RyanCare/TrumpCare

[Libertarian666]

The problem is that in the USA, administration costs can't disappear, or else American households go bankrupt.

Most of these admin jobs are worked by women. If you find a way to cut that fat, those women lose their jobs and their households lose their second incomes. Then the McMansion gets foreclosed on and the 3rd vehicle (a crew cab truck, naturally) gets repossessed. Upset that Apple cart and political careers get destroyed. Politicians know this, even if only intuitively.

You cannot cut the fat anymore. People's fragile livelihoods depend on that fat.

This is Keynesianism, which has been proven beyond doubt to be completely foolish. Paying people to dig holes and fill them in cannot make the country wealthier, and this is of the same level of valuelessness.

So if you don't have a better argument against getting rid of waste, you don't have an argument at all.

[WiseOne]

One thing that I'm trying to wrap my mind around in the desire to reduce health care costs (which I'm certainly in favor of)...

Since everyone's spending is someone else's income, who exactly will end up losing income when health care costs are reduced? Will the loss in income be spread around proportionally? What I'm afraid of is that the cuts end up hitting those who are actually delivering the care. That is, there will still be multiple layers of administration, but fewer doctors, nurses, and technicians.

Well that's what's happening now, sort of. More administration, whose job it is to push doctors/nurses to do more work for the same pay. So I guess we'll find out soon enough.

[Pointedstick]

The problem is that in the USA, administration costs can't disappear, or else American households go bankrupt.

Most of these admin jobs are worked by women. If you find a way to cut that fat, those women lose their jobs and their households lose their second incomes. Then the McMansion gets foreclosed on and the 3rd vehicle (a crew cab truck, naturally) gets repossessed. Upset that Apple cart and political careers get destroyed. Politicians know this, even if only intuitively.

You cannot cut the fat anymore. People's fragile livelihoods depend on that fat.

This is Keynesianism, which has been proven beyond doubt to be completely foolish. Paying people to dig holes and fill them in cannot make the country wealthier, and this is of the same level of valuelessness.

So if you don't have a better argument against getting rid of waste, you don't have an argument at all.

You misunderstand. I am not advocating this. I'm simply pointing out that it's a constraint of the current political system. Obviously you are correct that paying people to do useless work is a net drain on society. The problem is that it is very much a positive benefit for them personally, and they vote.

[farjean2]

Yes - if government and/or physicians can't convince people that a particular preventive test or treatment is worth their hard-earned money, precious time & missed work, and the associated pain & suffering, then it shouldn't happen - period!

I'm one that's not at all convinced. I eschew all the preventative tests that doctors prescribe like the plague unless I'm worried that I really do have some kind of problem in which case I'm at their mercy for all the tests they want to prescribe. Usually they don't find anything but end up prescribing cholesterol lowering medicine and scheduling appointments for blood tests and office visits every 6 months to check the numbers (and the last one was every 3 months).

I'm very skeptical but as a physician how do you actually see the idea of "preventative medicine".

End of life care is a separate issue, because it usually happens in the setting of a condition that should be covered by a government insurance plan.

I'm now on my second parent with "end of life" care issues. She's closing in on 100 years old (and I don't think she had a whole lot of preventative medicine along the way, BTW). Both her and my dad always complained about the huge doctor bills they got which they had no control over. I didn't have the heart to suggest that the only way they were going to get rid of the problem was to go ahead and die already but I must admit I've felt that way sometimes.

[Pointedstick]

IMHO "preventative medicine" is a bunch of bunko. The real ways to prevent illness are mostly lifestyle choices: healthy diet, exercise, fresh air, contact with friends and family, not too much stress, minimize or eliminate drugs and alcohol, stay busy, etc. Not really rocket science, but so far you can't put any of that in a pill or a test.

[Maddy]

IMHO "preventative medicine" is a bunch of bunko. The real ways to prevent illness are mostly lifestyle choices: healthy diet, exercise, fresh air, contact with friends and family, not too much stress, minimize or eliminate drugs and alcohol, stay busy, etc. Not really rocket science, but so far you can't put any of that in a pill or a test.

I can see getting a CBC and chem panel every now and then, just to keep tabs on things. But with the availability of order-it-yourself labs, getting basic or even specialized lab work no longer requires a doctor visit.

