails Europe with countries in the 4% to 8% range.

              Why is that?  Turns out that the Americas have high mortality rates amoung Native Americans and African.  WTF? Native Indians have single payer!  It's called IHS, Indian Health Services, provided by treaty from the Feds.  Trouble is that many of the reservations are so remote and geographically difficult to reach.  So when we turn the US health system on its head to reach the holy grail of single payer, how on earth will that remedy the 5 Native Indian statistic?  Answer: it won't.

              How about the statistical difference between white and African mortality rate.  It could be an ethic trend, the weathering hypothesis.

              As a possible explanation for racial variation in maternal age patterns of births and birth outcomes, the "weathering hypothesis" is proposed: namely, that the health of African-American women may begin to deteriorate in early adulthood as a physical consequence of cumulative socioeconomic disadvantage.

              My guess is that with any complicated system, there are many causes: prenatal care, and ethnomedical issues to name 2.  But to devotedly advocate Single Payer so solve what is likely a complicated problem is likely naive.

              Table 3.  Measles immunization.  American 93%.  Most of the developed world, 99%.  I just can't get excited about this statistics. Extremely low mortality rates in US from measles.  Also, how would Single Payer make things better.  Measle shots are cheap or free and still there are 7% who don't get them for their kids. Besides, part of that 7% is probably the nutjobs who think that the shot will cause autism.  Single payer a solution here?  I don't think so.

              Table 4. Maternal mortality rate.  US, 11 per 100,000. Behind Canada's 7 per 100,000 in the Americas, and once again, trailing Europe.  Why is that?  I know, I know, it's because we don't have Single payer.  Actually, I have no idea; it could have something to do with the fact that American mothers are older and therefore bear somewhat greater risk.  But comparing US to say France,  11 v. 8 per 100,000 the numbers aren't so different and certainly you can't affirmatively demonstrate that Single Payer made that difference of 3 per 100,000.

              Moving on, Table 5.  Births attended by skilled health personnel.  US = 99%.  Enough said.

              Table 6. Contraceptive prevalence.  Again, enough said, US is high on the list, measured against all the world.

              Table 7. Adolescent fertility rate.  Holy sweet lolita! 41%!  You telling me that Single Payer will have any affect on this? Bullshit.

              Table 8. Anenatal care.  No US data.

              Table 9. No US Data.

              Table 10. HIV.  US is pretty high here.    Treatment for HIV is state of the world in the US, and long term retro-virals are pretty much free.  But, once again, how could Single Payer improve on this?

              BTW, where would the world's HIV folks be if the US company hadn't invented retro virals? 6 feet down.  Pretty decent US system to encourage that innovation.

              Table 11 & 12 & 13. No US data.

              Table 14.  Malaria mortality.  Yeah right. Moving on.

              Table 15 & 16.  No US data.

              Table 17. Tuberculosis treatment success DOTS.  Kinda lousy at 64%.  Numbers are all over the board here; Sweden is for example 63%.  The trouble with DOTS (directly observed treatment) is that in the US, it's kinda difficult to treat someone, and observe them, if they don't want to be treated and observed. Once again, Single Payer solves this? Please explain how.

              Table 18.  Good drinking water and Table 19, sanitation  US = 99% and 100% respectively.  Moving on.

              Flip down to chart (not table) number 4. Access to health coverage, immunizations to 90+% to all kids 1.  Pretty frickin' damn impressive.

              Now, when all these statistics get poured into the political filter, we suck compared to all those great European countries because i) we spend more as percent of GDP and that's true.  We do.  However, remember that a full 20% of GOVERNMENT spending is healthcare. (compare to France at 16.7. All this at Chart #7)  and ii) some lack access.

              And access is the rub.  Because there are Americans with no insurance, this single statistic trumps all the other WHO stats to create the claim that US health is inferior.

              Anywaz, that's the WHO stats. US shapes up pretty well in my book.  My only gripe; it's expensive.  It's expensive because we want the best; doctors want the most; companies want to profit and sell their snazzy stuff and the US provides the world with snazzy stuff.  

              • you at least got one thing right

                Because there are Americans with no insurance, this single statistic trumps all the other WHO stats to create the claim that US health is inferior

                Unfortunately, your outrage over this "injustice" pretty much invalidates anything you have to say.

                • Really?

                  So you're saying that so long as everyone is covered with lousy coverage, it's better than most receiving great care. YMMV.  By that measure, under the Moore standard, Cuba excels over US.

                  • further invalidation

                    No one is saying that at all, except for GOP talking points.

                    As always, love your ability to cherry pick.

                    • That's rich

                      Me cherrypicking.  I went through each and every table of the recent WHO study, complete with links, and you pick out one sentence, criticize it poorly, then respond with something that approaches "uh, uh, mom, he's picking on me".

                      Here's the question:  Which health system is superior, one with successful outcomes 90% of the time but with 15% of the population lacking insurance, or one with successful outcomes 80% of the time but with 99% coverage?

                    • Math

                      if 90% are good outcomes, but only represent 75% of the population, that means that the whole population probably gets something much more akin to under 80% good outcomes.  Untreated diabetes alone probably crushes the good outcome problem.

                    • Outcomes

                      The outcomes in the WHO statistics aren't of 'those covered by insurance'. They are statistics of populations.  

                      Re: untreated diabetes.  In US stats are that 20.8 people suffer from diabetes.  Of those 6.2 are undiagnosed. 6.9% total of the population.

                      Compare to Europe. Here's a spreadsheet by country. France at 8.4%, just as example.  Lead in to this spreadsheet indicates 50% undiagnosed.  That's worse than US.

                      A failure of France single payer?  

                    • First, you'll have to...

                      ... show a link about the definition of WHO 'outcomes'.  Until then it's reasonable to assume that a bad outcome that doesn't actually happen in a doctor's office probably get's missed.

                      When you compare populations on diabetes rates you really need to control for age.  (here's some example data illustrating the point.)  As the European data you link to doesn't do that, it's hard to conclude much beyond total incidence across the countries represented.  

                    • $quot;Yeah right. Moving on.$quot;

                      No one said anything about picking on me.  However, if you actually bother to read the arguments in this thread, we're clearly discussing people lacking health care.  It's up to you to show that providing that coverage will automatically make it "lousy."

                      As for the rest, let's just say your arguments don't support your arrogance.

                    • The thread

                      The comment, to which I replied, said this:

                      It's not even close. Their health care system is top 10 in the world, our's isn't even top 50.

