Sunday, June 29, 2008

More on govenmental control (e.g., fat tax)

I started typing this as another comment in repsonse to the previous post, but I figured that since I had so much to say (and it's my blog), that I'd start a whole new post here on this issue, because so many other issues are brought up in my reply. Here is the reply:

Wow, this is certainly one of the most controversial and discussed topics on this blog. I appreciate all of the banter and the really good points brought up by everybody.

R. Waterhouse brings up fantastic points about civil liberties, and where to draw the line on other "dangerous" activities, such as promiscuous sex.

This is such a complex issue. Certainly, the most FAIR system would be NO entitlements and people paying for the consequences of their own indiscretions. There is a huge part of my internal psyche that feels it should be this way.

Then, the other part of my psyche that ends up causing me cognitive dissonance, is that as human beings, we cannot be completely selfish and we should help out the less fortunate. As pointed out by Kath, behaviors that may seem to be solely personal choice are considered by the medical community as "diseases" (e.g., alcoholism, drug addiction). The fact is, that too many people have some sort of combination of being either too "diseased", too weak, or too stupid not to get themselves in trouble with the evil pleasures in life. Thus, sometimes it behooves a government to try to willfully impose a kind of restriction, tax, or punishment for those behaviors. But that results in the predictament of the slippery slope of reaching a point of too much governmental control. I agree with Will that the banning of trans-fats and smoking in public places are probably good policies.

I think the only answer is some kind of balance. This argument can last forever. One of the classic examples is the whole "war on drugs" by the government. Why should we ban any drugs? I can make plenty of good arguments for abolishing all of the rules on drugs. Why should smoking pot, doing cocaine, doing heroin, or any other drug be illegal? The DEA and the billions of dollars spent on the war on drugs has largely been a waste. These drugs are still widely abused, and, one can argue, that making the drugs illegal has increased harm to society in terms of violence and costs of trials and imprisonments. If drugs were legal, there would be no drug lords. There would be less shootings over drug deals gone awry. The police force could be smaller. Our jails would have more room. There would be fewer trials funded by public monies to try to imprison and sentence these folks. Finally, drugs could be sold and taxed just like cigarettes, which would give the government more revenues to spend on more worthwhile causes.

Arguments can also be made in the other direction. Why is alcohol and tobacco legal, while the other drugs are not? Many more thousands of people die each year as a result of alcohol and tobacco, than all of marijuana, cocaine, heroin combined. If the government wanted to keep people safe, then they should ban alcohol and tobacco first, and then worry about the other drugs, and other things like fatty foods.

I don't have the best answer for how much governmental control is appropriate for all of these issues. In the end, or for the time being, I think that federalism (state's rights) might be best. I think it is best for the issue of gay marriage, and it may provide some semblance of a solution. Why? Because it would not require people to leave the country if their idea of appopriate governmental control was the complete opposite of their beliefs.

There could be gun-toting states and non-gun toting states. States that allow gay marriage and states that don't. States that ban drugs and states that don't. States that despise moral hazard and believe in pay for your own regarding healthcare, and states that believe health care should be a collective cost. I'm sure there would be plenty of comments about this as well from both sides (e.g., "poor people won't be able to be as mobile and move to another state" or "the country would be too fractured to run efficiently") but, really, many of the important issues are determined at a state level (e.g., death penalty, gay marriage, rules on abortion timing, etc).


Will said...

that's weird; my post didn't go through...and it was w/o expletives for once.

Anyway, when it comes to health, pay up front w/ cheap/ efficient things (flu vaccines, primary care, clean needles .. yeah, thought i'd try to slip that one in there) or wait til all heck breaks loose and the government has to pick up the pieces anyway.

Not that free preventative health keeps people out of ICUs but perhaps enough people to make it a good value. Not to mention people can't buy crack with insurance cards like they can with welfare checks.

Cocameister said...

I agree Will. Like it or not, Medicare and Medicaid will never go away, so monies spent up front on preventive care are a good investment for future costs incurred.

Isn't it interesting that about 1/2 of Americans hate government run health care, but 99% of Americans > age 65 sign up for Medicare? (yes, Medicare is optional)

Meeta said...