[ochotona]

IMHO "preventative medicine" is a bunch of bunko. The real ways to prevent illness are mostly lifestyle choices: healthy diet, exercise, fresh air, contact with friends and family, not too much stress, minimize or eliminate drugs and alcohol, stay busy, etc. Not really rocket science, but so far you can't put any of that in a pill or a test.

I can see getting a CBC and chem panel every now and then, just to keep tabs on things. But with the availability of order-it-yourself labs, getting basic or even specialized lab work no longer requires a doctor visit.

Why not show up to LabCorp for a CBC / chem, have someone take vitals and a history, get a machine learning preliminary diagnosis, when then gets escalated if it's something unknown? I can see some costs disappearing right there.

[WiseOne]

That's if you're in a state where direct labs are legal :-)

Of course, you can do the same thing now by visiting a nurse practitioner at an acute care clinic. No need for a PMD. Also I was careful to pick my employer's high deductible, no-referral insurance option, so I can go ahead and schedule most screening tests on my own. I don't even have a PMD - mainly because there are none left in Manhattan outside of the concierge practices that ask you to pay $1000 annual memberships. They have virtually no useful function in the medical system, as there is no longer such a thing as a "general practitioner" in cities - maybe different in some rural areas though.

Perhaps it would be useful to list preventive tests & procedures that are worth doing - here's mine. The physicians on the forum are welcome to add comments:

1. Screening colonoscopy
2. Blood glucose for diabetes (not "pre-diabetes"), BUN/creatinine for renal failure, and (maybe) ALT/AST/total bilirubin for liver function
3. BP checks for malignant hypertension (>180/100)
4. Dexascan for osteoporosis (postmenopausal women or family history)
5. PPD if possibility of tuberculosis exposure

That's all I can think of. Obviously there's lots of other stuff but none supported by data that I personally think holds up to serious scrutiny, or where the benefit is so miniscule it's not worth the cost.

[Maddy]

WiseOne, your #2 surprises me: I would have assumed that blood glucose would be an important thing to monitor, given my layperson's understanding of Type 2 diabetes as the culmination of a long-term, and potentially reversible, process. Your use of quotation marks around the term "pre-diabetes" makes me curious about your thoughts on this point.

[moda0306]

IMHO "preventative medicine" is a bunch of bunko. The real ways to prevent illness are mostly lifestyle choices: healthy diet, exercise, fresh air, contact with friends and family, not too much stress, minimize or eliminate drugs and alcohol, stay busy, etc. Not really rocket science, but so far you can't put any of that in a pill or a test.

More and more I'm inclined to agree. At this point, I'm convinced the best healthcare bill would consist of a sugar and industrial seed oil tax to pay for free produce delivered to every man, woman and child in the country. Our healthcare system truly is a sick care system.

[WiseOne]

Maddie: < 10% of the US population has diabetes, whereas 40-50% are considered to have pre-diabetes. Right away, you can see that pre-diabetes is not a useful predictor of who will develop diabetes, i.e. something that common cannot be a predictor of something rare. It's simply part of the ongoing effort to define most people as "sick".

Desert: My list is about screening tests, not diagnostic tests conducted as part of treatment of an established condition. Coronary angiogram is part of the latter. It would be very inadvisable to use it as a screening test. Check out the adverse effects/complications. Also, it's not clear that a blocked artery necessarily causes symptomatic disease.

[Maddy]

Maddie: < 10% of the US population has diabetes, whereas 40-50% are considered to have pre-diabetes. Right away, you can see that pre-diabetes is not a useful predictor of who will develop diabetes, i.e. something that common cannot be a predictor of something rare.

WiseOne, do you have any feel for whether these statistics have held constant over time? The reason I'm asking is that some of the more highly regarded alternative health gurus commonly talk about recent, dramatic increases in the incidence of both full-blown diabetes and sub-clinical states involving impaired insulin response. Could it be that we're looking at a trend that has yet to play out? In other words, is it reasonable to suggest that the gap between the 10% and the 40-50% may close as the "pre-diabetics" become full-blown? Are there studies that look directly at the proportion of individuals who, once diagnosed as "pre-diabetic," go on to meet the criteria for full-blown diabetes?

It's simply part of the ongoing effort to define most people as "sick".

