But if Americans had that free medical credit card, they'd probably all rush out to get Botox, boob jobs, Viagra prescriptions and birth control pills! Yay!

There is obvious, empirical proof that this argument is wrong -- so blatantly, blindingly obvious, that I don't know how people who make it avoid getting committed.

Get is straight: every single developed country in the world (and some less developed) have universal health care, almost all of them with minimal or no copays and deductibles. Every single one of them enjoys better health status than the United States. And every single one of them pays far less for health care than do Americans. The precise opposite of what this argument predicts.

Furthermore, the country that does have high co-pays and deductibles -- Switzerland -- also has the second highest health care costs in the world.

Q E fucking D

yeah, yeah, but what if it's some of that yummy cherry flavored cough syrup, hunh? what about that one?

we should count our blessings, at least this "luxury goods" spiel seems to have replaced the "if car insurance were like health insurance it would cover everything down to tune up" nonsense....

Ezra once again shows how clueless he is about American Healthcare and how it works. What would it take for you to put down the progressive reform propoganda for 2 seconds and actually read some real research on our system, not the imaginery one in your head but the one that 80% of American's with Insurance want you and like minded idiots to leave alone?

80% of insured's have minimial claims any given year. Being you have no comprehension of math that is a vast majority. The majority of the inflation the last 10 years has not been in high cost claims, it is in utilization. Transplants haven't doubled in cost nor has the per diem daily rate for ICU care. The average spent per person on drugs has sky rocketed. The numebr of office vists, x rays, and lab work has substantially increased. The reimbursement per visit, test, panel has gone up slightly but not near the total cost of HC inflation.

Hubbard's analogy is 100% accurate and supported by countless studies on utilizationa nd reimbursements. Your blog post on the other hand are the rabelings of a idiot that clearly doesn't have any understanding of our system or what drives cost.

Even McCain is learning how to use the internet; isn't it past time someone taught you Mr. Klien? American's with insurance fill far mor Rx then they use, see the doctor more, and have more test done. Utilization Utilization Utilization

It isn't about whether they are a "good time" but whether they are a good value. Of course folks don't want to do an MRI for fun. The issue is that the MRI costs $2000 (but they don't pay), but the MRI itself sometimes only has a negligible incremental benefit. If you're not paying a dollar of the MRI, then why not get it to ensure you don't have that extremely unusual diagnosis that the doctored mentioned is a rare but possible finding?

One thing is clear. Someone has to make a decision on when to restrict access to medical care. You seem to be arguing that patients aren't capable of making that decision in the context of their specific situation, and instead would prefer a governing body to do it at a population-level with no information on individual circumstances. I think that both incorporating the individual-level data and providing people choice should push us to do the hard work and figure out how we can have legitimate cost-sharing rather than government fiat.

http://drugtopics.modernmedicine.com/drugtopics/article/articleDetail.jsp?id=411533&ref=25

"Annual prescription use per person. Use of prescriptions on a per-capita basis has also grown exponentially in the past 75 years. In 1929, the average U.S. resident received 1.85 Rxs per year. During 2006, the annual per-capita prescription use rate is projected to be 13.7."

For you progressive simpletons there is even a chart that looks like your liberal global warming claims. Since 1990, when HMOs and Rx Co-pays became common, Rx utilization and cost has sky rocketed. Hubbards claim is completly validated by this chart any those on office visits and lab test. Your rebuttal was as ignorant and incorrect as your claim that HSAs don't cover women's preventaive care.

Your knowledge of healthcare is a joke. It took me 2 minutes to find this chart on the internet showing you were completly wrong. 2 minutes, do you really not have that much time to reserach your post? yahoo per capita prescriptions and see, do the same for other minor HC expenditures and see what comes up.

Making those things inaffordable is not an acceptable solution.

PS. This is such an unimaginative, binary strawman. You can find a away to do cost-sharing and make affordable at the same time. Think universal vouchers with a CDH/HSA component to cover co-pays. There are ways to solve this. But it requires Democrats to stop trashing CDH because Republicans have co-opted the concept, and Republicans to stop trashing universal access because its a Democratic core principle. Real people in this country want universal access and the ability to make better decisions about their health care, choice of physicians and hospitals. We just need the partisans in DC to start worrying about health care and stop focusing on winning political games.

http://www.grubb-ellis.com/research/Whitepapers/healthcareupdate.pdf

• The average number of visits per capita to physicians’ offices for all age groups increased from 2.7 in 1995
to 3.3 in 2005, suggesting a rising propensity among consumers to access healthcare services.

"Hubbard characterizes the purchase of medical tests as "our decisions," but that's inaccurate. They are our doctor's decisions. "

It's not always even our doctor's decision, as his decision is pressured by legal and insurance factors. If a doctor knows that the insurance company will pay for a test, he will err on the side of ordering the test when it's of questionable value. This covers his ass in the event of a malpractice suit. It also might give him some information that might change his diagnosis. So it's worth it to over-test, given the way our system works. Unless, of course the insurance company decides to not pay. Then it sucks for the patient, and sucks less so for the doctor (most patients eventually pay up).

The main problem with treating health care like a normal consumer good is that patients are really bad consumers. They lack even a basic knowledge of medicine and are easily swayed by medical fads and advertising. And they usually have little idea of what their symptoms even are. If you want to know how a patient is doing, the patient is probably the last person you want to ask. And that's if they're lucid. If not, then you really don't want to know what they have to say. It's probably best to keep the decisions on testing and treatment as far away from the patient as possible. And certainly as close to the doctor as possible.

"One thing is clear. Someone has to make a decision on when to restrict access to medical care."

Yes indeedy. And should it be a) Jane Patient, with a degree in, oh, mechanical engineering, or b) Jane's doctor, the one with the medical degree?

I'm all about patient rights and patient self education, and the right to choose, whenever possible, what course of treatment to pursue.

But I am not a doctor; I do not want a menu with a price list where I am supposed to use my Googling skils and that PBS special on diabetes I just saw to make life-altering medical decisions. **Because I'm not qualified to do that.** I want the doctor to tell me what he or she thinks the best course is, maybe get a second opinion, and then follow that course.

And as for who decides what courses are available, again, I want that to be doctors and scientists and researchers, working in a transparent system using good practice and good studies.

CDHPs, frankly, are the worse of all worlds. My health is not an investment vehicle.

Direct to Consumer advertising is probably the culprit for the increase in prescriptions. For example, when Viagra was first introduced it was primarily for men who lost erectile function due to prostate cancer - not a really big group because these tend to be men over 60. However, when "erectile disfunction, now ED" is reclassed to any man who ever has a problem getting an erection or can't maintain an erection for hours, the pool of users is increased to include basically every guy over age 18. And physicians willingly write scripts for the drug, as long as you aren't in the middle of a heart attack. More money for big pharma!