                      I went to the WHO data, and summarized the tables, one by one, showing the typical high rank of the US in each of the statistics.  In a less than superior ranking, I ask this question: why would single payer positively address the underperforming statistic.

                      Please show where my arguments are flawed.  You know, just one single, specific argument. I plainly set forth my argument in the first sentence: US healthcare isn't as lousy as some say.

                      Or, address the question: which in your opinion, is the superior system, one with total population favorable health outcomes of 90% (as the data shows for many of the US statistics), or a total population outcome of say, 80% or less (i.e. lousy), but where everyone has health insurance, like say, Cuba. I'd really like to know.

          • Again, what crap

            Exactly in what way am I "naive"? I was countering MCRD's bogus and stupid assumption that our existing private insurance system is not plagued by the same types of problems he wants to pin on a yet-to-be-defined public system.

            Also, his penchant for labeling everyone as a "hack" and assuming that all government officials are corrupt - especially Democratic ones - is most definitely "crap".

            This is a guy who regularly cuts and pastes the bulk of his posts from internet news sources.

            • Bogus and stupid ?

              You seem to take umbridge at my disdain for 80% of the public employees who are morons. I include elected officials in that group as well.

              Folks like Dick Durban who go out and sell all of their stock after being briefed that the house of cards is falling down---they same thing they put Martha Stewart in jail for. Ya----corruption like that.

              I never said all--I said most---you have a problem with English?

              Ya ---I cut and paste--what would you have me do?

              I am so dyslexic that it takes me one day what it takes you ten minutes to read. Wanna sent me to a xyklon B shower?

      • MCRD - Like George Plimpton, you claim to have 'DONE IT ALL'

        How about posting a resume?  You must be 100 years old to have done EVERYTHING you have claimed to do.  

        So, if you want credibility as to your claims of experience, it is resume time!

        and you know what - "hacks" i.e., public servants, have more hearts than the bean counters.

        After all, it is the drug company that is playing hardball, per the whole story, and demanding its 90% rate of return a/k/a "profit".

        • Geez Deb---in that case I suggest you buy pharmaceutical stock

          Course when they have a drug that fails--everyone loses their ases. Perhaps we should relegate pharmaceuticals to on half of one percent profot after Obama nationalizes them. Watch how many new drugs hit the shelves after that.  Resume? For what? So half the nitwits who post here can call it a fraud and a fabrication? I'm old enough to be the grandfather of may of the people that post and accuse me of being an uneducated simpleton who has delusions of accomplishment/. People here scoff at any fact or a reasonable observation posted as being a product of the great right wing conspiracy, outright fabrication, or delusionable.

          Deb--you post that you are a member of the bar and an advocate for the disabled as well as disabled yourself. Have you ever read anywhere, at anytime that I challenge your bonafides or for that matter anyone here? I accept what people state re their backgrounds. What possible purpose would it serve for anyone to inflate their alleged CV? These are but words on a computer monitor, that espouse many personal opinions and little else. Someone just criticized me for being a cut and paster. That's now a crime? I'm not half as intelligent as many of the kids here, but I have life experience beyond most folks wildest dreams to draw from. I learn something from every person I have ever met. I have always been ADD and terribly dyslexic. People read books in hours that takes me days and weeks. I learn aurally and when push comes to shove, like when I had to take chemistry, math, A&P, microbio courses it meant studing twelve hours a day and sleeping four hours because I had two jobs. Kinda sad that young folks find that so foreign because hard work is no longer admired nor desired or even rewarded. Why work hard when everything nowadays is given away..

          Tell you what Deb. You can contact me and send me a copy of your law license. When you status as an attorney is established, I will retain you as my attorney for the fee of $5.00. After we have established attorney/client privilege--I will send you or deliver to you in person a copy of my resume. Divulging the contents of which will obviously have consequence, but you will certainly be able to testify to the authenticity of any statement I have ever made on this website re my professional and educational background. I haven't looked at it in a long while, but I believe my CV is two full pages single spaced.  

          To add to your consternation:

          I have had interesting conversation with: Dean Rusk, Robert MacNamara, GHW Bush, and JE Carter. I have sat in Ronald Reagans seat. I have seen Kitty Dukakis in hair curlers and a nightgown screaming at her husband. I have spent more than one night at Perry St. I have had run ins with Ralph Nader, John Silber and John Deutch. I have been in Buckingham Palace and the Queen's "Master of the Post" is a family member. I had a very pleasant conversation with Jacqeline Kennedy Onassis several days prior to her daughter's marriage, and yes, Mrs Onassis was as charming and elegant as she appeared and she spoke with a very soft voice. The list goes on---all accurate---verifiable---of course not, but that doesn't make it untrue. I learned something many years ago. You treat everyone with courtesy and respect----because you never know who you are dealing with---and you can take that to the bank.

          • Now if only you would take your own advice

            "You treat everyone with courtesy and respect----because you never know who you are dealing with---and you can take that to the bank."

            Is it just me or do we see precious little of that from you on this site?

          • MCRD - I do not believe the content of your Tuesday 6/16/09 19:54 post

            As to that, what attorneys receive are bar cards, and certificates of admission.  As you may note, every one of my posts has my full name!  All you need to do to verify my admission and status as an attorney is go to this URL, and do a lawyer lookup:

            I am not willing to establish an "attorney/client" relationship with you in the future - Disclaimer at present:  

            There is NO attorney/client relationship between the anonymous individual who chooses to post at this site as MCRD and Deborah Sirotkin Butler, nor do I represent this individual who uses the alias "MCRD".

            I find you not credible - you want credibility?  Earn it.  The ball is in your court in that regard.

            You don't care if I find you credible or not?  Fine with me.  But to make this 100% clear - I think like the fictional Walter Mitty character, you make up whatever credentials and personal history appeals to you when you wake up in the morning.  

            I find you unconvincing, your claims to have been everywhere and done everything belong in the fictional history of Forrest Gump.  

          • Ooo! Ooo! I want to play!

            You're Walter Mitty!

  2. If it already does...

    ...isn't that something single-payer will remedy?  I would say you are correct since a private market by definition favors those who are willing and able to pay, the same who are often also well-connected.  The question that has to be asked, however, is can you cite examples of this happening in countries with this system, or even in the US among Medicare patients?  Keep in mind nobody is advocating the complete reinvention of the wheel.  We have the examples of EVERY OTHER INDUSTRTIALIZED NATION to look to, both to emulate what works AND try to avoid what doesn't.

    • Medicare and medicaid and billions of dollars in the hole.

