Let's care about folks who can pay

[mprotsenko]

I had a discussion recently about different types of healthcare system. Heard a very honest argument along those lines (not verbatim so I may misinterpret it but I do hope I summarize in the right way):

- Yep, the poor are screwed, but what about those who can pay? Shouldn't we care about them too? Does it make sense to prioritize that care? If we start caring about poor, others will suffer and that's bad.



Well, a couple of months ago I took part in a fundraiser. People were collecting money for a software developer (a friend of a friend of mine). Why? After all, if you work in Facebook, you get the best health insurance money can buy. If you work in Facebook - you are not poor, you belong to top 1-5% incomewise. He must have done something really wrong to screw things up so bad he needs to beg. It must be a poor decision. It will never happen to us. Right?


Well, wrong. Turns out - if you have a cancer, if you're too sick to work, you lose your job. After a certain period of time, your disability insurance stops paying - since you're "healthy" enough to be doing something (even if this something is paying 10x-20x less than your last job). You still need to make your mortgage payments (your kids need to go to a good school, right?), but you also need to travel out-of-state to a clinic that specialized in your type of cancer (and pay out-of-network copays and deductibles). And you need to rent another place to stay during your treatment. Ah, and in addition to that you need to make insurance premium payments (fortunately, due to CORBA you get to keep your insurance - but you still need to cough up several thousands dollars a month).


So if you think that a single payer system only benefits poor people - think again. When you are going to become sick (not if, when - it is a matter of time for all of us) - it is going to become about you, not about poor people. (Unless you have a few hundred thousand dollars stashed away.)


The only lucky break here is that you can be old enough to qualify for an existing single payer health coverage (Medicare, yep).

Comments

[malyj_gorgan]

I know all that but I don't see how any of that would change my point: a person that cannot afford expensive insurance because that person wants to (an is able to) maintain residence in the location that for most Americans of off-limits in the first place is not a good argument to use if you like to persuade others why universal healthcare is necessary for them. Because from the point of view of those others the subject of the story could easily afford that expensive insurance if he lived where the rest of us lives.
Your other conceptual examples that smth like that could happen to a lesser income person are better. Less personal, because they are hypothetical, but still.more relatable.

(Will use this comment to bunch up a few other points in our conversation, happen to have a few min now while the build is building :)

By "fancy" I did not mean "unnecessary", necessity is orthogonal. I meant advanced+expensive, so independently of necessity, not available to all.

Can't comment on your example from LA.. But can hypothesize based on two cases that I witnessed very closely. Which would possibly explain why some people might think that way, So, to patient cases, both in 2004, before Obamacare. Both involved a person getting into a terrible accident and ending with a person in ICU. With multiple surgeries, constant fancy (in a sense expensive and advanced) diagnostics. etc. Both survived, one after three weeks in ICU and several cutting-edge image-guided interventions, never got off the wheelchair after that, but got 10 more years of life. The other spent two months (!) in a coma on advanced life-support, never regained all of his cognitive skills, but lives on. The first person had to sell his business and his (fancy and expensive) house to pay for it, the second had to give up his mortgage and declare bankruptcy. Neither would like to lose that... but on the other hand, the level of care (by total cost etc) each of them got was so high that it is likely to not be available for just anybody. In the second case, I'm almost confident he wouldn't survive any triage approach: they wanted to turn him off the system quite a few times, his mom had to fight hard for his life. So the reason people might want to stick to current healthcare is this hope that when they really need it, they might get this kind of help that is only available here, but not in those socialized medicine places. To hell with it if they have to go bankrupt after that, life's more important. Now, neither you nor I know for sure if this kind of would have been available under a different system. But as long as there are examples of US healthcare, at least in some instances, being ahead of the rest of the world, such scenario remains realistic. As the fear of hitting such scenario remains a legitimate fear.
So my point is the following: first, I wouldn't be too condescending to the people who are trying to keep the current system, as they might be hedging against different risks that you or I. Second, until proponents of universal health-case genuinely address this issue, they are not likely to persuade the other side. Know thy opponent :)

[mprotsenko]

good argument to use if you like to persuade others why universal healthcare is necessary for them

This discussion is not an attempt to persuade anybody. I believe the time for persuasion is long gone. The data is out there, the personal examples are out there - but they cannot compete with propaganda because propaganda doesn't deal in logic and metrics.



And I am grateful to you for providing an illustration, for showing how "some of the people may think". I bet you have similar stories that took place in single-payer healthcare systems (or can easily look them up that). And you've seen similar or better outcomes minus the financial ruin.

