You keep talking about innovation. Do you have any way of measuring innovation or it's absence? Some actual metric or methodology? Some source? Or is that just your opinion?

For example, Medicare was passed in 1965. It seems to me that there's been a fair amount of innovation in health care since then. Maybe–probably?–you would say that without Medicare there would have been more innovation. But do you have any evidence of that? What is the source of your evidence?

And would you day other government agencies, like the Centers for Disease Control, or the National Institutes for Health, have also stymied innovation?

You've also referred to Medicare as “demonstrably incompetent”. Can you demonstrate its incompetence? Again, I'm looking for some sources. Something beside your own opinion.

How long will it take to reform the system? It depends how you do it. You could attempt reform by freeing the private sector from the smothering mismanagement the government heaps on it today. Or you could expand demonstrably incompetent programs like Medicare. The first way will be a lot faster.

What shall I take “it seems to me that 'half as disastrous' is a good place to start” to mean?

It means I think the current Canadian system is better than the current American system. And it means that I think moving to that kind of system would be an improvement over what we now have.

It doesn't mean I'm opposed to innovation. You had to make up a quote for that one, right?

Also, how long will it take?

Disagree. The current system is too expensive for poor outcomes. A government subsidy to pay more into a broken system doesn't seem like a good place to start. I'm with GS. If there's a system that's only HALF as expensive as ours with better outcomes, that is indeed a good place to start. Anyone who can come up with a system less than half as expensive and/or with better outcomes, great. But profit motive has not always been our friend.

My starting position in this debate is that insurance companies will never care as much about our health as their profit. That does not match our national goal of better health care for all at the best cost. The starting point has to be how do we improve health care and lower cost. Profit does not equal innovation (European drug makers, with government negotiated prices, have overtaken ours in both size and innovation, for instance. Many of our best medical procedures were developed by doctors, hospitals and researchers elsewhere at costs far less than here). Despite my rep here as a liberal, shoveling government money into the same broken system, versus shoveling employer money into it, is not a solution. It's rearranging deck chairs on the Titanic.

How do we get a system that's long on innovation and value for money? Through decentralizing control and setting up rules where people can make a few bucks by improving their corner of the industry, along the lines I described before. Courage, GreenDreams, but the P-word is our best friend as long as people are making profits for the right things. The best way to encourage millions of brains to improve the system is through their wallets.

What the private sector will not deliver is progressive subsidies, so this is the right role for the government. But it should do it as cleanly as possible, not by micromanaging prices and procedures and policies the way it does today. The solution to the 46 million people who can't afford insurance: write them a check.

I really hate it when someone out here quotes me as saying something that I never said. Mainly I hate it because the words they put into my mouth are usually a pretty crummy argument.

So, when you quote me as saying, “let's do what those guys are doing, ” rather than “let's get a system that does a lot better than anything out there,” I think you're being unfair to me. Also, since this is a public thread and everyone can see you putting a crummy argument into my mouth, I don't think you're really doing yourself any favors, either.

I do think the current Canadian system is better than the current American system. I can't tell if you disagree with me about that.

Still, for the record, I am in favor of innovation.

For the record, I am in favor of delivering health care cheaply enough that it doesn't consume 20% of GDP. (I think, though, that you're exaggerating when say 90% of the population is desperate to have the other 10% pay for their health care.)

Since you've raised that, maybe you can tell me how we get there.

Maybe you can tell me how long it will take to get there.

Maybe you can also tell me what we should do in the meantime about the 46 million Americans who currently don't have health insurance.

PM: Unbundling these two very different concepts would not only reform the way we're currently approaching the question, it would enable much more realistic definitions and funding.

Maybe so, but I think the single-payer system is better. If people need care, whether cancer treatment or just a checkup, they can just go and get it, without worrying if they can afford it this month. Both the costs and the outcomes are better than we've been able to achieve. In fact our health statistics have more in common with a Third World country than with the first world countries who pay far less than us. It seems to me that in this discussion we are prioritizing lower cost above better health, and I think that's a mistake. Any solution we come up with, I believe has to improve both, and for right now the benchmark has to be those countries that currently pay less for better health care.

DrJ: If you put the checkbook in the patients' hands–not just a few, but all of them–the dynamics will change dramatically.

This seems to be at odds with the warnings voiced here that doctors will flee the scene if reimbursement levels fall to that currently paid by Medicare. It cannot be both ways; it cannot be legitimately argued that doctors and hospitals are not paid enough under Medicare, and that they would accept less from their patients directly.

PM: I don't personally think that routine visits / preventative care (vaccinations, annuals, screenings, strep antibiotics, etc) need a specific vehicle.

The alternative to a specific vehicle is what Dr. J. seems to suggest, that patients themselves be responsible for all care except catastrophic care. As I said, this would probably result in less preventive and routine care, poorer physician income, and worse health care outcomes.

DrJ: Sick people negotiating with hospitals is a bogeyman argument… The classic chart showing we spend more than Europe is itself a bit of a fraud. Canadians are probably required to live two years longer so they can wait in the queues.

I assume you're joking here. Full analysis of single-payer systems suggests that, for example, waiting for treatment could be eliminated in the UK by their government paying 60% of what we do, instead of 50%. In other words, if they paid a little more, but still far less than us, this criticism would evaporate. I hasten to add that we have waiting lines too, as well as outright denial of treatment.