      This is much to complicated to get into here, but the system is now in the early stages of implosion as we speak. You start with Universal or single provider and you open the floodgates.

      Now---at this very instant---try and find an OB/Gyn in MA. Try and find a MD who is willing to take on any additional Pt's that are Medicare or medicaid.

      Because I work in the business--all I have to do is pick up a phone and I can see the best in Boston the next day and I have done it. Anyone else--sorry--Dr so snd so is no longer seeing any new Pt's. Md's and the exceptional MD's are now selecting patients by screening by many different criteria. I personally know a MD ( one of the best cardiologists in Boston) that will not take a Pt with a history of smoking in the past twenty years. People that don't work in medicine don't know what's going on. Practioners are threatening to close general practice and open a "designer" practice and this has already happened in Boston. Wake up people---you are about to kill the golden goose. This is not France, Sweden or Canada. This is America and our healthcare providers are not going to put with this. Are we to make healthcare providers practice by threat of taking their license or at gunpoint?

      • Then how does it work elsewhere?

        I don't pretend to have all the answers, but everybody else has seemed to figure it out, and yes I'm very willing to require that all medical professionals, practices, and hospitals accept the universal system.

        • If universal care works so well in other countries--then why are half the patients in Mass General from foreign countries?

          Why doesn't universal healthcare in foreign countries not foster the cutting edge of technology in procedure and pharmacy? I don't have the answer. I would much rather go to an ER in USA than an ER in any other country in this world. Do some research on how many other countries around the world produce their healthcare practioners. It's an eye opener. The be succinct--it ain't like USA---excepting UK and a few European countries. many countries have "apprenticeship programs." Our system is the best because it rewards the hard work and sacrifice of practioners. Ergo it is the most expensive.

          • Where do you get your numbers?

            Are you talking about "Medical Tourism" or immigrants being treated at Mass General?

            The US has the largest number of medical tourists traveling abroad for health care.

            Thailand has the largest number of medical tourists arriving for health care by far. Should we adopt the Thai health care system?

            • He's confusing measurements.

              In his case I wouldn't be surprised if the confusion were deliberate on his part.  People DO come to MGH (and other Boston hospitals) because it IS among the best in the world.  It consistantly ranks 1st or 2nd (usually competing most closely with Johns Hopkins) in various fields according to annual US News & World Report rankings.  I don't think you'll find many people arguing that the QUALITY of care in terms of technology and medical knowledge in the US is anything less than first class.  It's the COVERAGE side of the equation which leaves a lot to be desired.  It's pretty sad that Americans can go abroad for a less expensive procedure with good coverage even after adding travel expenses.  That right there should raise the red flag that something is amiss.  Doctors are well-compensated in other countries and I'm sure the US can find ways other than high costs to incentivize R&D for pharmaceuticals.

          • No

            It's the most expensive because of HMOs and a small percentage of profiteering doctors that push unnecessary treatments that don't improve the quality of care, yet add tremendously to the cost.

            You blow up your own argument, MCRD. "It ain't like the USA -- excepting UK and a few other European Countries." There. You admit the fact that there are other countries that cover everyone, with talented nurses and doctors, and manage to do so at a much smaller per capita cost.  

            • Huh

              You don't think that the US has the largest investment in end-of-life care, and has the highest per capita rates of obesity in the world, contribute even a tiny bit?

              sabutai   @   Tue 4 Dec 7:00 PM
              • Actually,...

                ... the evidence is that with our higher expenditures, we actually receive less in health resources.  If you buy that we're less healthy, then you'd think we'd be consuming more resources with the extra cash we're paying.  Turns out that it isn't so.


                None of that proves we don't use more services and better technologies. For that, you turn to "It's The Prices, Stupid," written by the same team:
                A study by the McKinsey Global Institute followed that more in-depth approach. The research team, which was advised by a number of prominent health economists, based its analysis on four tracer diseases: diabetes, cholelithiasis (gall stones), breast cancer, and lung cancer.31 Using PPP-adjusted U.S. dollars as the common yardstick, the McKinsey researchers found that in the study year of 1990 Americans spent about $1,000 (66 percent) more per capita on health care than Germans did. The researchers estimated that Americans paid 40 percent more per capita than Germans did but received 15 percent fewer real health care resources. A similar comparison revealed that the U.S. system used about 30 percent more inputs per capita than was used in the British system and spent about 75 percent more per capita on higher prices.32
                So, when tracking the utilization of resources for a variety of treatment-intensive diseases, we pay more and receive less than residents of other countries. The fiction that we pay more but receive proportionately greater amounts of care is just that: a fiction.
              • required reading:


                Will I say that obesity and other problems aren't causes? Of course not, but it's a helluva lot easier to knock off the 15-20% excessive care that doesn't improve patient outcomes (actually, makes things worse for them), than it is to make the large minority of this population who could stand to lose a lot of weight to actually lose that weight. Moreover, you're ignoring the fact that while many other European  countries and other similarly developed countries across the world may not have the same problem with obesity as we do, they often have much higher rates of smoking and other deadly, troublesome and expensive habits. Whether those problems are more expensive or worse than the ones we have, I don't know, but it's easy to pick out our problems whilst ignoring the very large ones other countries have going on. If you want to deal with the large problems of obesity in this country with a reform bill, do it in the farm bill.  

          • Our system is not the most expensive because it is the $quot;best$quot;

            Our system is the most expensive because it is profit driven, the head honchos are members of the New Baronial Class who feel that working less for seven figure or eight figure incomes is beneath them, and reserved for mere peons like you and I.

            I note that Partners Healthcare will often charge 5x, 10x more for the same procedure were it done in Lahey - and Lahey does a great hip replacement.  Just ask me.  Been there.  Done that.

            • Trivia

              Did you know that the first metalic hip replacement surgery was first done at Johns Hopkins (U.S.) then a bit later some guy out of Berma starting using Ivory for the prosthesis, then a guy out of U.K. used a stainless and teflon prosthetic.  

              Since then it's been US all the way baby.  Since the 1980s, most of the innovation has been out of the US.  Probably because it's most profitable to operate here: profit margins are high because people from the US and abroad are willing to visit to take advantage of the new procedures and devices.

              Biomet, a company Indiana makes a grip of cash for innovating some of the recent prosthetics, and given the choice, and the need for a hip replacement, I think I'd rather pay a guy in the US, who is expensive and up to date on the new procedures (say, for example, anterior hip transplant, advanced out of LA in 1996) using the newest in devices, $41K for a hip replacement rather than some guy in Thailand using an ivory insert.