I had not thought about it that way, but this makes sense. My neighbor recently informed me that over half of her daughter's elementary school class has been diagnosed as autistic. Add in the ADDs and ADHDs, and I'm betting that a full three-quarters of these kids carry a psychiatric or neurological diagnosis. How crazy is that?

I also recently learned that our cash-strapped local school district gets a shitload of extra funding to deal with special-needs kids. The funding is dolled out on a per-capita basis, so there is a meaningful amount of money attached to every diagnosis.

[Mountaineer]

Desert: My list is about screening tests, not diagnostic tests conducted as part of treatment of an established condition. Coronary angiogram is part of the latter. It would be very inadvisable to use it as a screening test. Check out the adverse effects/complications. Also, it's not clear that a blocked artery necessarily causes symptomatic disease.

Makes sense. I'm trying to figure out which screening test would be appropriate to detect heart disease.

A coworker died recently of a completely unexpected heart attack. I'm wondering if there is some screening test available that could provide warning to people. There may not be, I'm thinking.

Full body invasive catherization of arteries and veins down to 0.1mm in diameter, followed by cracking the chest, observation and palpation of exposed organs by a cardiac surgeon. That should tell one all that is necessary to determine if the plumbing is clogging.

[farjean2]

Full body invasive catherization of arteries and veins down to 0.1mm in diameter, followed by cracking the chest, observation and palpation of exposed organs by a cardiac surgeon. That should tell one all that is necessary to determine if the plumbing is clogging.

I got something in the mail the other day about some kind of intensive screening for heart issues that involved things like checking for calcification in the arteries, and things like that. It was being held at a local church, took about an hour, and cost around $175 if my memory is correct. If issues were found you could take the results to your doctor for further consultation.

Call me skeptical but I figured the whole thing was probably sponsored by a group of local cardiologists.

[Mountaineer]

Color me dense, but I don't quite "get" the obsession with subsidized medicine for everyone. Why single out medicine? Why not also subsidize my gasoline purchases, home utilities, restaurant charges, travel expenses, entertainment purchases, car payment, etc. if I "feel" they are just too high - certainly that is my RIGHT to not be burdened with all those high expenses? If I choose to buy insurance for my car, my home, my life, my long term care, my cat, my dog, and the like, why should I not be responsible for deciding (or not) to buy drug and health insurance - and be willing to endure the consequences, good or bad, of my choice? Is this just one more example of self-worship getting us into messes we could well avoid if we focused a bit more on the good of others instead of trying to maximize self-benefit no matter what? Damn the torpedos and full speed ahead!

[WiseOne]

Depends on what caused your co-worker's heart attack. If it was the usual clogged-artery kind, then yes there is indeed a screening test, as follows:

Do you get chest pain (including discomfort/squeezing feeling/unusual shortness of breath) on exertion? Like, running up a flight of stairs or fast walking?

If the answer is "yes", then go see a cardiologist as soon as possible.

Maddy, about your question: Yes there have been studies. I'm too lazy right now to look them up, but the proportion of patients with pre-diabetes who go on to develop diabetes is as small as you might expect. In order for pre-diabetes to be useful, the prevalence of diabetes would have to increase by a factor of 4 or 5 AND you'd have to show that nearly all arose from the pre-diabetic half of the population (which no one has done). No matter how dire the predictions get, I just can't bring myself to swallow that Kool-aid.

It is just SO much fun to bust up evidence-based medicine with simple logic. Here's one of my favorite examples: there are a lot of physicians who swear by an fMRI procedure to determine which hemisphere of the brain is dominant for language. fMRI is the diagnostic procedure that I most enjoy skewering as some of you already might know. Anyway, there's several studies "proving" the predictive value of fMRI for language lateralization, usually citing accuracy in the 80-90% range. However, I can beat them all with the following procedure: saying the word "Left". That's because >95% of the population is left language dominant. Too bad I can't bill for this procedure though.

[Tyler]

It is just SO much fun to bust up evidence-based medicine with simple logic. Here's one of my favorite examples: there are a lot of physicians who swear by an fMRI procedure to determine which hemisphere of the brain is dominant for language. fMRI is the diagnostic procedure that I most enjoy skewering as some of you already might know. Anyway, there's several studies "proving" the predictive value of fMRI for language lateralization, usually citing accuracy in the 80-90% range. However, I can beat them all with the following procedure: saying the word "Left". That's because >95% of the population is left language dominant. Too bad I can't bill for this procedure though.