Dr J: These statistical comparisons are a dismal exercise. There are plenty of data points to go around either way, and a million ways to misinterpret them all. Infant death survival rates differ because countries tally them differently.

I think it's a disingenuous argument to say that the best health-care statistics we have are “dismal”. These studies are done by the best healthcare institutions we have, and if the companies with a stake in this, the insurance industry and the AMA for example, believe the research is faulty, they could certainly fund studies of their own. I suspect they have, but the absence of studies by our best institutions disproving the UN numbers indicates to me that we cannot get better numbers by doing the research at better institutions. In particular, life expectancy and infant mortality figures are based on extremely finite endpoints, namely death. I can't believe that deaths are under-reported in Japan, France or Germany. These countries are certainly as capable of accurately reporting that endpoint as we are.

And if your imagination is having trouble stretching that far, here's a limbering-up exercise: how are we going to settle once and for all what a healthy diet looks like? Lord knows the current system hasn't even answered this one, despite spending trillions treating obesity, diabetes, heart disease, et cetera.

I'm not sure where you got the idea that I'm opposed to innovation.

I'm concerned you're setting the bar too low, aiming for a system that will better deliver the same half-loaves we're getting today. I think that's a mistake, we should think more about what full loaves would look like. Health care doesn't have to be outrageously expensive. We could be making much faster progress against cancer and a million other problems we don't treat well. Look at wheelchairs and prosthetic limbs: people have been living with the same centuries-old designs, until someone like Dean Kamen comes along and suddenly reinvents them. And he's just one guy; imagine what we might do if the system encouraged millions of people to innovate.

And your counterargument is that starving people have access to grocery stores?

Have you ever heard of WIC, Dr_J? Do you think government programs like WIC have had anything to do with reducing hunger her in the USA? Anything at all?

How long do you think it will take to fix the problem of lack of price transparency? What do you think we should do in the meantime about the 46 million people who currently don't have health insurance? Maybe we should just let that number keep growing until we can get things just right?

What do you think we should do about the comparatively low cancer survival rates in Europe, if not improve early detection? Do you think we ought to tell the Europeans who get cancer to just keep dying younger until we've flippin' cured it?

And when you say, “statistical comparisons are a dismal exercise”–you remember that you're the one who brought up European cancer survival rates, right?

And your comment, “Canadians are probably required to live two years longer so they can wait in the queues.”–?

Seriously, Dr_J?

That's what you've got?

These statistical comparisons are a dismal exercise. There are plenty of data points to go around either way, and a million ways to misinterpret them all. Infant death survival rates differ because countries tally them differently. The classic we spend more than Europe chart is itself a bit of a fraud. Canadians are probably required to live two years longer so they can wait in the queues.

But it's all ultimately about arguing who's not quite as awful as the other guy. The fact is early-detection would help European cancer stats only because we still haven't flippin' cured it. Let's quit aiming so low and start demanding a lot more from an industry we're spending 17% of our GDP on.

I have to agree with GreenDreams–I doubt that it's practical for sick people to negotiate with hospitals. And what to do about the Emergency Room, where you seemed to concede there's no negotiation possible.

I don't know anything about European cancer survival rates–the link you provided is for subscribers only–but I'm willing to believe you. I imagine that better early-detection cancer screenings would help the Europeans.

I would, however, note that life expectancy in general is longer in France, Iceland, Italy, Spain, Norway, Greece, Austria, the Netherlands, Luxembourg, Germany, Belgium, The United Kingdom and Finland than it is in the USA. Japan, Singapore, Hong Kong and South Korea are also better.

And Canadian life expectancy is almost two years longer than ours.

I originally thought you were going to say something like, people should just pay for the routine stuff out of their own pockets. But then you agreed with GreenDreams about how that would discourage routine check-ups. As you said:

We (people) need a way to ensure (NOT to be confused with insure) that we can affordably access preventative / normal / routine medical care.

I sure agree with that.

But my point here is that if a health care reform bill is going to encompass cradle-to-crave comprehensive health care, then it in no way resembles, and should not be confused with, insurance.

In any case, I agree, we have a health care culture where patients/consumers have very little clout and hardly any of them even *ask* what something's going to cost. Because they don't care. Because someone else is picking up the bills. And that someone else is a giant bureaucracy that only asks once a year and doesn't even care much what the answer is, because they're just passing the cost on.

Even if you ask a hospital what your stay will cost, the hospital can't give you an answer. Because they're not set up to. Because no one ever asks. Get 500 people asking them, every day, and they'll start learning how to answer.

If you put the checkbook in the patients' hands–not just a few, but all of them–the dynamics will change dramatically.

Checkups are just like new tires on your car. Get them if you think you should, don't if you don't. But don't expect your car insurance company to pay for them without simply passing the cost (plus their overhead) back to you. Same story with balancing lower costs vs. improved outcomes. You should be deciding those priorities, not your insurance company, and not some Washington lobbyist.

Those foreigners' results you talk about are a decidedly mixed bag. Europe's cancer survival stats are a good notch worse than ours, and George's scopes link paints Canada as a culture of queues.

There's nothing unexpected about routine health care. Doctor's visits aren't catastrophic loss against which one should insure.

That's about as basic as I can figure out. Hope that helps?