              Of course, the guy in Thailand is probably using the newest thing out of the US just like he's using the newest pharma drugs out of the US.  All, innovated out of the US where the guys are just trying to invent the best next thing and make a buck doing so.  I find it hard to begrudge some snooty doctor his 7 or 8 figures income or the CEO of Biomet if either is cranking out successful hip replacements per year.

              • Compelling.

                Wanna take a poll?

                Who wants to remain the most expensive system in the world?


                Hmmm... 300,000,000 people worth of silence.   Might be more compelling.

                • Another poll

                  Who says single payer will cause it to be less expensive?


                  • If single payer...

                    ... is really all you're worried about, then you should love the Obama plan because the public component is only a choice.  If it competes well, we'll see it.  If it competes really well, we'll see a flood of how 'unfair' it is.  

                    In the meantime, trumpeting the costs as a feature and not a bug will bankrupt us.

                    • Neo Lib

                      Neo Con:  look, let's cut tax rates, to raise tax revenues.

                      Neo Lib: look, let's increase the number of insured to reduce medical costs.

                      Same coin; different sides:  trumpet a false claim to get to where you want. Neo Cons want lower taxes; neo libs want single payer.

                    • Funny how systems..

                      ... that do insure everyone actually do seem to cost less.  But just in case we're wrong, we'll set it up to compete and see if it works, while simultaneously tackling the cost issue from other directions.  Of course one danger is that it wont.  The other danger is that it will work well, be amazingly popular.  

                    • Cost savings

                      It seems to me that the burden of proof is on you.  When you can demonstrate that Medicare, an enormous Government single payer for a particular group, can actually contain costs relative to private plans, then it's time to consider Medicare for all.

                      With regards to a public plan.  Here's my plan.  As soon as there's a public plan, if the tax incentive is removed, I will immediately drop my employees' coverage.  Of course, the private insurer will attempt to keep the business, but if the public plan is subsidized, there's no way a private business can compete.  If it is not subsidized, then the government public option is no different from a national not for profit.

                      So, to summarize, if 1) there's no tax incentive and 2) subsidy, the public plan will eliminate private coverage.

                      If the public option receives no subsidy and payments of premiums receive the same tax incentives as private, then 1) what's the point because the US has just created another non-profit insurer AND/OR 2) if the public plan becomes the insurer of last resort, then it will attract individuals who are most in need of insurance and the costs will spiral, just as they do with Medicare and Medicaid, leaving the US to either subsidize the plan or else abandon it.

                    • See below

              • US is great for innovation

                I haven't heard anyone deny that.  Seems to me that such does not have to require that we're stuck with the entire bill, however.  Since we are so great at innovation it seems we should be able to innovate a health coverage system which both keeps costs low AND promotes a healthy and competitive R&D environment.

                • Is the US subsidizing worldwide drug costs?

                  I've heard the argument that the US subsidizes the rest of the world's drug costs and that a drop in prices in the US would make drugs more expensive everywhere else.  

                  Much of this line of reasoning is undercut because drug companies spend more on advertising than research, but it's still an interesting notion...  If anyone could point the way towards research on the international effect of single payer in the US, I'd be thankful.  

            • Deb--lokk at the differences in pay between the staff at Lahey and the staff at Mass General

              personally---I think Mass general has waaaaaaaay too many people on the payroll who have essentially no job---this is purely anecdotal frompersonal observation. But I ask people " What's your job" and they take great offense---which means something to me.

              • I bet what it means

                to you is that they're "hacks." If some random guy walked up and started quizzing me about my job, I probably would not react in a way you'd approve of, either.

            • Lahey

              My father collapsed at work a few years ago at the age of 78.  He worked up the street from lahey and was in their ER within 15 mins of being stricken.  He was vomiting, suffering from vertigo and hypersensitive to light.  The triage nurse diagnosed him with some sort of stomach ailment. He sat on a gurney in a hallway in the waiting room for 7 hours before he was seen by a doctor.  I watched a procession of pick up basketball induced sprained ankles get treated while he lay flat with a blanket over his head, unable to sit up.  My protests were completely ignored.  

              After a battery of tests it was determined he had suffered a severe stroke.  It took him a month before he could lift his head off of a pillow.  His PCP, who had an office in the hospital, did not come to see him once during his entire stay.  Not once.  Of course, the PCP had misdiagnosed a small stroke that my father suffered previously.

              I wouldn't bring my pet rat to Lahey.

              • Lahey_2

                I have similar Lahey stories. A close relative with what turned out to be a life-threatening condition sat for hours in the ER waiting room while her PCP sat upstairs; his staff would neither let us talk to him nor push the ER people to look at her (a week later he claimed "nobody told me.") I assume one of the nurses did an end-run around the ER intern who eventually did see the patient, and who was going to send her home, because all of a sudden the head of the GI department appeared and had her in a room for the weekend. He said she could have died.

                For a while, I had that same PCP. After the above incident, and several other less-than-reassuring performances, I found a young doctor near my home who was accepting new patients. He's been great, and the group practice he's part of arranges same-day appointments routinely. The Lahey doc would never see one of us without an appointment weeks in advance.

                Lahey's specialists - at least the ones I've encountered - are very good. Their ER is the pits. Their system in general seems designed to discourage patient access to doctors. At least one of their generalists is incompetent.  

                • A different Lahey experienced

                  I have had the same PCP since 1983.  He responds to e-mail, returns phone calls on page the same day, always, and emergencies within 15 minutes.

                  When our cat bit my husband who had had the hubris to try and groom lumps out of his fur, our PCP had me take him to emergency immediately; some bacteria in the cats saliva had caused a streak up my husband's arm in less then 60 minutes; they had my spouse on an IV within 15 minutes of arrival.

                  Same speed when my husband had a heart attack.  I find what kirth had to say so different from our experience as to sound like something from another universe.

      • universal, single payer saves money

        an indisputable fact

        • I think that the VAT takes care of it in France.

          I am coming around to supporting a VAT for our health care mostly because of the huge disadvantage our companies have when competing their products with those of countries which have nationalized health care.  I don't know if it is true but I think that about $2,000.+ of medical costs is built into every car made in Detroit.

        • Ryan---you are absolutely correct. Single payer does indeed do that. It's called dictatorial

          I can cut the entire US healthcare budget by 50% tomorrow if someone would give me the authority. No medical care prior to one year of age and none after age 50. Problem solved.