Wow. A's in science, D's in statistics.

[Pointedstick]

Color me dense, but I don't quite "get" the obsession with subsidized medicine for everyone. Why single out medicine? Why not also subsidize my gasoline purchases, home utilities, restaurant charges, travel expenses, entertainment purchases, car payment, etc. if I "feel" they are just too high - certainly that is my RIGHT to not be burdened with all those high expenses? If I choose to buy insurance for my car, my home, my life, my long term care, my cat, my dog, and the like, why should I not be responsible for deciding (or not) to buy drug and health insurance - and be willing to endure the consequences, good or bad, of my choice? Is this just one more example of self-worship getting us into messes we could well avoid if we focused a bit more on the good of others instead of trying to maximize self-benefit no matter what? Damn the torpedos and full speed ahead!

Color ME dense, but I'm not seeing anyone here (or anywhere) obsessing about subsidized medicine for everyone.

In any case, yes, most people see health care as different than gasoline purchases, home entertainment, etc. I am saddened by the fact that you think they are the same. It is quite at odds with the sentiment expressed in your current signature.

I know, for example, that my in-laws see health care as very different. Yes, they have benefited from subsidies for the health care of their 41 year-old (though cognitively 5 y/o) permanently wheelchair-bound daughter, who has undergone multiple brain surgeries in her lifetime. Without subsidies, I doubt she would still be alive, because they could not afford the medical bills. Also, from what I have seen, they have sacrificed many things to ensure her well-being. It boggles my mind that you would see this as self-worship.

Health care is so contentious because it is--along with abortion, gun control, the death penalty, and war--a life or death issue. By making any policy or choice at all, the government is drawing moral distinctions regarding who deserves life and who doesn't. Human individuality implies and yields a diversity of opinions, making the issue irresolvable at the distributional policy level; any level of government distribution makes some group feel like a great injustice is being committed.

The only solution is to make it much less about life or death, which generally requires a marketplace of some kind--manipulated or otherwise. Food and water are likewise required for life, but due to markets, hidden subsidies, and municipal monopolies, they are so cheap that we barely see them as life-and-death issues because nobody starves or dies of thirst anymore in the USA. The solution is the same for health care: somehow get the price down so that more and more people are able to afford it on their own, without having to trigger people's moral feelings regarding to whom government should or shouldn't directly provide goods and services.

Any plan that doesn't target cash affordability is a joke, and will just be un-done or worsened by the other party when they regain control.

[Mountaineer]

Color me dense, but I don't quite "get" the obsession with subsidized medicine for everyone. Why single out medicine? Why not also subsidize my gasoline purchases, home utilities, restaurant charges, travel expenses, entertainment purchases, car payment, etc. if I "feel" they are just too high - certainly that is my RIGHT to not be burdened with all those high expenses? If I choose to buy insurance for my car, my home, my life, my long term care, my cat, my dog, and the like, why should I not be responsible for deciding (or not) to buy drug and health insurance - and be willing to endure the consequences, good or bad, of my choice? Is this just one more example of self-worship getting us into messes we could well avoid if we focused a bit more on the good of others instead of trying to maximize self-benefit no matter what? Damn the torpedos and full speed ahead!

Color ME dense, but I'm not seeing anyone here (or anywhere) obsessing about subsidized medicine for everyone.

In any case, yes, most people see health care as different than gasoline purchases, home entertainment, etc. I am saddened by the fact that you think they are the same. It is quite at odds with the sentiment expressed in your current signature.

I know, for example, that my in-laws see health care as very different. Yes, they have benefited from subsidies for the health care of their 41 year-old (though cognitively 5 y/o) permanently wheelchair-bound daughter, who has undergone multiple brain surgeries in her lifetime. Without subsidies, I doubt she would still be alive, because they could not afford the medical bills. Also, from what I have seen, they have sacrificed many things to ensure her well-being. It boggles my mind that you would see this as self-worship.

