I'm surprised to see so much discussion here about healthcare in the USA and so few anecdotes about firsthand experiences with and in that system. Of course, anecdotes can provide only limited understanding of a complex system, but so also can statistics or partisan rhetoric. I'm surprised because my (thankfully limited) interactions with the system have led me to believe that all this uproar about the mandate and Justice Roberts and the IRS is rather missing the point. The real point - where the rubber meets the road - is rationing.

Assumption: the demand for care is greater than supply, and certainly greater than affordable supply.

Assumption: there are very, very few sure things in medicine. Almost everything is a matter of probabilities. Will antibiotic X rid patient Y of infection Z? Will a triple bypass operation improve the life quality of 80-year-old patient X enough to justify the cost and risk?

With just these two assumptions as a starting point an argument can be made for enlightened rationing. If we were to limit the provision of healthcare resources to only those with a greater than X% chance of being effective, we could bring supply and demand into balance in such as way as to achieve universal coverage. This is the most simplistic way of explaining rationing. Wikipedia has a more in-depth article: http://en.wikipedia.org/wiki/Healthcare_rationing_in_the_United_States

There are different ways to ration. There are different reasons to ration. There are different ways to legislate and administer rationing. There are different goals to seek via rationing. But all-in-all I don't think the subject is beyond comprehension. It may, however, be beyond our political willpower. "Rationing", despite being a fact of the current system and a complete necessity, is something of a dirty word. Presidential candidates aren't going to discuss it very much. It gets discussed behind the closed doors of congressional committees. But we don't have a big national debate about it, and we need one, because the first question that needs to be answered before a really good rationing system can be in place is: do we want everyone to have equal access to healthcare or should access be proportional to wealth, and if proportional, to how great a degree?

I'd be interested to hear discussion of that question here.

Do we want everyone to have equal access to healthcare or should access be proportional to wealth, and if proportional, to how great a degree?

You're jumping ahead. Who says there aren't the resources in the US to provide complete coverage in a timely manner?
Before you even talk of rationing you have to examine whether or not a system is efficient or cost efffective, and what best practices are out there to follow to improve.. ... There is so much to gain from greater efficiency and effectiveness ...But then, it would mean applying lessons learned from abroad...
From a Fareed Zakaria column (linked below)

To understand the issue better, I spoke with Daniel Vasella, the chairman (and former chief executive) of Novartis and a physician by training. He is also frankly pro-market and pro-American, both of which have made him a target for some criticism in Europe.
Vasella emphasized that there is no single model that works best, but he explained that France and Britain are better at tackling diabetes and lung disease because they take a systemic approach that gives all health-care providers incentive to focus on early detection and cost-effective treatment and that makes wellness the goal. “In America,” he said, “no one has incentives to make quality and cost-effective outcomes the goal. There are so many stakeholders and they each want to protect themselves. Someone needs to ask, ‘What are the critical elements to increase quality?’ That’s what we’re going to pay for, nothing else.”
I asked him whether the lesson he has drawn is that only the government can produce system-wide improvements. “It pains me to say this as a free-market advocate, but you have to have [the] government act in this case. Health care is very complex. Only at a systemic level can you figure out what works best based on the evidence, and what procedures and treatments are not worth the money,” he said.

http://www.washingtonpost.com/opinions/ ... story.html

For something as vital as health care a person will have a demand for the most expensive care as quickly as possible when they are not paying for it. So we have to find ways of reducing the demand (which will necessarily be supplied as long as there is an insurance company or medicare to pay for it). I think there three ways to do this: (1) Triage, (2) reduce the incidence of premature babies, (3) reduce expenditures on end-of-life care. With regard to triage, you have to empower doctors to make decisions about likely outcomes and not worry about every conceivable etiolog; also, if your disease is not life-threatening you may have to wait a period of time for tests or treatment. A lot of money is spent on taking care of premature babies and we may be able to take steps to reduce the number of premature babies (encouraging mothers to have babies earliers, ensure pre-natal care for poor families, etc.) And with regard to end-of-life care, we would have to agree as a society that it does not make much sense to be spending enormous amounts of money on end-of-life care that accomplishes very little.