(I actually have witnessed a similar story - my friend's mother was hit by a car in Canada and went through similar ordeals - several weeks in ICU, image-guided surgeries, prolonged rehabilitation - but there were no bankruptcy or financial ruin. On the contrary - her rehabilitation went much better partially because she didn't have to deal with financial issues while recovering. Yep, not having to choose between getting PT or selling your house actually helps.)

But you've shown us pretty well that no statistics or counter-examples will change the way "some people think" because for them is not about statistics or anecdotes. They will always find their example they will cling to, ignoring counter-examples, statistics and other arguments. Because they can always say:
- your examples and your statistics prove nothing
- we never can be 100% certain
- there is a risk that for 1 person in a hundred million the changes will you propose will make things worse
- there is no truth,

...and there is nothing you can do with this line of defense.

You cannot convince people that God doesn't exist (or does exist) using logical arguments. It is the same here.




Now, neither you nor I know for sure if this kind of [help] would have been available under a different system.

And that is not true. I do know that that kind of help is available under a different system. I have personal examples, if you haven't them - you can look them up really easy.

You can see affluent US doctors/politicians going to Canada to get their surgeries done.

You can look up statistics.

And finally, nobody can stop you from getting the best available private care even under single-payer system (paying out-of-pocket or using a private insurance).


Second, until proponents of universal health-case genuinely address this issue, they are not likely to persuade the other side. Know thy opponent

It has been addressed over and over again (I just did, for example) - but the opponents keep choosing to ignore that. So it does helpful to know the opponents, but I don't think we have a lot of opponents that are acting in good faith.



So this post of mine is not about convincing right-wingers. Hence, it's productivity shouldn't be judged by that metric ;)

[malyj_gorgan]

Sorry, was offline for trip with kids

> ... This discussion is not an attempt to persuade anybody. ...
Well, then I misrepresented your original point, where you talked about adding efficiency as yet another obvious argument to the healthcare debate. Mea culpa, after that I treated your points as persuasion arguments (what's the alternatives, self-persuasion?) So by now my point is not only to show how "some people may think" but to comment on your arguments. I'd say this: had I been undecided on the healthcare approach I would be persuaded by them: solely because while some of them are OK, the others are counterproductive. Lemme know if you care to hear why ;-)

Still, just to wrap up a few earlier points where I thought you left hanging questions to me:

> personal choice Canada vs US on healthcare.
Yes, when I was making my choice I did indent to have a job in either country (without a job I'd be gone out of either, so simple choice here), but no, I did not plan to be healthy. As a matter of fact, I was making the choice at the time when my wife was going through a complex treatment with multiple diagnostic procedures, therapies, and a surgery. I was working at a major university hospital in the US and considering either a major research hospital in Canada or a National Lab in the US. The latter won, both in specs and in private polling between a bunch of friends and colleagues who switched countries one or another direction. Both in near-medical research settings and in private business like coding. So while I agree that when you have no job or a bad one, Canadian system would be better, but until then not really. BTW, funny, I formed that opinion back then comparing specific health plans and talking to live people Just now, writing this, I looked up the stats, and found quite a lot of supporting statistics. Just read a WaPo article from 2016 on that. The article is debunking Trumps lie about Canadians coming in droves for US treatments but the data they quote aligns 100% with what I have been hearing back 15 years ago: you have to wait longer, sometime ridiculously long, for appointments deemed non-critical by someone other than you.

> ... high consumer spending and you shrugging it off as victim blaming...
You gave a few examples about how a poor person might need a truck to haul, how everything's so far you can't get by without a car or how they get cheap used trucks. But despite all of those things being possible, they don't make up the statistic, and this one one argument that I made about stats: not to state that anyone can afford the medical bills if s/he lives more frugally (wrong) but that if people lived more on-par with those other single-payer countries, that would free up much $, which could sway the terrible healthcare involvement statistics you started up with. It's not about sheer amount of dollars, the purchasing power does differ, its about bulk of consumed goods. Don't want to re-look-up links (I check on my phone some days ago) but if you care, just check out "list of countries by *" categories on wiki or elsewhere. Americans do have one of the biggest ecological footprints, consume consume most food ( by calorie and by meat content), have the most square feet per person, use up as much energy as the top spenders, same for textiles, cars, movies seen in theaters, or home electronics. Far ahead of anyone else in terms of guns and ammo (those things cost a lot, btw). Most of those statistics take everyone to contribute to, not just the top 1% or the top 50%. Say, the aforementioned trucks: they are not the cheapest vehicles possible, especially to use. Yet more than 50% or personal vehicles in the US are trucks. And I haven't checked how much of the remaining fourty-smth % cars are SUVs, but sure that of the new ones it's more than half. Are 3/4 of Americans in the business of regular hauling? Or are just way too many people spending way more than they should on their cars following fashion and clever marketing campaigns. So, if there could be a way to blame the society, not single people, I would be totally blaming the US society on wasting money on personal stuff instead of better things.