I'm not sure that's all that interesting, Steve. The alternative to basically free medicare coverage for a 65-year-old is to pay quite a bit out-of-pocket for medical insurance or fee-for-service. And medicare doesn't totally run the healthcare system. Hospitals and outpatient offices do their own thing administratively. Isn't it more that Americans don't favor a socialized healthcare system? Seriously, does anyone think the VA is a model for how care should be delivered? (Nothing personal, Will.) But isn't that what we could expect nationalized healthcare would look like here in the US?

But I digress from the original point of your post...I agree that paying for the cheap preventative stuff makes good sense for a lot of reasons. I wonder, though, instead of keeping people out of ICUs, would people just end up there later in life and sicker? From purely a healthcare dollars standpoint (and I know it's way more complicated that this...the benefits can't only be measured in money), the "cheap" stuff may ultimately cost us more.

Cocameister said...


What's wrong the VA system? Studies have shown that the VA actually performs better on quality measures than non-VA facilities.

Second, I agree with you that preventive care may lead to increased costs. I reference the landmark NEJM study that found that smoking cessation, while leading to a transient decrease in costs, would actually lead to increased health care costs in the long-term because of increased life expectancy.

Will said...

Of course, my real feeling is that basic healthcare is a right that should be afforded to all Americans under a somewhat generous interpretation of "life liberty and the pursuit of happiness." Trying to show that it saves money is just an attempt to appeal to the small government aficionados.

REgarding the VA, there's pluses and minuses. I think for people who are well-insured, the VA looks second-rate but we do get people seen and we do have rates of quality indicators (e.g. ASA/ACE inihibitors for DM2) that compete w/ the best HMOs and trounce public clinics of course.

The question of whether preventative care saves money probably varies from issue to issue. The 'keeping people healthy leads to older, more costly patients' argument may not be true either. I would venture to guess that long-lived people may be more likely to die in home hospice with the "it's been a good ride" mentality. Of course, these people tend to be of higher SES so plenty of confounders.

Don said...

I can guarantee that Mr. Jefferson did not include free healthcare in his definition of "life, liberty, and the pursuit of happiness."

But, once you assume that free healthcare is a "right," then you have to deal with the consequences. There is nothing free about free healthcare. Taxing people for their unhealthful activities will just create other costs and not answer the problem.

I will give Will credit for sticking to his intellectually honest guns of socialism, though. Better than the "states' rights" cop-out, Steve.... I agree that states should have such rights, but the question remains -- what would you want in YOUR state?

As for the V.A., I have only antecdotal evidence to offer. My dad was a proud veteran and always went to the V.A. before any other governmnet assisted (he qualified for Medicaid) or private health care. Each time he went, I found the care below the standards afforded to dirt poor Appalachian folk in the emergency room or when we had insurance.

But, it still wasn't that bad. I am sure it is much better than most of the rest of the world.

You guys are convincing me more and more that we should not tinker with our imperfect but still pretty darn good system in the U.S.

Meeta said...

First, about the VA...I admit I don't know the medical literature well regarding outcomes and benchmarking of VA care. I buy it, though, that in some measures, the VA does well. They've got that computer system, for one thing (wasn't it featured on 60 Minutes once? It's gotta be good.). And having worked there, I agree with Will that people get seen, etc. So, fine, the VA does better than average at some quality measures. But what about patient satisfaction? Employee satisfaction? What about all the inefficiencies? In a thread about balancing costs, all I'm saying is that I don't think the VA is an example of how we can maximize our healthcare dollars in this country.

And regarding the the idea of older people dying at home with hospice...I'd guess (and this is just a guess; I obviously am biased) that the vast majority of people think about hospice only after a major illness (maybe putting them in an ICU) forces them to think about end-of-life issues. Thus the cost of initial ICU care is incurred even in many people that end up in hospice, I'd bet.

Will said...