Ricky: I read that article earlier this morning. In your quoted part, look again at the very last thing said: "not worth the money" is a strong hint that what he's talking about there is rationing. I recommend to you the wiki article to which I linked. Some guy from the NYT quoted there: "The choice isn’t between rationing and not rationing. It’s between rationing well and rationing badly."

When you write "Who says there aren't the resources in the US to provide complete coverage in a timely manner?" you have some concept of what "complete coverage" means. I believe that if we discussed it enough you'd come to see that your "complete" coverage is already rationed. It's pretty much inconceivable, by definition, for any healthcare system to not ration care. Please read that wiki article.

However, while some sort of rationing is inevitable, there is an argument to be made that in the US we provide, in many many cases, way TOO MUCH care, and if we could cut back on that we'd have lots of extra resources to spread around. But what I'm really saying here is that we need to ration in an enlightened manner.

For instance, I recently had a bad sinus infection. Sinus infections can be caused by bacteria, viruses, or a fungus - many different varieties. Bacteria are the most common agent. These infections, even when caused by bacteria, are resistant to antibiotics because the sinuses are largely isolated from the bloodstream - the drugs can't get to the site of the problem. My PCP prescribed for me one antibiotic after another. I think I ended up trying four. Eventually, the infection cleared up. It's very possible, maybe even overwhelmingly probable, that none of the antibiotics did a damn thing. But at least my doc was trying something. That will usually make a patient feel better. A patient who's told: there's not much medicine can do for you - just rest, drink fluids, and wait it out - can get cranky. Angry. Litigious! (In fact, my doc did tell me the antibiotics probably wouldn't help, but since neither of us cared about the $$$ - why not at least try?)

In my opinion, a large percentage of the care provided in the USA is provided out of fear of litigation, not out of a scientific justification based on costs and benefits. If this could be corrected, we'd free up a lot of resources. We'd still have to ration, of course, but overall savings would be greatly enhanced.

freeman2 wrote:...we have to find ways of reducing the demand... I think there three ways to do this: (1) Triage, (2) reduce the incidence of premature babies, (3) reduce expenditures on end-of-life care.

"Triage" is essentially a close synonym of "rationing", and your end-of-life comments are all about rationing. I agree with you in both cases, and also see much merit in preventing premature babies (and lots and lots of other prevention efforts).

So far no one has tackled the question:

Do we want everyone to have equal access to healthcare or should access be proportional to wealth, and if proportional, to how great a degree?

The problem with rationing end of life care is that you risk reducing the level of dignity for people. People who often will have been contributing to society all of their lives. It should not always simply come down to resources and the question of chances.

Purple wrote:So far no one has tackled the question:

Do we want everyone to have equal access to healthcare or should access be proportional to wealth, and if proportional, to how great a degree?

I would say it should be proportional to health need, which I guess is the former over the latter.

However, even with a public system, the rich will still be able to get a premium service. This happens in the UK as much as anywhere. But we also have free (at the point of use) and equal access via the NHS.

Purple, I live in Canada. This means I live where everyone has equal access to health care.(Actually not purely because our proximity to the US means people with means can go to the US for very expensive care. But its not done a lot. But this small relief valve aside...)

Ostensibly this means, by your terms, that we have a system of rationing .
What you call rationing we found, and to a limited degree still find, in long wait times for certain services... When resources are thrown at wait times in specific areas, and when hospitals and other health professionals work together there has usually been significant improvement in wait times.
In fact the wait times that are considered excessive, and which are played up in American press, are limited to geographical areas underserviced by specific specialists. (Orthopedic surgeons in BC is probably worst.) .

The problem I find with your use of the word "ration" is that it suggests that there are no other answers. In attacking wait times, health systems try things that sometimes change the way health care is being conducted. Use of local clinics , nurse practitioners, different diagnostic tools. Once health systems are actually managed the disparate stakeholders can work in concert rather than in opposition...Or worse, in just plain wasteful ways.

Want an example? Because Canadian hospitals deal with only one insurer they have far fewer staff doing accounting, and they have almost no claims denials or problems. One Dallas hospital had an accounting staff of 17 whereas the same size in Mississauga had 2. Why 17? Dealing with dozens of insurance companies, all of who denied all or part of claims at a rate of at least 25% when first submited.
Imagine if the resources in the US health care system weren't spent on accounting or insurance administration?
The point I'll make in a macro sense is that the US spends 17% of its GDP on health care. Switerland is at 12% and canada below that. We pretty much assume in Canada, that if we wanted to spend 17% of GDP on health care we'd all have gold plated care are and no wait times... (We'd just rather wait a little and pay lower taxes)
Start managing your system, rarther than letting the stakeholders get rich running it, and you won't have to ration.