Myself, I think that the problem with healthcare in the US is not that it's bad, for many it works out fine, that's why it's so hard to change the thing. The problem is specifically (the good argument among the ones you used, but didn't follow through) that the most basic guaranteed care (Medicare) here kicks in only after you've lost more that you have to lose. And then the obvious conclusions etc... But effectiveness and fairness are not always supporting the argument in the obvious way, by far.

Anyway, time to go again

[mprotsenko]

Can you please elaborate what numbers did you crunch to decide that Canadian healthcare system is a worse choice for you? (For me it is obvious - I don't need life-saving surgeries or complex treatments or everyday treatments yet I would have to pay more in taxes.)

Longer waiting times for non-critical care don't make people happy - but are there any numbers to show that they worsen the medical outcomes? I have a very fresh example of the contrary - I just got my knee scanned. The waiting time was about 7-10 days. They found some inflammation and a minor ligament tear - which I lived with for ~20 years. If the waiting time would be about a year - there would be literally no change in the outcome (and they could have spent time and money on diagnosing/treating people who actually needed care, not on some grumpy guy with a moderately injured knee).


Most of those statistics take everyone to contribute to, not just the top 1% or the top 50%.

Can you please prove it? You made only one verifiable claim - about 50% of personal vehicles being trucks.

Let's look it up.

https://www.eia.gov/todayinenergy/detail.php?id=36674

As far as I see, trucks make up about 16% of total cars sales, that's not even close to 50%. And we see that cars and crossovers - which are much more fuel-efficient that SUVs - make up the majority of sales.

So I don't know where you got your data from - but it is not confirmed neither by other data nor by personal observation (really? more than 50%? try counting cars next time you stuck in traffic and you will see that "more than 50% of vehicles are trucks" - well, how do I put that mildly? - is not even remotely true). The only way to get to 50% is to lump up trucks and SUVs into one category and then count the market share by dollars, not by cars sold or owned.

But that would be a dirty trick and I cannot imagine you stooping that low. It seems like someone fed you the false data.

So pardon my lack of trust, but I have no reason to accept the rest of your statements on that matter ("poor people make poor spending choices instead of spending money on healthcare/education") without any proof. At least not until you bring the data. (And by data I mean full distribution chart, not just the average number - since top 1% can skew up average numbers pretty bad).


Myself, I think that the problem with healthcare in the US is not that it's bad, for many it works out fine, that's why it's so hard to change the thing.

The same argument could have been made by Marie Antoinette. Indeed, the system worked really well not just for her but for a lot of other people as well. Until it didn't. But you right - it was hard to change it even then.

[mprotsenko]

So while I agree that when you have no job or a bad one, Canadian system would be better, but until then not really.

So unless you get seriously sick (and thus cannot work), Canadian system works better.

If you get mildly sick or don't get sick at all - the US system works better. (though it is 2-4x more expensive)

And many people have that illusion that they don't get sick (or hope that when they will get sick, they will be old enough to be enrolled in the existing single-payer system).

It seems that we have no disagreement here.




Indeed, on a personal level, there is no sense in paying healthcare-related taxes or buying insurance until you get sick.

So those suckers who do buy insurance while healthy - will have to pay more (because the patients'/payers' pool is less healthy as a whole and thus have more expenses which insurance will have to cover). So some of them will not be able to afford it, and will drop out of the pool, driving the costs even higher for the rest. And so it goes...



Basics of game theory - in non-zero sum game you can make a move that provides a short-term gain to you, but you pay for it with a long-term loss to both you and your fellow player.

[chuka_lis]

по показателям здоровья и лечения Канада обгоняет США. по отдельным категориям заболеваемости- Канада лучше США.
единственное по чему США впереди всех- это по ценам на медуслуги и затратам государста на медицину. затраты огромные, потому что цены огромные, и потому что много запущенных больных. которым помогает государство (пожилые, бедные, или инвалиды, или все вместе).