Allow me to clarify what I meant (of course, you may still think I'm a heartless bastard, but so be it). I'm appalled at those who want handouts and freebies that someone else has to pay for without choice in the matter. I'm all for people helping one another, just not at gunpoint or the government equivalent. What I'm saying is that I choose or not to purchase all types of insurance. Why make medical insurance different? I think it is totally reasonable to tell people that perhaps they don't need that large flat screen TV, cell phone, or cigarettes quite as much as they might need health insurance so they should choose wisely how to spend their hard earned welfare check. I equate those who pick the flat screen TV, cell phones, and a Starbucks twice a day over health insurance to be heavily into self-worship at the expense of others who have to foot the bill. I can almost hear them saying "to hell with everyone else, it's my right to enjoy those frivolous purchases and my right to expect others to pay for my health care". However, I realize you can't cure stupid. I would prefer a system where one self-financed routine medical stuff, i.e. get the insurance companies out of the equation for minor stuff (if they wanted to go to the ER for a cold, they are certainly welcome to do so as long as it is on their own dollar), and one purchased only catestrophic "major medical" insurance. I can't help but think if there were incentives to reduce health care use at the individual level (e.g. that snotty cold stuff is not ER worthy) costs would decrease substantially. I'm definitely not one for social engineering by the government, everything that is touched by big bro turns to shit, in my opinion based on observations over many decades. I would further say, if you are not a citizen, .... sorry, no free medical; cash on the barrel head if you need services. Is you mind still boggled?

[WiseOne]

Mountaineer, were you thinking that *routine* costs shouldn't be subsidized? Routine health care should be treated like the electric or telephone bill, or grocery bill: as necessities of life that each person should bear responsibility for paying. It's the high level, catastrophic costs that needs to be a shared expense. I'd love to see those two entities treated separately.

Interestingly, the main argument for lumping together routine & catastrophic health costs is to force as many people as possible to participate in preventive medicine, and keep coming back for routine followups with no fixed agenda in mind. Those things are a hard sell for very good reasons!

[Mountaineer]

Mountaineer, were you thinking that *routine* costs shouldn't be subsidized? Routine health care should be treated like the electric or telephone bill, or grocery bill: as necessities of life that each person should bear responsibility for paying. It's the high level, catastrophic costs that needs to be a shared expense. I'd love to see those two entities treated separately.

Interestingly, the main argument for lumping together routine & catastrophic health costs is to force as many people as possible to participate in preventive medicine, and keep coming back for routine followups with no fixed agenda in mind. Those things are a hard sell for very good reasons!

Yes to your first paragraph. No lumping together. No force, just free choice. I'm an advocate of personal responsibility in 99+% of cases. I do recognize there are outliers that may need to be considered separately - however, not too many people look at it that way. It smacks of political rhetoric that many get on their high horse for political gain to advocate making the <1% representative of the >99%. BS is all I can say to that. Sorry for venting, I'm tired and just finished cleaning up a mess of ice/snow/sleet/huge pile left by the street plower in front of my driveway. I'm not in the mood for Monday morning quarterbacks on the poor, poor pitiful who refuse to take accountability for their actions.

[farjean2]

It is just SO much fun to bust up evidence-based medicine with simple logic. Here's one of my favorite examples: there are a lot of physicians who swear by an fMRI procedure to determine which hemisphere of the brain is dominant for language. fMRI is the diagnostic procedure that I most enjoy skewering as some of you already might know. Anyway, there's several studies "proving" the predictive value of fMRI for language lateralization, usually citing accuracy in the 80-90% range. However, I can beat them all with the following procedure: saying the word "Left". That's because >95% of the population is left language dominant. Too bad I can't bill for this procedure though.

It's also too bad you can't get your money back when you diagnose your own condition which I have actually done on several occasions. The last was when I was having chronic stomach pain and after visiting a primary care doctor, having CT Scans, MRI's, blood tests up the Wazoo, and then I was sent to a Gastroenterologist and getting whatever that thing is where they put you to sleep and stick something down your throat. They found nothing wrong. So I had to resort to Google to discover something called "referred pain" in which the pain from arthritis in your back can be referred into your stomach. I suggested that as a possibility so they decided to give it a try with Lidocaine patches on my back which I needed a prescription for, BTW. Problem solved. Except for my back, of course. They only gave me a two months supply. I would need to see another kind of doctor if I wanted more. So I said no thanks, GFY, I'll learn to live with it.