"Direct to Consumer advertising is probably the culprit for the increase in prescriptions."

Yup. Advertising is great for sales, but not so much for patients. But I just want to bring up some really random trivia. The album cover for Pink Floyd's "A Nice Pair" release was banned in England. Not because of the naked female breasts on the cover (yes, it's a nice pair), but because of the picture of W.R. Phang's dental office. It was considered to be illegal medical advertising.

A quick comment from somebody who has lived in Denmark (most of my life until 10 years ago) and in the US (the last 10 years).

Just based on my impressions from friends and co-workers here in the US: There seems to be a tendency to feel that you since you pay for your health insurance here, and since health insurance is in short supply (you may lose it at any point, if you lose your job), you should try to get everything out of it while you can. This translates into "I want every single test and scan that I can possibly wrangle from my HMO", "I want a second opinion about everything", "I want every elective surgery I can get", etc.

I don't see the same attitudes in Denmark (no threat that necessary treatment will not be available), but it does make me think that it would actually be difficult to introduce a single-payer system in the US. If people continue to think along those same lines (I need to get everything out of the system that I possibly can), then it will indeed be very expensive and prove the sceptics right.

And by the way: if given the choice between health care in Denmark and the US, there is no contest. I would choose Denmark. Quality is high, and there is no paperwork. The paperwork is what drives me nuts here...

I'm not sure why conservatives favor this juvenile, bullying, insulting, and self-adoring style. Smart people are capable of civil disagreement, but the right in this country is full of a kind of mindless adolescent rage. They seem to think it makes them more appealing or convincing somehow, but it actually proves that they are fools.

Anyway, as I said, in the other wealthy countries, everybody has good, comprehensive insurance, with very low copays, and yet they spend, typically, half as much on health care as we do, and get much better results. So health insurance cannot possibly be the explanation for rising costs. Even a conservative bullying fool has to concede that point.

It is true that utilization of services and drugs has steadily increased in the U.S., and that this is the principal explanation for rising health care costs. But it's not because people have health insurance. In fact, as this has been happening, the percentage of Americans without any health insurance has been increasing, while the copays and deductibles of those who do have insurance has generally been increasing as well.

The main explanation is new technology -- when it becomes available, we have to have it. Marketing of drugs doesn't help, certainly. Insurers mostly sell to employers, not individuals, and they do compete on price, but employers have also found that people their employers don't like it when insurers start denying services -- remember the era of managed care?

In Europe and Canada, there is either a single payer, or where there are competing insurers, they are regulated in such a way that they act more or less like a single payer. There are guidelines for what drugs and what services are appropriate, and doctors have to follow them. The single payer, or single payer-like buyers, can negotiate for better prices from drug companies and other suppliers. If people want gold plated services that the basic package won't cover, they have to pay or buy extra insurance out of pocket.

So it's rationing, in a sense, but in the sense of providing services on a rational basis -- what is worth the cost. It isn't consumer co-pays and deductibles that makes that happen, it's smart management. Consumers are unable to make those decisions because they don't have the expertise, so high copays mean people will forego preventive services that will keep them healthy and save money in the long run, while they still may pay for services that just aren't worth it when they feel an acute need.

Real health policy experts understand this. Self righteous, pompous, immature fools do not.

Hubbard characterizes the purchase of medical tests as "our decisions," but that's inaccurate. They are our doctor's decisions.

On the flipside, there are medical decisions that aren't doctors' decisions, in the sense that they're 'ask your doctor if Ass Effects is right for you' decisions.

The issue is that the MRI costs $2000 (but they don't pay), but the MRI itself sometimes only has a negligible incremental benefit.

No, wisewon: the issue is that MRI machines don't pay for themselves.

That's not quite a patient decision: it's a combination of the cultural promotion of the Magic Imaging Tube as a panacea, the liability environment that promotes the Magic Imaging Tube as an alibi for malpractice suits, and the financial environment in which the Magic Imaging Tube is a moneyspinner once you cover its costs.

Changing the system doesn't change the culture all by itself, but it goes a long, long way.

Your knowledge of healthcare is a joke.

Your abject shilling is no joke.

the percentage of Americans without any health insurance has been increasing, while the copays and deductibles of those who do have insurance has generally been increasing as well.

Precisely correct. Why people think that the solution is to "do what we're doing, but do even more of it" in the face of evidence that the result is the opposite of what they claimed in beyond me.

I'm not sure why conservatives favor this juvenile, bullying, insulting, and self-adoring style.

While Nate is in many ways a typical conservative, his attitudes are part of a vicious cycle. He is in health insurance sales, which is basically the absolute bottom of the white-collar totem pole, but nevertheless places him slightly above his rust-belt peers. So he knows, deep down, that he's basically in a profession that offers very little respect, but needs to take any possible opportunity he can to lord over whatever feelings of superiority he can muster when given the chance.

"That's not quite a patient decision: it's a combination of the cultural promotion of the Magic Imaging Tube as a panacea, the liability environment that promotes the Magic Imaging Tube as an alibi for malpractice suits, and the financial environment in which the Magic Imaging Tube is a moneyspinner once you cover its costs."

I have a story about that. I had slipped and hit my head on a granite floor. As this was my 8th concussion, I thought nothing of it. That changed when I discovered that I was bleeding out of my ears the next morning. So, I went to the hospital and X-rays determined that I had fractured my skull. The doctor told me that I there was nothing they could do, but he still wanted to take an MRI. "Umm, we already know my skull is fractured and there's nothing you can do, so how does an MRI help?" I ask. So he explains how I might have fluid building up in my skull and that the MRI would determine that (MRI's read water density, so this makes sense). So I ask if this is an effect that I might be able to determine on my own. He says: "Yeah, it'll hurt like hell." So I ask what they would do if that situation happened, and he explained that they would drill a hole in my head and drain the fluid (that's normal). So I replied: "So, If I walk in here six hours from now and tell the receptionist that I'm Mr. Foster and I need a hole in my head, they'll know what to do?" "Umm, yeah," he replies. "So why do I need an MRI?" I ask. His reply: "Umm, nobody has ever asked me this question before. I guess you don't really need it." So I didn't get it.

I don't advocate that anyone take this kind of approach to medical care, but I don't have insurance, so that's how I must deal with it. But even I still listen to my doctor.

emjaybee -- on who should make the decision on restricting access to healthcare, you forgot answer(c)-- an insurance company who profits by denying care and who isn't penalized if the patient is harmed!