          You think for a second that with single payer that you will not have eventual rationing of services to those who are perceived as "minimal need" because of age, income or voter registration?

          Folks---do not place your faith in the best of intentions of anyone. Look around. How did the economic collapse occur? With the best of intentions. How did the Iraq War come about? With the best of intentions. The road to hell is paved with the best of intentions.  

          • bull shit

            Our system of care is far below that of even the average single payer system. They cover everyone -- and do a damn better job of it, too. That goes for the best ones, like France, to the middling ones, like Canada and the UK. They're just far superior systems in every single freaking way.

            I'm sorry, but you're just delusional if you think otherwise. Completely and utterly delusional.  

            • If I wanted to live in UK, France or Canada I would move there

              I don't want to be taxed to death because of the sow down the street, the gimme girl with four kids by four fathers, the smokers, and drinkers. To be blunt----I don't care what happens to them. They are victims of their own stupidity, lack of education, or being raised by like a minded parent. The apple does not fall far from the tree.  

              • And as a matter of fact

                When I was your age, all we heard was the Soviets have this great medical system. Holy Jesus Christ on the cross, thank god we didn't swallow that line of bullshit forty years ago!

          • OK, time to show your hand

            How would YOU propose covering the 47 million uninsured, including all ages, including all degrees of pre-existing health conditions, including all income levels?  I get the distinct sense that caring for your fellow human beings isn't even a priority for you, which I guess would be appallingly consistant with your support expressed elsewhere for torture.  If you don't have a solution then I would submit that there is nothing more to discuss with you on this topic.

            • Deport the first 15 million.

              Require a pay as you go system and the taxpayers make up the difference. Unless you have a significant medical issue which precludes employment (and I mean medical issue by my standard)  No work   euals no medical care. We will pay for a one way ticket to Canada, UK, or France.

              BTW last year my cousin had a cholescystectomy in France. They required that he pay up front via credit card for the procedure and then seek reimbursement from his healthcare Ins which is medicare and B medex.

              • I'm not prepared to kick people out...

                ...unless you're talking about those here illegally, in which case I could see only covering those who should be here except in dire emergencies.  (Even then I'm not a fan of the "just round 'em up and deport 'em method, but that's another topic.)  Even though we've gotten accustomed to the idea that employers provide coverage, I don't think the two should necessarily be connected.  Human life and health has intrinsic value that should in no way be based on one's work, simply the fact of one's existence.

          • you don't think we have that now?

            Again, our health care system is driven by capitation.  Doctors are actively incented not to find ways not to treat people:

            Capitation payments are used by managed care organizations to control health care costs. Capitation payments control use of health care resources by putting the physician at financial risk for services provided to patients. At the same time, in order to ensure that patients do not receive suboptimal care through under-utilization of health care services, managed care organizations measure rates of resource utilization in physician practices. These reports are made available to the public as a measure of health care quality, and can be linked to financial rewards, such as bonuses.
          • even worse than capitation: rescission


            Blue Cross of California encouraged employees through performance evaluations to cancel the health insurance policies of individuals with expensive illnesses, Rep. Bart Stupak (D-Mich.) charged at the start of a congressional hearing today on the controversial practice known as rescission.

            The state's largest for-profit health insurer told The Times 18 months ago that it did not tie employee performance evaluations to rescission activity. And executives with Blue Cross parent company WellPoint Inc. reiterated that position today.

            But documents obtained by the House Committee on Energy and Commerce and released today show that the company's employee performance evaluation program did include a review of rescission activity.

            The documents show, for instance, that one Blue Cross employee earned a perfect score of "5" for "exceptional performance" on an evaluation that noted the employee's role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

            WellPoint's Blue Cross of California subsidiary and two other insurers saved more than $300 million in medical claims by canceling more than 20,000 sick policyholders over a five-year period, the House committee said.

          • The economic collapse came from greed and lies, the Iraq war from lies and dogma

            NEITHER the economic collapse NOR the Iraq war resulted from good intentions.

            Just as the Wall Street Barons who waltzed away with billions, or the AIG honchos who received 165 MILLION in bonuses from bailout money.

            WHAT good intentions?

        • GIC - the state empoloyees plan with negotiations by Delores Mitchell is a case in point

          Better plan for 1000 for a family of four then BC/BS has for $1600.

          I know.  Right now we are waiting on COBRA due to my husband's layoff and have no insurance at all in this bridge time.  Just picked up three prescriptions - $466.15.

          Hoping that once the COBRA'd plan comes in we will be reimbursed.  No, we cannot keep up those prescriptions at that cost.

          The "actual" cost of manufacture for what cost ME/OUR FAMILY $466.15 is about $12.00.

          Ah yes.  The profit motive.  How American, MCRD.

        • I take exception to that and dispute it.

          Prove otherwise

  3. because HMOs have NEVER denied anyone coverage in the US n/t

    • Yes they have

       This occasion is probably so old, because I can't find the reference. But it is real. A man walks in to Fallon in Worcester (Summer St. or Central St.) complaining of chest pain. He'snot a client, they refused to treat him.

      • I'm pretty sure Ryan was being sarcastic.

        What you describe is immoral in the extreme, and is exactly what motivates those of us who want universal coverage.

  4. You're absolutely right that...

    ...there are hard decisions to be made because various treatments for various issues have a wide range of costs, some becoming stratospheric.  Single payer systems are the most efficient at spreading cost burdens because they spread the risk pool across the largest possible population (everybody).  Even so, there will always be some form of rationing in the system because it's implausible to do everything for everybody all the time.  We ration now by pricing people out of the system entirely.  

    Now your objections regarding political favors within such a system seem extremely misguided.  All that's required to worry about the government conveying special treatment is for them to spend any money on anything.  You handle those problems through the laws and the political system, but you don't throw up your hands and cry 'oh no, some people might be up to no good so what's the point!'.  You handle it.

    • One thing to consider, though

      is under a strong, reformed national single payer system, we'd probably ration a great deal less.

      Let's consider this. 50+ million Americans have no health insurance. I needn't go further, but I will. Another 100 million Americans have bad/overly expensive health care: these people choose not to go to the doctors when they should, burdening our system when they're sicker and can't afford to wait any longer. Is it possible to ration anymore than we currently do? I doubt it.