Since most people who look at this blog either currently work or trained in the VA, I probably don't need to say this but anecdotally and non-anecdotally (see Steve's link), it's pretty good. Single payer that takes care of a large group of otherwise uninsured folks with a great EMR, a strong inpt/outpt linkage and a health system that has been far ahead of the curve w/ group visits, mid-level practitioners and other huge cost-saving mechanisms that, unexpectedly, have decent patient satisfaction. When any vet at any time can go to his congressman and complain and VA is the first stop on JHACO's trail, there is serious incentive to keep the ship afloat.

definitely there is administrative lethargy in my clinic and probably many others around the VA but I wonder if that's not also the case in the private sector. (i don't wonder...we all know about Jega's two-hour waits )

one of the biggest frustrations for me is people who come in w/ multiple providers - VA, private (medicare funded) w/ a bunch of specialists (medicare funded as well). nobody knows what the other is doing ... total chaos. sad part is , people think they're getting 'cadillac' care but in reality it's a set up for medical errors. not to mention huge government waste.

Meeta - this is an interesting issue. As a pcp, it seems like i see a fair number of people who at least *say* they want nothing to do w/ hospitals when it's their time. Everyone who comes to the ICU obviously is in a different category for one reason or another. It would be interesting to see how many people never get admitted to a hospital or an ICU at least before they die.

and lastly, Don, I never said anything about taxing people for unhealthful activities nor did I say basic healthcare for all would be free. But it might be less than 18% of GDP.

kath said...

The VA system has set a high standard that I would gladly use if offered. Because they are publicly funded, they feel the pressure to meet the needs of patients, not their investors. And the computer system is > 15 yrs old and is still the ambition of other healthcare systems in our country.

As for what our founding fathers intended, I would argue that health care, had it been considered, would have been an explicit right. You know, "establish justice" and "promote the general welfare"...without publicly-funded healthcare, we devolve into an ill caste system.

These recent posts are making me appreciate the US more and more. Kudos, Steve!

Cocameister said...

Yes, healthcare should be considered a basic need and provided to all, at least at a basic level.

Regarding hospice admissions, I scoured the internets (ha ha for those of you who get the joke), but could not find any data on what percentage of hospice admissions come from home versus from ICU.

I don't like to quote personal experience, because it is not evidence-based data, but I would say that half of hospice admissions come from the hospital and half come from home.

I did come across an interesting study here:

that demonstrated that shortening the length of ICU care for terminal cases would not save much money because so many costs are incurred up front.

This is not based on evidence but common sense, but doctors and families should have conversations with patients with terminal illnesses (all metastatic cancers, stage III/IV congestive heart failure, and advanced COPD- GOLD stage IIb or III), and make a plan for end-of-life care. This plan should likely NOT include aggressive in-hospital care, unless the patient has a good quality of life. Otherwise, there is no better care than hospice, which is respectful to the needs of the person, provides dignity, and avoids tubes in every orifice, and the excessive "abuse" of aggressive care (cracked ribs, pin cushion arms, recurrent nosocomial infections, bed sores, etc).

Meeta said...

So Will and Kath are convincing me that I'm probably not giving the VA a totally fair shake. I guess my perspective is that of one of the physicians dealing with the inefficiencies of the system and feeling frustration with how things are run. Here's an example: at the Philly VA, it is a MAJOR struggle to try to schedule more than one bronchoscopy in a day--I'm told that there's not a nurse or a respiratory therapist available or it takes too long to clean the room or something. At the hospital up the street (HUP), we schedule and do 4-6 everyday. One procedure at the VA takes an average of 2.5 hours of the fellow's time, including often wheeling the patient to the procedure suite myself, transporting the samples to the lab myself, etc. At HUP, it's maybe 1.5 hours. It's interesting that you make the point the VA uses mid-level practitioners effectively as a major cost-saving measure; I feel they're not maximizing the time and skills of their physicians. I could potentially do more procedures or see more patients if I weren't wheeling people around. But there's no monetary incentive to see more patients or do more procedures, so there won't be an investment in things that can make that happen (like hiring more transport staff or more administrative people). There is currently a several month back-log of patients waiting to be seen in the Philly VA pulmonary clinic.

Just to be clear, I'm not totally down on the VA. I know there are pluses, and you're convincing me that our vets are well cared for. Maybe the sentiment I really mean to express is that it can be frustrating to work there as a physician.