I like fostert's example-- the point isn't that the patient "makes the decision" but that cost-sharing encourages increased dialogue. In fostert's example, the patient AND the doctor were involved in the decision-making.

He listened to his doctor in the end. But the doctor's first inclination was to do the MRI, and only on further questioning did the doctor explain the consequences of not getting it.

That said-- two caveats: One, from a medical perspective, this example is likely not one that should have this type of restriction. I'm assuming it was actually a CT scan, not an MRI that was in question. Two, not having insurance is an extreme example. I think a much more reasonable co-pay could have encouraged the same conversation.

Nate and Al Hubbard are dumbasses.

And thank you, Ezra, for your insightful posts on health care in America.

The most expensive in the world and 40+ million without coverage.

It's a very sore subject for me as I have a deaf daughter and what the cocksucking insurance companies have done to me has been quite an obstacle to get my daughter to hear again.

wisewon, honestly, the doctor is at fault there for not understanding that there was no added value for ordering the MRI. Even a $50-$100 co-pay wouldn't have convinced me to forgo an MRI while in the middle of dealing with a concussion, if the doctor ordered one (though it probably would have prevented me from asking/demanding one).

fostert's example is an interesting one, but the "dialog" was sparked out of desperation (the guy doesn't have health insurance).

Some dialog -- eg, "what are the tradeoffs of surgery vs. pharmaceutical treatment for this condition?" -- are good ones. However, it is the doctor who should understand the tradeoffs of diagnostic decisions, rather than hoping that if only the patients are squeezed and desperate enough that they'll start feeling enough pain to start questioning whether some tests are necessary.

Asymmetric information.

My dad had colon cancer and was definitely a goner. But an oncologist bullied him and my mom into trying chemo. In addition to the pain of the chemo itself, for the last four months of my dad's life he had bile oozing into his throat, but he couldn't spit or swallow, it just stayed there burning. He had other chemo-related symptoms, but that was the worst. It was non-stop torture, actual torture for six months. Finally he was able to get into a hospice, and they were able to just keep him knocked out so he wouldn't feel the pain.

And we never saw the oncologist after he made his sale. Basically, this guy wanders around hospitals, prescribes chemo, has nurses do his dirty work, and disappears. Guilt-tripping my mom and scribbling out his "prescription" was all it took for him to make a few grand.

There are little Guantanamos all over America, thanks to our medical system.

"I'm assuming it was actually a CT scan, not an MRI that was in question."

No, it was an MRI. The reason is that MRIs detect water, so if you're looking for fluids, MRIs are the best way to do it. Whether you need imaging for that is another question. To detect it with a CT scan would require a Barium injection.

that last one was mine.

"fostert's example is an interesting one, but the "dialog" was sparked out of desperation "

No, I'm just a freak. I work in medicine, so I have better knowledge. And I can take a hit to the head and still be coherent. Very few people would ever be in my situation. But the reason I am in my situation is that because of my multiple head and neck injuries, I know a lot about them. And because of my multiple head and neck injuries, nobody will even think of giving me insurance. I can afford it, but they won't cover me for anything related to my previous injuries. Given that those are my most likely problems in the future, there's really no point in buying insurance.

I'll add this: my inability to use the comma properly might be related to my head injuries.

honestly, the doctor is at fault there for not understanding that there was no added value for ordering the MRI. Even a $50-$100 co-pay wouldn't have convinced me to forgo an MRI while in the middle of dealing with a concussion, if the doctor ordered one (though it probably would have prevented me from asking/demanding one).

The medically appropriate thing IS to order the MRI, i.e. the clinical benefits outweigh the clinical risks. Only the cost considerations would push a physician not to do so. And right now, they don't have a financial incentive to even do so. So 1) Capitation is a questionable model as it creates an adversarial component to doctor-patient relationships 2) physicians don't feel like their role should be ruling out diagnostic/treatment options purely based on cost.

A $50-100 co-pay shouldn't convince you to skip the MRI post-concussion. That's the point of the co-pay (with the caveat that urgent care shouldn't have co-pays). But if its some back pain and the doctor says that there is no medical risk to waiting three months to see if the pain resolves first, many would not spend the $50-100 on the back pain MRI.

Fostert,

I obviously don't know the details of your case, but if you were my patient and walked into the hospital with a fractured skull and blood in your ears, I would have had you sent immediately for a CT to rule out hemorrhage (as would most docs). So assuming you had a CT to rule that out, and the MRI was in addition, your docs advice seems reasonable.

The medically appropriate thing IS to order the MRI, i.e. the clinical benefits outweigh the clinical risks. Only the cost considerations would push a physician not to do so. And right now, they don't have a financial incentive to even do so. So 1) Capitation is a questionable model as it creates an adversarial component to doctor-patient relationships 2) physicians don't feel like their role should be ruling out diagnostic/treatment options purely based on cost.

I'll quote myself. Because its an important point. A lot of you folks say "it should be the doctor's decision, they have the training" to determine if something should be done or not. If we need to stop doing things for purely financial reasons, physician do not want to be the ones responsible for making that decision. Making the right decisions based on the medical risks and benefits is enough of a challenge.

"There are little Guantanamos all over America, thanks to our medical system. "

I can't comfort you, but I've been there. When my brother got cancer, he bought a bunch of heroin on the street and checked out. I think he made the right decision. I watched my parents go through chemo hell, and that overdose looks pretty good in comparison.

Having just had a colonoscopy, I can attest that it's not a steak.

A friend who had one recently had such a hard time with it, he said he isn't going to get the next one in 10 years time, since he was clean, with no family history.

A friend who had one recently had such a hard time with it, he said he isn't going to get the next one in 10 years time, since he was clean, with no family history.

Virtual colonoscopies (MRIs) should be an approved alternative within 10 years. The only question is whether you'll need to take the prep beforehand (maybe/maybe not depending on the technology).

"I would have had you sent immediately for a CT to rule out hemorrhage (as would most docs). So assuming you had a CT to rule that out"

I didn't have a CT, that was rare in those days, and the MRI would have shown it more clearly, anyway. But my fractures were so internal that there was no way the likely hemorrhage could have been operated upon without essentially giving me a lobotomy. My doctor did bring that issue up, but I left it out of the story for brevity. Suffice it to say that he recommended against surgery in any circumstance because of the location of the fracture. In my situation, the only choice was to drain any excess fluids. But that's any easy call when they build up.

I think we continue to lose sight of the point cervantes made at the beginning of this thread: other nations manage to control costs much better than we do, with very low cost sharing at the point of care. They also provide universal access and little or no rationing for essential care (elective care is another matter).