      Finally -- and perhaps most importantly -- in many parts of the country, there's simply too much care, at least for those who do have insurance. The Mayo clinics and others have taught us that. A lot of doctors and their practices overly push care, prescriptions and other treatments. Unnecessary treatments result in unnecessary side effects and consequences -- they don't improve the quality of our healthcare. The Mayo clinics spend a great deal less on the average patient, yet give amongst the best care in the country. I don't think it's a stretch to say we could reduce unnecessary treatment by 15-20% in this country, whilst simultaneously improving care.

  5. I was disgusted by one paragraph in the article

    In Genzyme's new glass Kenmore Square headquarters, the president of the firm's international group, Sanford Smith, keeps a brass gong outside his office. Every time a foreign government agrees to pay for one of the company's drugs, he takes out a mallet and rings it.

    As I read that I heard, Oh good we have just nearly bankrupted another poor country and increased our profits so that we can accumulate more wealth. There just seems to be something wrong with making a profit on somebody's health.

    • well

      people do have to make a living, including those who practice money. They should be paid well for all the work they do and training they needed to do it.

      That said, it's horrible that we create "insurance" agencies that profit off human health -- and do everything in their power to deny coverage. The medical profession should be paid, but we don't need this middleman class that rips off a huge chunk of the costs of medicine and decides who should and should not receive care, and what kind of care they get, instead of nurses and doctors.

  6. This entire thread feels like

    death by a thousand anecdotes.  

    There is only one way to assess the efficacy of any health care system and that is through measured outcomes.  Your Uncle Sal's experience in Burkina Fasso, subjectively good or bad, is worthless in the big picture.

    Indicators of health, as used by international NGOs, the WHO, and other professional clinical organizations are generally used to arrive at an index as to the overall health of a particular nation and its subpopulations and subgroups.  

    Health care policy based on personal experience or observation is nothing more than fuel for indignant internetz exchanges that do nothing to advance anyone's thinking on this matter.  

    Do your homework  (gee!  what a novel concept!) and get the facts on population health with respect to access, cost, outcomes, and cultural influences.  Then you might have something.  


    • I find anecdotes useful...

      ...not so much to prove an affirmative assertion as to negate and point out exceptions.  Such exceptions may lead to reassess how accurate the original assertion was to begin with.  For example, I used an anecdote about a classmate who got good care in a European system without having to wait to negate what I see as the myth of long waiting periods and general inefficiency of such systems.  I agree that for actual policy meeting there would need to be a more comprehensive study.  Hopefully, we can get the best aspects of the various universal systems, as well as those of our own, while doing our best to avoid as many of the negatives as possible.

      • That's the problem.

        It isn't the case that you  "...used an anecdote about a classmate who got good care in a European system without having to wait to negate what I see as the myth of long waiting periods". The whole point about what you can conclude from an anecdote is that you can't conclude much, which is why you really didn't 'negate' anything, unfortunately.

        • To clarify

          I did not intend to "negate" to the extreme of saying something never happens.  What I thought I did was simply negate the absolute element to previous assertions.  When somebody asserts in the form of a practical guarantee that we are doomed to long waiting periods, I can bring this anecdote forward as a way of saying no we're not, and here's an example.  It's the absolutes we need to be careful of.  I for one very rarely use the words "always" and "never" because in my experience those words are often not literally true.

          • I agree

            personal experiences are an important part of a debate.   Analysis of statistics seem to take the majority, and make it a fact, when in reality, the majority is only part of the truth.  The personal experiences give insight into what can occur, at the very least it educates about what to watch out for. It also allows for addressing potential problems or amazing successes while policies are being formed.  

            A good example is BrooklineTom's post on dangerous situations around some T locations.  According to statistics, (I would imagine, I've never looked at safety stats for the T) I should have little to worry about. However, hearing what BT had to say, makes me more aware and knowledgable about potential hazards of riding the T.

      • Well, I'll concede that anecdotes

        are interesting, but this:

        Such exceptions may lead to reassess how accurate the original assertion was to begin with.  

        strikes me as short-sighted and ill-advised.  Are you really suggesting that an anecdote that you might find on a blog is going to sway your opinion about whether or not a particular nation's approach to health care is advantageous or effective?  

        The complexities of measuring health care access, delivery, and effectivness are enormous.  There is absolutely nothing that any single person can say about his or her own personal observations that would be of any value whatsoever in a rational and informed debate.    

        • The misunderstanding...

          ... is actually a common one.  Many people have heard of 'the exception that disproves the rule'.  This logical concept works very very well, when appropriate.  A single anecdote can provide such an exception.  The problem is misapplication.  Someone would have to be asserting a rule that applies to all outcomes before this technique can be said to be applicable.  Of course, in this case, nobody is asserting any 'rule' that 'there are never horror stories' for any particular existing system.  Thus the anecdotal horror stories can provide no conclusions about the system in this regard.  Similarly, nobody is asserting that 'all outcomes in a given system are horror stories'.  Thus an anecdotal data point of a 'good outcome' doesn't 'disprove the rule' any more than it's counterpart in the other example.

          The technique of finding an exception to disprove a rule is almost second nature in an attempt at reason.  Unfortunately it's so much second nature that it is frequently misapplied.  Especially with compelling anecdotes.

          • Your point is well taken.

            I guess my frustration stems from the fact that intelligent people who readily acknowledge we have a serious issue in this nation are exhibiting such laziness in their thinking.   I understand the rhetorical point you are making; it's entirely valid and relevant.   That said, however, the anecdotal "evidence" on this thread seems to be carrying the discussion, and I would argue that, in the big picture, it's exactly this sort of thing that can and probably will derail support for meaningful reform.  This is grass-roots behavior at its worst because the end result is often a poisoning of the well.   People don't want to wade through longitudinal outcomes-based studies of the Canadian model or the Norwegian model.  They don't care about wellness measures based on twenty-year initiatives in Great Britain.  They want to make reflexive decisions about legitimate health care models based on nothing but truthiness.    If someone as intelligent as Christopher can be swayed in favor of one model over another based on anecdotal evidence masquerading as relevant information, then there is little hope that large numbers of people prone to truthiness will be able to discern the forest for the trees or even listen to public health experts who have done the research.    

            • We need to fight...

              ... against this reflexive attitude of being compelled by anecdote.  This failing is what causes politicians like Reagan to make up the 'welfare queen of Chicago' out of whole cloth.  

              Governing by anecdote is no way to craft a policy.

