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What Atul Gawande Got Wrong about U.S. Health Care Spending

bostonreview.net

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Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#61

Post by antisthenes »

darawk wrote: post #58
SketchySeaBeast wrote: post #56

Earlier quoted context omitted.

What sort of money are we assuming these individuals will get? In your plan is this $100? $1,000? $10,000? With the ratio of the desperate to people who require kidneys, suddenly organs become a buyers market.

Ok, again. Let's play this all the way through. Let's say they get $1. If I choose to sell you my kidney for $1, because i'm desperate and I think that that $1 is worth more to me than my kidney, where do the problems start?

On the off chance you're not trolling (assume best intent and all that). The answer is trivial:

The problems start because 99% people aren't educated on the true value of their kidney.

They are not in an adequate position to judge the value of an essential organ and the ramifications for missing it for the rest of their life. Because they are not doctors and not experts.

It's immoral, because in this exchange exists information asymmetry, where the kidney seller is not informed enough.

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#62

Post by darawk »

cmiles74 wrote: post #57
darawk wrote: post #9

Earlier quoted context omitted.

That's not really true, though. Prices are set by the intersection of supply and demand. Oil demand is relatively inelastic, for instance, but the price is quite reasonable because there is tremendous competition in supply. Prices are high in healthcare in part due to inelastic demand, but much moreso due to supply constriction. For just one, particularly egregious example of this: https://en.wikipedia.org/wiki/Certi…

While this is true and it's difficult to open a new hospital in the US, it strikes me as unlikely that this could be blamed for the high cost of care. In fact, US hospitals have been merging and this seems to be a trend that is continuing to this day.[0] I entirely agree that hospitals are part of the problem, but I think that casting this as a supply and demand issue is oversimplifying the issue. People who need hea…

> While this is true and it's difficult to open a new hospital in the US, it strikes me as unlikely that this could be blamed for the high cost of care. In fact, US hospitals have been merging and this seems to be a trend that is continuing to this day.[0]

You're citing this as a case against supply restriction...but I think it makes the opposite point. Hospitals are consolidating because it increases their pricing power. However, that only works because it's so hard to create new hospitals. If it were easier for new entrants to enter the market, consolidation amongst existing providers wouldn't have the power that it seems to.

> I entirely agree that hospitals are part of the problem, but I think that casting this as a supply and demand issue is oversimplifying the issue. People who need health care very often cannot choose to "shop around" for their provider, the increase in mergers make it less likely there are any competitors in their area. Agreements between hospitals and insurance companies often place other health care providers "outside network", thus artificially increasing their costs. In the same way consumers do not choose their hospital, they also frequently cannot choose their insurance provider; often the health insurance comes along with their employment.

Ya, this is certainly a problem as well. I suppose I would consider it to be within the umbrella of "supply and demand" though.

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#63

Post by SketchySeaBeast »

darawk wrote: post #59
SketchySeaBeast wrote: post #55

Earlier quoted context omitted.

A major surgery like that isn't low risk - the chance of major complications is quite high. You're asking people to put their lives at risk in a very real way to make a quick buck, which probably isn't actually solving any long term problems as it's a single cash infusion and not any sort of actual revenue stream they can rely on. And, as I asked elsewhere - how much money are you expecting these organs to be sold fo…

> A major surgery like that isn't low risk - the chance of major complications is quite high. You're asking people to put their lives at risk in a very real way to make a quick buck, which probably isn't actually solving any long term problems as it's a single cash infusion and not any sort of actual revenue stream they can rely on. So, you think people are incapable of making this decision for themselves? Or perhaps…

> Or perhaps that, in general, the government should step in to prevent people from taking undue risks in exchange for money?

Yes, literally why OHS exists and should continue to exist.

> $4,000 seems like a perfectly reasonable and fair price for someone to undertake the risks associated with kidney donation.

Who is going to need that sum, but also afford all the post-op medical care and time off? In case of complication, who is responsible? Something tells me if you're needing that sum, you're not going to have the medical coverage required to take care of yourself. Iran seems to have a higher level of general healthcare coverage than America [1].

[1]https://en.wikipedia.org/wiki/Healthcare_in_Iran

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#65

Post by zaptheimpaler »

darawk wrote: post #48
zaptheimpaler wrote: post #12

Earlier quoted context omitted.

Wow. Incentivizing people who need money to sell their organs has "zero negative effects"? Really?

Let's actually talk this through. What do you think the negative effects are?

Consider a poor or indebted person that owns a car, and needs some benefits from social security. Many republicans would argue (as they do now) that they should "lift themselves by the bootstraps" and sell their car, use public transit instead as a first step to increasing their income right ? Now what do you think will happen when that poor person suddenly has the option to sell their kidney for $50k? The same thing. Their KIDNEY will be considered a "luxury" that they should part with rather than something a little more important than that. Think about the same narrative around "millenials should just stop eating avocado toast" vs. the real problems of wage stagnation or college debt.

What if debt collectors could one day consider a kidney a monetary asset like a house, and force them to give it up? How would you feel, if you sold a kidney at 30, and now you're 70 and your remaining kidney fails?