That's just one of about 4 stories of my own that I can tell. Another was diagnosing rectal bleeding and a swollen lump under my jaw which really had me worried. I was referred to another gastroenterologist for a colonoscopy and an ENT doctor who prescribed sucking on lemon drops. Searching google on those symptoms I discovered that a cause may be an abscessed tooth. My primary care doctor didn't like me searching on Google and assured me that would be a very rare thing and was probably not the cause but I decided to go the dentist to have it checked out any way. It took her less than a minute to show me the pus-filled abscess in my mouth with a mirror and when I had a root canal the problem was solved.

And then there was my first wife's lung cancer from which she died and how long it took for anyone to order the tests even though the symptoms were so obvious they could smack you in the face with the help of google. That's actually a long story that's almost unbelievable. It took a whiff of chlorine gas in her face followed by visits to different emergency rooms on two different nights, one of which sent her home with two collapsed lungs, near death before someone finally did an xray and said, "gee look at that spot, maybe it isn't just allergies after all, but maybe a woman smoking for 50 years since the age of 13 might have lung cancer" and we should do some tests.

Well that's the end of my rant. I actually do have great respect for people who devote themselves to the practice of medicine but I tend to stay as far away from them as I can get.

[Tyler]

It's also too bad you can't get your money back when you diagnose your own condition which I have actually done on several occasions. The last was when I was having chronic stomach pain and after visiting a primary care doctor, having CT Scans, MRI's, blood tests up the Wazoo, and then I was sent to a Gastroenterologist and getting whatever that thing is where they put you to sleep and stick something down your throat. They found nothing wrong. So I had to resort to Google to discover something called "referred pain" in which the pain from arthritis in your back can be referred into your stomach. I suggested that as a possibility so they decided to give it a try with Lidocaine patches on my back which I needed a prescription for, BTW. Problem solved. Except for my back, of course. They only gave me a two months supply. I would need to see another kind of doctor if I wanted more. So I said no thanks, GFY, I'll learn to live with it.

I had a very similar experience. Last year I suffered from extreme acid reflux, to the point where it often left me gasping for breath and I thought I was having a heart attack. Taking antacids would help, but only temporarily. As a result, I barely ate and had a very tough time sleeping.

My primary doctor looked me over, confirmed nothing was seriously wrong, and prescribed me a PPI. I took that for a month with no improvement. I went back, and she basically said I should switch brands until I find one that helps and take them for life (just like she did). She was maybe 30. That was clearly ignoring the root cause, so I stopped the PPIs and saw a gastro.

He heard my story and signed me up for a series of very uncomfortable and expensive tests. About a month later, the results came back and they could find nothing wrong. I asked what he could do next, and he said I should set up another appointment and we could discuss more tests. Maybe surgery was an option. Knowing how useless the last round was, I decided to try my own thing first.

I knew from my own research while waiting for test results that acid reflux is sometimes caused by bacterial problems in the gut. I also found a good book on controlling acid reflux with diet. So I took an OTC probiotic and watched what I ate, and was basically cured within a few weeks.

In all, it took many months and many thousands of dollars funneled to the best doctors I had access to in order to eventually ignore their advice of lifetime medication and surgery and discover that very simple personal steps could fix my problem. Why they didn't simply recommend that from day one is beyond me.

[farjean2]

In all, it took many months and many thousands of dollars funneled to the best doctors I had access to in order to eventually ignore their advice of lifetime medication and surgery and discover that very simple personal steps could fix my problem. Why they didn't simply recommend that from day one is beyond me.

I suspect there are many stories like this in the Naked City. I have a lot more that I could share.

I find that with medicine it's like the old saying, "it's not what you don't know that bothers me, it's what you know that ain't so". The fact that a doctor will prescribe a lifetime regimen of medicine based on what is actually just the best guess he/she can make should be very concerning to any rational person.

[Tyler]

Yep -- that's good advice!

FWIW, I figured out for myself that the prescribed PPIs (which prevent stomach acid creation) were poor suggestions for my own problem when 1) my symptoms only got worse, and 2) drinking apple cider vinegar right before a meal made me feel better almost immediately. So Gumby was right that excess acid really wasn't the problem. For me, it was more about figuring out my food triggers, maintaining acid levels at a healthy level, and restoring a healthy gut microbiome. Basically, I chose good health instead of perpetual treatment. Pretty crazy, I know.