Patients do not need more "skin" in the game in the form of cost-sharing at the point of care. They already have skin in the game in the form of their health and happiness. As the examples of chemo above point out, lack of information and unwarranted trust in medical advice can cause enormous suffering. Educating people honestly about their options and the consequences can provide as much of a sense of skin in the game as making them pay 10 times as much out of pocket.

This is not speculation, this is the reality of nation after nation.

And part of getting that sober advice about options and consequences is removing any incentive for physicians to be too aggressive. I'm fine with wisewon's point that doctors don't want to take financial considerations into account. But then you need to get rid of fee for service, and you need to get rid of imaging centers that are owned by physicians, hospitals that are owned by physicians, etc. Get rid of all of it; don't just get rid of the cost-consciousness that results in conservative care.

And in the end, I think the best way to do that is to make physicians salaried. It works for millions of Americans in their jobs. It works for integrated delivery systems now. It's not a change that can happen overnight, but one what a wise administration can encourage with incentives and regulations.

Ezra this:
By contrast, colonoscopies and MRIs aren't a good time. If I won a $5,000 spending spree from my local bank, I would not rush to for a gastrointestinal check-up, even if it came with a side of general anesthesia. But if my doctors told me I need a colonoscopy or an MRI, I'd get one. Diagnostic tests and medical treatments are not luxury goods. They are necessities. They do not feel like a choice. Which is why some many of us go into debt, take out second mortgages, and draw down savings. Hubbard characterizes the purchase of medical tests as "our decisions," but that's inaccurate. They are our doctor's decisions. We don't want to make those purchases; we're informed that we need to make them. Then we try and figure out how to pay for them. But the economics around luxury goods are quite different than the economics around necessary goods; you can't compare chemotherapy with a sumptuous steak.

Is pure BS. The only reasons to socialize medical care are monetary. The current system is taking people to the cleaners. I think that I read that colonoscopies before age sixty cost like $6,000,000 per year of life saved. We should receive 1 in a life time at age 60 but the Doctors are ripping us off. If there are more MRI machines in an area the people in that area get more MRIs but are not any healthier.

We take risks to make and to save money! Going without a colonoscopy is like taking any other risk!

Also look up the Rand health insurance experiment.

Asking a doctor if you need a test is like asking anyone selling anything if you need the product that they are selling.

On the context here: the Illinois AG filed a lawsuit against Chicago-area imaging clinics, alleging an extensive kickback scheme. (The case was dismissed and is going to be refiled after the judge asked for more specifics.)

Open Advanced MRI, one of the companies included in that lawsuit, has promoted similar referral schemes across the country.

The nagging suspicion that medical decisions may be prompted by the desire to get rich -- or, in the case of some doctors, pay off that mortgage's worth of med-school debt -- is a cancer on the industry.

It saddens me that I have to treat medical professionals with the same suspicion that should be reserved for the shiny-suited types on the car lot.

cervantes, your unbelievably simplistic "analysis" is about as useful as this ball of lint in my pocket. QE fucking D indeed.

Nate, you make the occasional good point, but your antagonistic and insulting tone cheapens anything you have to say.

And once again wisewon is the sole voice of reason. It's disappointing to see Ezra continually descend further into parroting the far left's (absurd and worthless) talking points.

How else do you want to address the abusers of the system? i.e those that don't give a damn about their own health and we all pay the bill or those that are gaming the system for their own benefit. Ezra acts like they don't exist, he obviously has never taken care of someone angling for disability or worker's comp I agree with him in this, they are not having the MRI for fun. It's often a career decision, like deciding to go to DeVry or get your GED. On the other spectrum it's not uncommon for a noncompliant diabetic to run through 3-4 million in healthcare dollars in a 5 year time span. How else do you want address someone that would rather eat their weight in energy intense grain fed Beef Big Macs and 64 oz of high fructose corn syrup, while trying to hit Hank Aaron's 744 on the glucometer every night. Why again should we all be paying for this? I can sum up the essential counter to having people take some responsibility in two lines.
Americans don't know shit.
It's Cruel.

"Two, not having insurance is an extreme example."

Extreme? Let's put it this way: Jewish people represent about 2% of the population. Their opinions are considered to be not only reasonable, but a necessary opinion to consider. The opinions of those of us who have no insurance are considered to be irrelevant. But we are 20% of the population. How does that work? And I apologize for using the Jews as an example, I have the utmost respect for them (they're my doctors, after all). I'm only trying to make make a point about how large a minority can be an still be ignored. And those of us without insurance are always ignored. Especially those of us who can afford insurance, but can't get coverage.

your liberal global warming claims

pretty much kills any credibility Nate might have had. I'm sure there's some room for legitimate reality-based debate on health care reform, but not for people who've already proven themselves to be dogmatic ideologues.

I think we continue to lose sight of the point cervantes made at the beginning of this thread: other nations manage to control costs much better than we do, with very low cost sharing at the point of care. They also provide universal access and little or no rationing for essential care (elective care is another matter).

jd,

1. These nations also haven't figured out how to control cost successfully. Better than us, true, but there systems are not sustainable either. Which leads to...

2. Skin in the game is something that is increasingly being discussed in European health policy circles to help them get to next-generation care. In other words, you're arguing for us to reform from version 1.0 (our system) to version 2.0 (current European systems), while Europe is thinking about version 3.0. Shouldn't we be learning from the problems of their systems also rather than being content with merely improving our position somewhat (particularly when you adjust for structural differences that won't be reformed in our system compared to Europe, e.g. level of physician compensation?).

Second, you acknowledge my point that physicians don't want to be involved in the financial side, but I'm unclear who you're proposing to make the value choices. It isn't as simple as taking away fee-for-service, etc. Whether looking at staff-model HMOs from the 80's, Kaiser, or health systems with salaried physicians-- none have an appreciable difference in lower costs compared to fee-for-service docs. The fee-for-service element is mostly a red herring. As I mentioned upstream, from a pure clinical perspective-- most things ARE justified in terms of clinical risks and benefits. Its the value element that is the issue. Docs don't want to consider costs. So who is putting the restrictions based on value?

How else do you want address someone that would rather eat their weight in energy intense grain fed Beef Big Macs and 64 oz of high fructose corn syrup

Ezra discussed this very issue a few threads down. He got a huge amount of pushback for raising it. Something to do with a bunch of indignant responses about "telling me how to live" were the complaints.

In any case, those diabetics end up getting their feet amputated. I don't think I'd want to trade places with them. They have literal skin in the game and end up paying the consequences.

There seem to be several commenters here who are frustrated that people take (or have the tendency to take) more tests than necessary. Maybe there are people out there that actively go seeking medical tests, but I haven't met any of them.