            • that's why you have to do both

              There's an amazing amount of FUD (Fear, Uncertainty, Doubt) being thrown around about this issue.  The examples in this thread are typical:

              - pretending that the UK, Ireland, and Canada all have the same system - asserting that single payer is a "British style system." - asserting that health care in all other countries is a failure - asserting that single payer will create a two tier system when we already have a three tier system

              Since we're dealing with an appeal to ignorance, you have to both provide anecdotal evidence (from personal experience the UK system is really quite good) and systematic evidence (the statistics and initiatives you cite).  Otherwise, all people remember is the FUD.

        • Actually, yes

          I can't think of examples at the moment, but I know I have given ratings of 5 to comments that include anecdotes as a way of saying the commenter brings up an interesting counterexample that is worth pondering.  It may or may not ultimately lead me to revise my previous opinion, but I do find them useful.

    • This is a fair assessment, but in this instant case, if it doesn't work

      and the system implodes, we will be stuck with a catastrophe and I get stuck with the tab---if I am still around.

  7. Canada / US WHO data

    In the interests of everyone being able to see if anyone is cherrypicking anything, here is the WHO mortality and Disease comparison data (replicated below).

    © World Health Organization The information in this database is provided as a service to our users.  The responsibility for the interpretation and use of the material lies with the user.  In no event shall the World Health Organization be liable for any damages arising from the use of the information linked to in this section.  For explanatory notes, please refer to the latest version of the World Health Statistics publication available at

    CanadaUSA Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) both sexes, 1990102132 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) both sexes, 200081114 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) both sexes, 200672109 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) female, 19907191 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) female, 20006183 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) female, 20065580 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) male, 1990132172 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) male, 2000100144 Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) male, 200689137 Age-standardized mortality rate for cancer (per 100 000 population), 2002138134 Age-standardized mortality rate for cardiovascular diseases (per 100 000 population), 2002141188 Age-standardized mortality rate for injuries (per 100 000 population), 20023447 Age-standardized mortality rate for non-communicable diseases (per 100 000 population), 2002388460 Deaths among children under five years of age due to diarrhoeal diseases (%), 20000.20.1 Deaths among children under five years of age due to HIV/AIDS (%), 200000.1 Deaths among children under five years of age due to injuries (%), 20007.210.3 Deaths among children under five years of age due to malaria (%), 200000 Deaths among children under five years of age due to measles (%), 200000 Deaths among children under five years of age due to neonatal causes (%), 200058.556.9 Deaths among children under five years of age due to other causes (%), 200032.931.3 Deaths among children under five years of age due to pneumonia (%), 20001.11.3 Deaths due to HIV/AIDS (per 100 000 population per year), 200510.05 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199011 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199111 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199211 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199311 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199411 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199511 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199611 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199711 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199811 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 199911 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 200011 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 200110 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 200210 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 200310 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 200400 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 200500 Deaths due to tuberculosis among HIV-negative people (per 100 000 population), 200600 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199000 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199100 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199200 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199300 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199400 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199500 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199600 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199700 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199800 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 199900 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 200000 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 200100 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 200200 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 200300 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 200400 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 200500 Deaths due to tuberculosis among HIV-positive people (per 100 000 population), 200600 Healthy life expectancy (HALE) at birth (years) both sexes, 20037269 Healthy life expectancy (HALE) at birth (years) female, 20037471 Healthy life expectancy (HALE) at birth (years) male, 20037067 Incidence of tuberculosis (per 100 000 population per year), 1990109 Incidence of tuberculosis (per 100 000 population per year), 1991910 Incidence of tuberculosis (per 100 000 population per year), 1992910 Incidence of tuberculosis (per 100 000 population per year), 199389 Incidence of tuberculosis (per 100 000 population per year), 199489 Incidence of tuberculosis (per 100 000 population per year), 199578 Incidence of tuberculosis (per 100 000 population per year), 199677 Incidence of tuberculosis (per 100 000 population per year), 199777 Incidence of tuberculosis (per 100 000 population per year), 199876 Incidence of tuberculosis (per 100 000 population per year), 199966 Incidence of tuberculosis (per 100 000 population per year), 200066 Incidence of tuberculosis (per 100 000 population per year), 200165 Incidence of tuberculosis (per 100 000 population per year), 200265 Incidence of tuberculosis (per 100 000 population per year), 200355 Incidence of tuberculosis (per 100 000 population per year), 200455 Incidence of tuberculosis (per 100 000 population per year), 200555 Incidence of tuberculosis (per 100 000 population per year), 200654 Infant mortality rate (per 1 000 live births) both sexes, 1990710 Infant mortality rate (per 1 000 live births) both sexes, 200057 Infant mortality rate (per 1 000 live births) both sexes, 200657 Infant mortality rate (per 1 000 live births) female, 199068 Infant mortality rate (per 1 000 live births) female, 200057 Infant mortality rate (per 1 000 live births) female, 200656 Infant mortality rate (per 1 000 live births) male, 1990811 Infant mortality rate (per 1 000 live births) male, 200068 Infant mortality rate (per 1 000 live births) male, 200657 Life expectancy at birth (years) both sexes, 19907775 Life expectancy at birth (years) both sexes, 20007977 Life expectancy at birth (years) both sexes, 20068178 Life expectancy at birth (years) female , 19908079 Life expectancy at birth (years) female , 20008280 Life expectancy at birth (years) female , 20068380 Life expectancy at birth (years) male, 19907472 Life expectancy at birth (years) male, 20007774 Life expectancy at birth (years) male, 20067875 Maternal mortality ratio (per 100 000 live births), 2005711 Neonatal mortality rate (per 1 000 live births), 200434 Prevalence of HIV among adults aged =15 years (per 100 000 population), 2005222508 Prevalence of tuberculosis (per 100 000 population), 199077 Prevalence of tuberculosis (per 100 000 population), 199177 Prevalence of tuberculosis (per 100 000 population), 199277 Prevalence of tuberculosis (per 100 000 population), 199367 Prevalence of tuberculosis (per 100 000 population), 199466 Prevalence of tuberculosis (per 100 000 population), 199566 Prevalence of tuberculosis (per 100 000 population), 199656 Prevalence of tuberculosis (per 100 000 population), 199755 Prevalence of tuberculosis (per 100 000 population), 199855 Prevalence of tuberculosis (per 100 000 population), 199954 Prevalence of tuberculosis (per 100 000 population), 200054 Prevalence of tuberculosis (per 100 000 population), 200144 Prevalence of tuberculosis (per 100 000 population), 200244 Prevalence of tuberculosis (per 100 000 population), 200344 Prevalence of tuberculosis (per 100 000 population), 200443 Prevalence of tuberculosis (per 100 000 population), 200543 Prevalence of tuberculosis (per 100 000 population), 200643 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) both sexes, 1990811 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) both sexes, 200069 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) both sexes, 200668 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) female, 1990710 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) female, 200058 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) female, 200657 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) male, 1990913 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) male, 200079 Under-5 mortality rate (probability of dying by age 5 per 1000 live births) male, 200668 Years of life lost to communicable diseases (%), 200269 Years of life lost to injuries (%), 20021517 Years of life lost to non-communicable diseases (%), 20028075
    • thanks, it's much more compelling without snark

      And, as has already been pointed out, the Canadian system beats us in almost every category.