What if the social security basket shrinks proportionally because 10% of people now opt to sell their kidneys and take less social security- is that REALLY better than letting them keep their damn kidney and paying a bit more taxes on social security? A purely economic perspective would say yes...

Broadly speaking, you are reducing a much bigger problem into a small "economics 101" lens.

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#66

Post by fluentmundo »

darawk wrote: post #49
fluentmundo wrote: post #11

Earlier quoted context omitted.

a) You must not have read the piece: "the bills are high because of who is paying them"; "insurance companies spend some eighteen cents for every dollar they collect in premiums on administration costs: 'marketing, determining eligibility, utilization controls (e.g., prior authorization of particular procedures), claims processing, and negotiating fees with each and every physician, hospital, and other health care wo…

That is not an argument, it is an assertion that offers no real explanation whatsoever. An argument would connect who is paying to the high prices, this article fails to do that. The 18% overhead of insurance companies, just like the overuse of care argument rebutted in the article, does not explain the high relative cost of care in the US.

Of course it is part of the explanation. That administrative overhead — the bureaucratic army it pays for and marshals as a lobbying and negotiating tool — encourages hospital monopolization, which gives providers greater bargaining power, driving up prices.

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#67

Post by darawk »

antisthenes wrote: post #61
darawk wrote: post #58

Earlier quoted context omitted.

Ok, again. Let's play this all the way through. Let's say they get $1. If I choose to sell you my kidney for $1, because i'm desperate and I think that that $1 is worth more to me than my kidney, where do the problems start?

On the off chance you're not trolling (assume best intent and all that). The answer is trivial: The problems start because 99% people aren't educated on the true value of their kidney. They are not in an adequate position to judge the value of an essential organ and the ramifications for missing it for the rest of their life. Because they are not doctors and not experts. It's immoral, because in this exchange exists…

> The problems start because 99% people aren't educated on the true value of their kidney.

And which problems are those? There are no significant issues that arise from having one fewer kidney.

> They are not in an adequate position to judge the value of an essential organ and the ramifications for missing it for the rest of their life. Because they are not doctors and not experts.

Sure, but that problem exists in tons of market interactions that we solve in various ways. Information disclosure and education, certification programs, etc..This is a very, very easy solve.

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#68

Post by darawk »

SketchySeaBeast wrote: post #63
darawk wrote: post #59

Earlier quoted context omitted.

> A major surgery like that isn't low risk - the chance of major complications is quite high. You're asking people to put their lives at risk in a very real way to make a quick buck, which probably isn't actually solving any long term problems as it's a single cash infusion and not any sort of actual revenue stream they can rely on. So, you think people are incapable of making this decision for themselves? Or perhaps…

> Or perhaps that, in general, the government should step in to prevent people from taking undue risks in exchange for money? Yes, literally why OHS exists and should continue to exist. > $4,000 seems like a perfectly reasonable and fair price for someone to undertake the risks associated with kidney donation. Who is going to need that sum, but also afford all the post-op medical care and time off? In case of complic…

> Yes, literally why OHS exists and should continue to exist.

I'm not familiar with any agency by the name of OHS. Do you mean OSHA? Because they don't regulate employees, they regulate employers.

> Who is going to need that sum, but also afford all the post-op medical care and time off? In case of complication, who is responsible? Something tells me if you're needing that sum, you're not going to have the medical coverage required to take care of yourself. Iran seems to have a higher level of general healthcare coverage than America [1].

First of all, 'time off' isn't a thing for many people. Many people are unemployed, so time off costs them nothing. Secondly, obviously the person purchasing the kidney would cover all aspects of care related to the operation.

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#69

Post by darawk »

fluentmundo wrote: post #66
darawk wrote: post #49

Earlier quoted context omitted.

That is not an argument, it is an assertion that offers no real explanation whatsoever. An argument would connect who is paying to the high prices, this article fails to do that. The 18% overhead of insurance companies, just like the overuse of care argument rebutted in the article, does not explain the high relative cost of care in the US.

Of course it is part of the explanation. That administrative overhead — the bureaucratic army it pays for and marshals as a lobbying and negotiating tool — encourages hospital monopolization, which gives providers greater bargaining power, driving up prices.

Yes, but per the article itself it only explains 18% of cost. And overhead is never going to be zero, so you can maybe, what cut that in half? At best? That's not even close to explaining the discrepancy between US per capita spending and other countries.

Re: What Atul Gawande Got Wrong about U.S. Health Care Spending

#70

Post by darawk »

zaptheimpaler wrote: post #65
darawk wrote: post #48

Earlier quoted context omitted.

Let's actually talk this through. What do you think the negative effects are?

Consider a poor or indebted person that owns a car, and needs some benefits from social security. Many republicans would argue (as they do now) that they should "lift themselves by the bootstraps" and sell their car, use public transit instead as a first step to increasing their income right ? Now what do you think will happen when that poor person suddenly has the option to sell their kidney for $50k? The same thing…

Ok. And then what? Where do the problems start?
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