I think most people who are taking "excessive" amounts of test are doing so at the recommendation of their doctor. If you're sick, you're scared. You have gone to a doctor because, clearly, you know you don't possess the ability to treat your illness on your own. Yes, there is such a thing as being informed to a certain extent about what could be wrong with you, but doctors are trained to know how to treat you. Expecting patients to shoulder the burden of determining whether a test a doctor recommends they take is necessary is unreasonable.

As for doctors themselves, I don't believe that all of them just order every test under the sun because they'll get kickbacks or something. As much as we do revere and trust doctors, medicine is very inexact. Diseases manifest differently for different people (just ask anyone with an autoimmune illness), and it can be quite a puzzle to figure out what's going on. Tests are an important tool that helps your doctor figure out why you're sick.

An earlier commenter mentioned that utilization costs had increased over time, not transplants or some such thing. I'd think this could be due to increased technology capabilities in testing for illnesses, and the increased amounts spent on prescriptions could be indicative of increased ability to prevent serious illnesses from progressing/becoming fatal. Another interesting point is that maybe these tests/prescription costs have risen, but since we're able to treat/catch diseases before they become life-threatening in some cases has caused other health care costs to go down?

In any case, those diabetics end up getting their feet amputated. I don't think I'd want to trade places with them. They have literal skin in the game and end up paying the consequences.

The "lucky duckies" of the health care world. Just as fortunate as the folks who don't owe taxes because they don't make any money.

I think most people who are taking "excessive" amounts of test are doing so at the recommendation of their doctor.

Ezra, seriously some people do want lots of testing -- maybe not colonoscopies -- but there are many more popular tests. A large number of people want yearly cholesterol tests, for instance. Cholesterol is mostly genetic. Excluding some sort of massive lifestyle change, if it was good last year, it's good this year. A lot of people go to doctors for yearly "physicals". No doctors organization (the AAFP or the ACP) have recommended that bit of idiocy for 40 or 50 years. It's really common to request an x-ray or even an MRI for a minor sprain or day-after neck stiffness following a fender-bender.

On the other hand, I've had young women look me in the eye and tell me that they haven't had a Pap ($125 less 15% for cash at time of service) for 5 years because they haven't had insurance. They have a Coach bag, a cell phone, a $5 Star$s, and a cute little pedicure peeping out at me, but they didn't want to spend the money on a yearly (or ever 3 years after 30) test.

fostert, you were lucky you didn't accumulate so much fluid (aka "blood") so quickly that you herniated your brain stem and wound up dead.

wisewon,

It's not clear yet where the European (and Austral-NZ) experiments with more cost sharing are going, or whether they will bear fruit. I'm not sure there is any 3.0 version to leap to. Where there looks to be good evidence, I will follow.

We've debate each other about whether Europe controls its health care costs before. Hopefully this isn't just about semantics. Part of my disagreement with you is that even though they are paying half as much for healthcare as we do, they are already (in many nations) on top of unsustainable cost trends and proposing often quite large system reforms to stop them. I see no evidence that they are ever going to catch up to us (though we may slow down to meet them one day). Some amount of growth in health care faster than inflation and GDP is natural for two reasons: 1) our populations are aging, 2) we are increasingly service economies and health care is largely a service industry. There is much more going on, of course, but at the end of the day a slight expansion of the health care sector relative to GDP is to be expected these days, and probably for a generation more barring deep reforms.

Finally, I know that you are wrong about the following: "Whether looking at staff-model HMOs from the 80's, Kaiser, or health systems with salaried physicians-- none have an appreciable difference in lower costs compared to fee-for-service docs."

Staff or group model HMOs have medical costs 10-20% less than FFS docs in the same area. I think it's around 10% on the west coast, and I have intimate knowledge of some large medical groups on the east coast where it is more like 20%. If you have any data suggesting otherwise, I'd be eager to see it.

To answer the question/challenge about who makes the decisions on necessary care...any answer will be a compromise and have limitations.

If physicians are not part of a FFS culture and have less fear of litigation, then they will have less bias in favor of excessive care and in particular, excessive testing and aggressive end of life care. Much of that bias is unconscious, but if you compare the decisions of, say, Mayo clinic physicians with FFS physicians in Florida, it is clearly present.

I think that once the over-supply bias is gone, we won't have to worry as much about micro-managing doctors to reduce costs. To the extent that we still do want guidelines for quality and cost purposes, a combined board of physicians and other stakeholders makes sense (government, industry, consumer representatives).

This isn't well thought-out. I would want to look at how France, Germany, The Netherlands, Japan, etc. do it.

There are HMOs that have cost 10-20% lower then FFS but I would credit most of that to regulatory issues. If you have a link to any such studies I would like to see how the compare cost.

Take CA for example. Their small group reform with it's narrow rating band greatly distorts cost. NY and MA are the same way, HMOs are cheaper then PPOs but the price of those PPOs have been pushed so high by regulation the comparison isn't accurate.

You also need to adjust for provider compensation, in NV and CA providers are paid significatly less under capitation then FFS if they were forced to accept capitation for all their patients they would go out of business. It's similar to Medicare reimbursment. Yes if we paid all care at Medicare rates we would save a fortune but providers couldn't stay in business.

We need to stop comparing American Average HC cost to other nations. We have a huge vriance from state to state. MA cost 2-3 times as much as Utah. If you eliminated CA, NY, and MA from our national average we wouldn't be that much higher then the systems everyone wants to move to.

Tom, every liberal progressive here knows what the hockey stick chart looks like, almost flat line then huge jump. It's been proven inaccurate but EVERYONE knows what it looks like. Per Capital Rxs looks exactly like it. Since 90-95 the per capita rx has shot up like the global warming hockey stick.

Doctors shouldn't be responsible for making people's financial decisions. They should give the patient honest analysis of what their options are, what the cost of those options are then leave it up to the patient to make a decision knowing they have skin in the game. No other system ever has been or will be sustainable.Every system that has ever detached consumption from paying has experienced unsustainable inflation.

(particularly when you adjust for structural differences that won't be reformed in our system compared to Europe, e.g. level of physician compensation?).

Why not? Yes, the differentials are hard to overcome, but they exist in the context of med-school debt that burden newly qualified doctors with the equivalent of an additional mortgage. Changing that bit of healthcare culture has all sorts of potential knock-ons.

Much of that bias is unconscious, but if you compare the decisions of, say, Mayo clinic physicians with FFS physicians in Florida, it is clearly present.