      • Hmmmmmmmmmmmmmmmm

        I would suggest that morbidity and mortality using Canada and USA as examples may be affected by many variables that likely have significant effects on the bottom line.

        • I was going to say the same thing

          what about lifestyle. I suppose I should read the link, perhaps it is already factored in. I am curious about the slightly higher cancer death rate in Canada. I'm not surprised by the higher cardiovascular death rate in the US.  In my opinion, if you're going to eat dinner at McDonalds, you might as well eat a large bag of potato chips for dinner.  Maybe a slightly higher protein gain from McDonalds.

          • how different do you think Canada and America are?


            And yes, please read the link.  There's a world of information...

            • Why, isn't Canada the 51st state? n/t

              • Not really...

                ... Canada minus Quebec is the 51st state.  Quebec might be the 52nd, but only in the mind of non-Quebecois.  

                • I'd take poutine over a Big Mac anyday

                  But then, I'm half Cajun.  My people are from thereabouts, way back when.

                  Which is kinda my point.

                • Fun with analogies....

                  Quebec is to Texas what Canada is to the U.S.?  McGill is to Harvard what UToronto is to MIT?  PEI is to Hawaii what Nunavut is to Alaska?  Lunenburg, NS is to Lunenburg,MA what Halifax, NS is to Halifax, MA?  YT is to Idaho what NWT is to Montana?  NFLD is to Michigan what Labrador is to the UP?  St. Pierre & Miquelon is to Canada what Bermuda is to the U.S.?


            • I followed the link...

              It appears you can adjust the outcomes based on different indicators, including health care. Tried it, didn't change the outcome, or maybe I'm doing it wrong, or maybe the indicators were already in place.  I will play with it more later.

            • How different?

              You mean how different is Canada and the US with regards to factors that affects life expectancies like violent crime where the US is 24th in the world and Canada 44th, or poverty where Canada has a 10.8% poverty rate compared to 12% in US, or maybe obesity where US leads the world with over 30% of the population obese compared to Canada larding in at 14.3%,. How about tobacco use?  Here's a nice chart correlating tobacco use to longevity.  Note that there are more US smokers than Canadian.

              So yeah, objectively comparing factors that affect longevity, Canada and America look very different.

              • Aren't lower obesity and smoking rates...

                ...results of an effective health care system?

                It's not like the two countries are that different demographically.  

                As I'm guessing you know, violent crime is already accounted for in the WHO numbers.

              • $quot;factors that affects life expectancies...$quot;

                like access to basic health care.

                • obviously

                  That is one of the relevant factors.  In combination, all affect life expectancy.  That's the point, you can't claim that single payer alone is the cause for greater longevity as has been implied.

                  • who implied that besides you?

                    • quote

                      how different do you think Canada and America are? (6.00 / 1) Seriously?   And yes, please read the link.  There's a world of information...

                    • say what?

                      I was responding to a question about lifestyle differences. No mention of single payer at all.  On the other hand, I've been consistent in calling you on your claims that care for all isn't important.  It is.  Which is the point of the comparisons to Canada, France, the UK, etc.  They have wildly different systems, but all of them cover everyone.

            • Having spent some time in Quebec province,

              I'd say that most Canadians ( my apologies anglophones) are far more independent and hardy. They tend to be less urban ( I hope that is a fair observation) they do not have immediate access to physicians  so they are less apt to run to a MD for a sniffle.

              In my experience---way to may patients being seen for somatic issues are in reality dealing with psychological and psychiatric problems. They need pschological assistance rather than medical treatment r/t a physical ailment. In more mundane terms we are spending way too much money on nuts.

              • that doesn't even make sense...

                It's also not true, according to the Public Health Agency of Canada:

                Most Canadians live in urban settings with over 80% of the population residing in towns and cities. It is a growing trend. Since 2001, nearly 90% of the country's population growth has been concentrated in Canada's large  metropolitan areas.

  8. The current Obama plan...

    ... indicates that the public plan option will pay for itself, once it gets off the ground.  

    "...can actually contain costs relative to private plans."

    Jacob Hacker:

    ...First, public insurance has a better track record than private insurance when it comes to reining in costs while preserving access. By way of illustration, between 1997 and 2006, health spending per enrollee (for comparable benefits) grew at 4.6 percent a year under Medicare, compared with 7.3 percent a year under private health insurance. At the same time, Medicare has maintained high levels of provider participation and patient access to care. Medicare has proven superior at cost control not just to health plans in the private sector, but also to private plans that contract with the federal government, such as those offered through the Federal Employees Health Benefits Program (FEHBP)-suggesting that public insurance can outperform private plans even in the context of insurance reforms. Second, over the last generation, public insurance has pioneered new payment and quality-improvement methods that have frequently set the standard for private plans. More important, it has the potential to carry out these vital tasks much more effectively in the future, using information technology, large databases of practices and outcomes, and new payment approaches and care-coordination strategies. Indeed, a new public plan could spearhead improvement of existing public programs as well as private plans.

    He has a whole section on Medicare's relative efficiences starting on pg. 9.

    The Lewin Group:

    Administrative costs, including profit and commissions, for privately insured small groups are on average equal to about 31.7 percent of covered benefits. If implemented through Medicare, administrative costs would be equal to about 13.2 percent of covered services.  Our estimate of administrative costs is based upon a detailed analysis of administrative costs under insurance pools which we present in our model documentation.5 These administrative costs are about twice what administrative costs currently are in the Medicare program (about 6.5 percent of benefits). Costs will be higher in the public plan than in Medicare because the program will need to process the movement of individuals across health plans when people decide to change their source of coverage. The plan will also need to collect premiums from individuals and employers who decide to enroll. These functions are not required for the current Medicare populations once enrolled.   Figure 2 presents our estimates of the average cost of insurance for individuals in the public plan and in the private insurance markets. Premiums for family coverage under the public plan would average $761 per month compared with $970 per month in the current private insurance market.

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