Purple wrote:I'm surprised to see so much discussion here about healthcare in the USA and so few anecdotes about firsthand experiences with and in that system.

Honestly, it is because certain posters refused to accept anecdotal evidence as unscientific and unreliable and would dismiss it out of hand when offered. Therefore, it stopped being offered.

Purple wrote:For instance, I recently had a bad sinus infection. Sinus infections can be caused by bacteria, viruses, or a fungus - many different varieties. Bacteria are the most common agent. These infections, even when caused by bacteria, are resistant to antibiotics because the sinuses are largely isolated from the bloodstream - the drugs can't get to the site of the problem. My PCP prescribed for me one antibiotic after another. I think I ended up trying four. Eventually, the infection cleared up. It's very possible, maybe even overwhelmingly probable, that none of the antibiotics did a damn thing. But at least my doc was trying something. That will usually make a patient feel better. A patient who's told: there's not much medicine can do for you - just rest, drink fluids, and wait it out - can get cranky. Angry. Litigious! (In fact, my doc did tell me the antibiotics probably wouldn't help, but since neither of us cared about the $$$ - why not at least try?)

In my opinion, a large percentage of the care provided in the USA is provided out of fear of litigation, not out of a scientific justification based on costs and benefits...

I had a very similar experience about 3 years ago. I was in work when I lost 1/2 of my vision (not vision out one eye but 1/2 my field of vision). All I could see on the right side of my field of vision was white. I called my doctor who said it sounded like a textbook migraine but since I was 40 and it was the first time it I experienced it go to the hospital and have a neurologist look me over. I went to the ER and they gave me a CAT scan that showed nothing and ER doc said it was most likely a migraine. However, since the neurologist wasn't in and would be until noon the next day, they admitted me to the hospital for an overnight. I think 1 more doctor looked at me before the neurologist saw me. Both said it was a migraine. So I had 4 different doctors all said it was just a migraine but none of the others were willing to just give me migraine meds, I had an ER visit, an overnight hospital stay, a CAT scan, carotid ultrasound and a total of 4 doctors. Since I had insurance, I wasn't worried about it.

In answer to your question Purple I believe the design should be that everyone should have equal access to health care (though as Danivon points out you can always probably get "better" care if you are wealthy). Everyone is entitled to a lawyer but the wealthy can buy the "best" representation. I don't have any moral qualms with those kinds of differences, but I think we have reached a level of wealth as a society that everyone should have access to health care as a matter of right. I think our system before Obamacare was immoral but we are now at least taking some steps to improving equal access to health care. Ultimately single-payer carries within it a built-in rationing system because there will only so much money allotted to pay for care.

Freeman: thank-you for addressing the very difficult question. Could I ask you to please elaborate just a little on how our pre-Obamacare system was immoral? (I'll then invite any courageous person of a different viewpoint to counter your assertions of morality and of healthcare being "a matter of right".)

Purple, I think it is immoral for a society to have some members having so much wealth they could never spend it all if they tried while others are going hungry, do not have adequate shelter, or have adequate health care. I don't have a problem with there being large differences in income, that is going to happen in a capitalistic society and to the extent it is the result of competition it is also fair as well, but everyone in this society should have certain basic needs met. At our level of societal wealth I see the minimum rights as the following: (1) food, (2) shelter, (3) education, and (4) health care. After those basic needs are met for everyone, then all other wealth should be up for grabs based on as fair of competition as we can make it. So based on my argument that it is immoral to allow some to have unparalleled levels of wealth while others do not have basic needs met, then the pre-Obamacare failure to cover 45-50 million Americans was immoral.

Now I'm sure RJ is ready to jump in with that we have tried all kinds of government programs to fix these problems and they haven't worked. All I can say to that anticipated argument is that we haven't tried hard enough.

I wasn't sure where to post this but anyway I found this article about a program in Alaska that helps treats native Alaskans that has shown dramatric cuts in health care cost (while increasing quality)

http://www.nytimes.com/2012/07/22/opini ... ral&src=me