Mayo is Mayo. If you compare Florida FFS docs with Harvard-affiliated hospital staff physicians (and many other centers) there won't be a difference. The oversupply bias, to the degree that it exists, won't change things sufficiently-- because the medical justification for conducting tests/procedures still exists for things that are financially low value. There isn't an easy way around this one. Other countries have top-down controls. Governments provide criteria on when drugs/surgery/etc. is indicated for patients. Doctots follow the guidelines. The point is-- someone is going to have to make the decision, it won'e magically get better. Other countries use NICE-type bodies to make these decisions. I don't think our country would accept that. And other countries are still struggling to make it work. Skin in the game is going to happen.

pseudo,

I know medical student debt is a favorite topic for you, but here's the reality:

The pay differentials discussed between high-income specialties and primary care fully account for the total cost of medical school within 2-3 years. So while full loan forgiveness sounds nice, besides a few really risk-averse medical students, most can see the overall cash flows and figure out the incentives still strongly lie with the same exact specialties. In other words, when you're evaluating career paths with incomes ranging from 150K to 500K annually, forgiving a one time cost of 200K doesn't really help that much.

In other words, you're going to be taking away their nice incomes. There isn't any way around that. Forgiving the equivalent of one-year's salary isn't going to change that for many.

"Get is straight: every single developed country in the world (and some less developed) have universal health care, almost all of them with minimal or no copays and deductibles. Every single one of them enjoys better health status than the United States. And every single one of them pays far less for health care than do Americans. The precise opposite of what this argument predicts."

This is incorrect. Out of pocket spending in OECD countries is higher than it is in the US. This is true even as the US figure includes out of pocket spending by the uninsured who bear the entire brunt of the cost. Restricting the analysis to the insured population shows that OECD countries require far more cost sharing.

jd,

I missed your first response earlier.

We've debate each other about whether Europe controls its health care costs before. Hopefully this isn't just about semantics. Part of my disagreement with you is that even though they are paying half as much for healthcare as we do, they are already (in many nations) on top of unsustainable cost trends and proposing often quite large system reforms to stop them. I see no evidence that they are ever going to catch up to us (though we may slow down to meet them one day). Some amount of growth in health care faster than inflation and GDP is natural for two reasons: 1) our populations are aging, 2) we are increasingly service economies and health care is largely a service industry. There is much more going on, of course, but at the end of the day a slight expansion of the health care sector relative to GDP is to be expected these days, and probably for a generation more barring deep reforms.

A few thoughts, this isn't a semantics question. I think you're short-shelling the remaining problems in other countries, particularly with respect to costs and cost control. As you suggested, there isn't a version 3.0 yet, so while they are searching for reform (as are we), they ARE on an unsustainable path without real solutions yet. That's not a small point.

Another important point-- comparative health systems analysis isn't about whether they'll catch us or we'll catch them. There are long-standing differences in the % of GDP between US and Europe. As we've discussed before, if you look at data since 1990, our rate of growth relative to GDP is within the spectrum of OECD countries. Our problem is overcoming these long-standing differences. That doesn't happen by simply taking some parts of other countries' systems and implementing them here. We have hospitals with debt obligations for capital expansion based on projected revenues, physicians who undertook brutal training that required them to sacrifice most of their 20's in exchange for salary expectations, investments in nursing homes based on current and expected revenues, etc. I'm not excusing these things, but they ARE reality. Implementing single-payer doesn't make these problems go away. They are long-standing structural differences in our system that have driven differences in % of GDP spend for several decades. We will never catch up to them barring a complete nuclear-like reform effort that completely screws over today's hospitals, physicians and other health institutions. The "one man's waste is another man's profit" is informative here. So beyond the fact that version 2.0 is an increasingly outdated type of health care reform with significant remaining issues, version 2.0 probably doesn't apply to our actual reality.

Staff or group model HMOs have medical costs 10-20% less than FFS docs in the same area. I think it's around 10% on the west coast, and I have intimate knowledge of some large medical groups on the east coast where it is more like 20%. If you have any data suggesting otherwise, I'd be eager to see it.

This one is more semantics. 10% would be what I would expect-- but you have to factor in that those group practices provide other means that drive lower costs than salary. Simply being part of a group practice leads to greater adherence to evidence-based medicine (there is good data on this), and the scale allows for lower overhead. So we need to compare apples to apples-- similarly sized physician practices that receive FFS type compensation vs. pure salaried docs. What you're left with is the not "appreciable difference" I mentioned before i.e. 5-10%, or around 1 year of health care cost growth. That doesn't get us that far. I'm not opposed to the reform itself, but that isn't the core of the problem.

This post of Ezra's seems like a red herring, I have to say. It might be that a universal health care system might not result in higher consumption of health care services, but it might not. (There's a great natural experiment happening in Oregon or Washington right now that's going to test exactly that hypothesis.) Either way, I don't want to hang my progressive hat on the conjecture that consumption of health services won't go up. If we're wrong, will we stop pushing for universal health care?

I think that we should focus on the fact that the insurer, whoever that is, will need help from the insured if it will control costs. The insured needs to gain significantly by controlling costs but since much of the cost comes in very big lumps deductibles below 30k are not effective. I have a few ideas, they have problems but here they are:

1. The Fed Gov. could provide insurance with a deductable that is equal a families’ income minus the poverty rate. If the poverty rate for a family of four is 15k per year then if a families income was 150k in the prior year there deductable would be 135K. If 15k is enough for poor people to live on it is enough for rich people to live on.

2. The Gov. could prodivide term health insurance with a growing annuity and a growing deductable. After all it seems like healthcare in old age is not an insurable even but almost assured.

Also they could try to educate the people about what medical is useful and what is not.

BTW It seems that other countries control medical costs mostly by sqeezeing providers. I am also for that. Sqeezeing providers is equal to price controls but since we have a situation where providers have used state regulators to drive up their incomes and becuase expensive medical care has little effect on health you do not get as bad shortages from price controls as you do with other goods and services.

Let me say one other thing to those who say let the doctors decide:

If you let the doctors decide what you should do you would have a boring life indeed.

No playing football.
No smoking
No drinking
No candy
No fatty food
No cigarettes
No eating enough get out side of the “ideal” BMI, which BTW is wacky low weight.
No sky driving
Aerobic exercise 30 minutes a day, preferable walking not jogging(too hard on the feet and ankles), whether you want to not.
Very low salt intake.

And most, not all, of it has been proven ineffective.

Oh and I forgot say out of the sun!

Apparently Floccina's idea of a good time/"not boring" life is eating doritos, pizza, and candy while sitting on his couch smoking and drinking beer. In the sun, without sunscreen.

Tyro I do like salt on my food. And btw there is no credible evidence that I should cut back on salt.

I rarely drink and if I do I drink one no more. I do not smoke. I do not often eat chips (I was raised on Italian food which most people would call healthy but I eat it becuase I like. My diet, being heavily Italian, is even low on meat. But I will defend the people who choose more fat and I will defnd the facts as I see them. ) and I use sun screen but that will not make a doctors happy, you must avoid the sun. To each his own.

As a Canadian and long-time user of universal health care, here's my take on some of these issues:

1. Doctors in Canada don't order MRIs frivolously. Why? They don't get anything out of ordering more tests; they know that there are limited resources; and the government provides guidelines on when tests should be ordered.

By contrast, doctors in the US do all sorts of unnecessary things because they make a profit from doing so.

2. Boob jobs and Viagra are not covered by any universal health care plans I know of. There are limits. Recently, the Ontario health insurance plan stopped funding tatoo removal, for example.

3. In many cases, what is needed is MORE health care, not less. Regular checkups and other types of preventative health care is actually cheaper in that it lowers the number of serious problems. We want people to get their annual flu shot so they don't miss weeks of work every winter. It pays to make them free.

4. Stats showing greater use of health services over the last ten years are caused by demographics. As a population we're getting older.

5. IMO the main thing in the US is to get rid of the for-profit health system. All these voucher and other for-profit plans are still going to be extremely inefficient. There are just too many profit-takers in the US health system, and too many decision-makers who are motivated by their own profit.

In addition, the for-profit system leads to dangerous cost cutting. US hospitals have the worst rate of staph infections, for example. This is due to the need to boost profits.

Decisions about health care should be made for the best interest of citizens, not for the best interest of the health industry.

I forgot to add... I had that egg caviar dish at Jean George once. It's the first course in their classic tasting menu. They screwed it up - forgot to cook the egg part, so it was just liquid and the cream and caviar both sank into it making an inedible glop. Then the waiter disappeared. I told the bus boy but he ignored me and just took it away. I have no idea why that restaurant has such a great reputation. For over $300/person, it serves pretty crappy food!

Ezra once again shows how clueless he is about American Healthcare and how it works.

You know, I argue with Ezra sometimes because I don't think that the private sector-individual mandate style reforms that he sometimes favors will actually improve the situation.

But I would never in a million years say Ezra, who has clearly studied this stuff a lot more than I have or most people have, doesn't know how health care works. He owns this issue. He can tell you the difference between the different national health care plans in European countries. He can tell you how fast health care costs are rising in the US. He can describe the way the Medicare drug benefit works.

Really, one of the worst conservative tendencies is to go beyond arguing their ideology and to pretend that people who are obviously experts, but who have different opinions from those held by conservatives, in fact "don't know anything" about the subject. People who say such things only discredit themselves.

Yappa Y
ou can't hit the jackpot suing your doctor in Canada. The VAST majority of physcians have no finacial ties to the tests they order. There is no incentive not to test and every incentive to do so.
You are more than welcome to eliminate profit motive, but you can't bitch when your Doc goes from seeing 40 patients a day to seeing 3 and refusing to ever let someone "squeeze in" an appointment. In every field the most productive work more and get paid more. If you get paid the same or less you work less. Eliminating all profit motives is not a smart thing to do when you want to add 40 mil to the system

Tyro
You may not want to trade places with them, but we all shouldn't have to pay for their stupidity. They should go bankrupt.

www.joepaduda.com
Only here do we have bodybuilding firefighters on disability. To deny patients have no motivation to use the system is living in a fantasy.

I'm just a lowly consumer, who goes to work 40 hours a week and has an HMO with my company. I lost my partner a year ago, so now I live alone and have double the bills (cause we used to share them). I live paycheck to paycheck now. I'm 43 years old.

Back in late March I woke up one morning to a weird headache. I shrugged it off. Over the next two weeks, the headache came and went, but got progressively worse. I hate going to the doctor, and put it off until I get so scared I finally give in. Anyhow, during the third week the headaches came every single day, and got worse as the day progressed. Finally, at the end of the third week, on a Sunday, the headache was so bad all day I thought I must be dying. I didn't go to the emergency room. I waited till Monday morning and called the doctor. He got me in that day. $25 co-pay. He looked me over, asked me questions, and said, I can't find anything to indicate anything serious, go home and if it gets worse, come back. Bewildered, I left, thinking how can I have such bad headaches and have nothing wrong? But I left. In the meantime, I was going through ibuprofen like crazy but it didn't really help. Then another week 1/2 goes by and I start getting a weird buzzing in my head. This really freaks me out. So I go back to the doctor. This time I have a temperature, but the doctor thinks I'm a nut when I talk about the buzzing. Another $25 copay and he gives me a prescription for an anti-biotic and an inhaler. He thinks it's a sinus infection. (I have no clogged nose, not sneezing, no pain in my face), but the headache gets worse if I bend over or if I use my muscles an it hurts in one spot more, so he says my sinus cavity is clogged. Off I go. I pay for my two prescriptions (neither are generic, so $30 copays both). Pharmacist says I should have asked for generic. Uh, I didn't even think about that in my fear, I just trusted the doctor to give me what he thought I needed.

Okay, while I'm taking the pills, my ears completely clog up. And the clog sometimes gets better, sometimes worse, and it moves from ear to ear at times. There is a continual buzzing in my head. But the pills finally start to work and I get better. Hurray. But not so fast. Another week goes by and back it comes. I'm leaving on a work trip. I call the doctor and tell him it's worse again, maybe the antibiotic wasn't strong enough, or maybe he didn't prescribe it for long enough. No he says, you don't need anything else. Just take lots of clariton and sudafed. It will get better. I tell him I'm going on a trip and I'm afraid it will get worse while I'm there. Just call me if it gets worse he tells me. So off I go. And the clogged ears are horrible. The buzzing is driving me crazy. So I call. And the doctors office tells me I have to go to an office in the other state. I balk at that one, as I'm on a work trip, I don't want to miss work. So he calls in a prescription for an inhaler, but still won't give me another antibiotic. Another $30 copay.

I get home and I call again. He tells me it something to do with the tubes in my ears so I'll have to go to a specialist. (he couldn't have told me this a few weeks ago)? So now I have to go to an ear/nose/throat doctor, even though my own doctor knows what's wrong. The specialist has a $40 copay. She looks in my ears, tells me the tubes are constricted, and gives me a prescription to help open them up and clean out my ears. But she's concerned cause this wouldn't cause the headaches. Back to the pharmacy, another $30 copay for this prescription. (you know, because nothing doctors prescribe anymore has a friggen generic). She wants to see me again in 3 weeks. Gradually, the ears start to clear and the headaches subside. I go back to her in 3 weeks, she looks in my ears, asks how I feel. Better. Okay, come back if you get worse again. For this terrific advice, another $40 copay.

So this is where I'm at. The weird buzzing is mostly gone, the headaches are mostly gone. I've spent $250 dollars of money I don't have, plus lots more money for claritan, sudafed, and ibuprofen. And NO ONE figured out what really caused all this, how it could be fixed or prevented. That 250 dollars could have paid my electric bill, which is now way over due. Plus, I have gotten two more bills from the insurance co, one for $25 and another for $50. For what I don't know. They are just sitting there until I can pay my electric bill and then save up some more money.

And this is the system all you conservative want? Huh!?!? What's funny is that neither doctor ordered ANY tests. Not one.

This is what I want. Health insurance that isn't tied to my employer, so if I get layed off I don't have to struggle to pay cobra. So I won't be denied care for any pre-existing conditions. Health care that doesn't force me to pay higher copays for medicine that doesn't have any generic available. It's not my fault there isn't one. I want health care that doesn't surprise me with bills in the mail, when it says nothing about that in my pan or on my card. I paid the copay, why are thy sending me more bills? Bills I didn't know were coming. How can I decide on care when I don't even know what I'm going to get charged?

I don't really care if it's universal or what. Just please get me the above!!

john....

a very upsetting story.
the amount of fear and anxiety caused by illness is oftentimes just as horrible as the pain and suffering caused by an illness.
i am not a doctor, but i thought i would take the liberty of sharing this, upon reading your story.
....you mentioned that you were taking a great deal of ibuprofen and then developed the tinnitus.
one of the side effects of large amounts of ibuprofen and other anti-inflammatory drugs can be tinnitus, or ringing in the ears.

glad you are feeling better.
wishes for your good health and peacefulness.

john....

a very upsetting story.
the amount of fear and anxiety caused by illness is oftentimes just as horrible as the pain and suffering caused by an illness.
i am not a doctor, but i thought i would take the liberty of sharing this, upon reading your story.
....you mentioned that you were taking a great deal of ibuprofen and then developed the tinnitus.
one of the side effects of large amounts of ibuprofen and other anti-inflammatory drugs can be tinnitus, or ringing in the ears.

glad you are feeling better.
wishes for your good health and peacefulness.

John,

“And this is the system all you conservative want? Huh!?!?”

Actually what you describe is the system Ted Kennedy and Liberals wanted. Google Ted Kennedy and HMO Act 1973. It was your boy Teddy that decided everyone should be in an HMO. Business owners and Republicans hated the bill but it was Federal Law they offer HMOs. Do you think Ted will get it right this time?

Dilan Esper,

Go back a week and look at Ezra’s post where he claimed HSAs discriminate against women because they don’t cover their preventative care. This claim and the entire post was 100% wrong as most HSAs actually cover it at 100%. Last I checked he never corrected the false information. Almost every post Ezra writes about our system is factually inaccurate. I am curious by what measure you consider him an expert. He attends to many progressive reform panels and reads biased propaganda. He has never worked a day in the field to my knowledge. Has never studied the fundamentals of how it operates. Can’t accurately interrupt data, see IVF above. Besides championing the majority of your political beliefs what qualifications does he have? You can also look at his claims of that Lewin group being the “gold standard” when they are nobodies. By no subjective measure could Ezra be considered an expert on any portion of healthcare except progressive reform.

You may not want to trade places with them, but we all shouldn't have to pay for their stupidity. They should go bankrupt.

Actually, I'm more or less willing to accept that some of the built-in costs of health care are people who have problems following protocol. If losing a foot isn't going to motivate someone, bankrupting him won't, either. Doesn't make sense except if it's something to be done out of spite.

Plus, I'm not sure I have any interest in a "compliance agency" which judges whether your health behavior is sufficiently moral enough to justify having my health care covered.

One of these days you need to learn to settle down and get over your deep-seated anger at the possibility that someone, somewhere is getting something you feel they don't "deserve."

Jenga said "You can't hit the jackpot suing your doctor in Canada. The VAST majority of physcians have no finacial ties to the tests they order. There is no incentive not to test and every incentive to do so.
You are more than welcome to eliminate profit motive, but you can't bitch when your Doc goes from seeing 40 patients a day to seeing 3 and refusing to ever let someone "squeeze in" an appointment. In every field the most productive work more and get paid more. If you get paid the same or less you work less. Eliminating all profit motives is not a smart thing to do when you want to add 40 mil to the system"

Americans should really learn more about the realities of universal health care. You are assuming that there are no incentives other than the US for-profit style, but you are wrong.

In Canada, doctors are reimbursed on a per-visit basis - to a limit. The limit is designed to keep them busy but not too busy. The UK has other ways of dealing with workload. It's just irresponsible to make crazy claims like doctors will see only 3 patients a day under universal health care.

Also, as I said, there are sufficient incentives to limit unnecessary tests: government guidelines, the knowledge that there are limited facilities, lack of profit motive to order them, and professional standards of practice. Unnecessary tests are a problem in the US, not in other countries.

Hubbard's argument is based on the incorrect assumption that healthcare costs are driven by consumer demand.

Wennberg (Dartmouth Atlas) and many others have demonstrated that just the opposite is true: healthcare services are driven by the supply of services available. More cardiologists mean more heart procedures. More MRIs mean more MRI tests.

Not to say that consumers - citizens - can do a lot to reduce their NEED for healthcare by improving their weight, level of exercise, diet, etc.

Another bi-product of having a national health system, as my Canadian grandparents have told me, is that they feel that there is a duty to keep their weight down, take their medications, etc, because they feel bad (that they're taking more than their fair share of the national pot of resources) when they fail to take care of themselves and get sick.

That's a culturally different perspective than your average American.

Go back a week and look at Ezra’s post where he claimed HSAs discriminate against women because they don’t cover their preventative care. This claim and the entire post was 100% wrong as most HSAs actually cover it at 100%.

That's a strange claim. Isn't the normal structure of an HSA that it combines a catastrophic coverage policy with a high deductible with a savings account for routine care? And you are supposed to save money on the routine care by comparing costs and foregoing unnecessary procedures because it's coming out of the HSA? And that's the basis for the claim that HSA's control costs?

If preventative care is covered by the policy, then people aren't going to be able to shop for it, and all the alleged demons of third party payment are going to occur, right?

Doesn't seem to me like your right on this.

As for the rest of your post, I think Ezra's knowledge of this issue goes far beyond attending a few panels. If you read this blog, you'd know that he also talks to many of the major players including conservative health care experts as well as liberals, and practitioners as well.

"Hubbard's argument is based on the incorrect assumption that healthcare costs are driven by consumer demand."

No, it's based on the assumption that the person in the best position to contain the spending is the patient and that our system of third part payment enables supply to drive demand.

HSAs combined with HDHP generally do cover preventive services. Design is to encourage preventive care while having consumer engagement in things like outpatient surgery,