March 25, 2017

I've been averting my eyes from the healthcare roundelay.

Hey, that is the first time in my life that I stopped to think of the right word and came up with roundelay. Where did that come from? This must be a special kind of aversion I've been feeling....

And is roundelay even correct?

Roundelay — originally "A short simple song with a refrain," according to the OED — has the figurative meaning "A repetitive and apparently pointless cycle of events; a farce." Here are the historical examples for the figurative usage, which — though it sounds very old-fashioned to me — go back only to 1949:
1949 Los Angeles Times 3 Nov. ii. 5/1 So long as this roundelay continues, the nation will be losing real wealth, and our standard of living will slowly deteriorate.
1968 Wall St. Jrnl. 9 July 18 Some cynics have treated all this as just another political roundelay.
1990 N.Y. Mag. 30 Apr. 48/2 It's another night at the office, another in the constant roundelay of political money-making exercises.
2005 D. Goewey Crash Out viii. 118 The past decade had been a roundelay of failed attempts to keep him out of lockup.
I went looking to see where roundelay appeared in the NYT archive and this headline from WWII grabbed my attention — from 1941 (so, still the figurative usage):

ADDED: Maybe this animation at the NYT caused me to think "roundelay":

Needs a few more pointing hands, no?


Sprezzatura said...

Cog dis is no fun.

Beloved Commenter AReasonableMan said...

Everything is proceeding as I have foreseen.

rehajm said...

A roundelay about man eatin' skeeters.

The swamp is winning.

Michael K said...

The Democrats are on a suicide mission on Gorsuch, which will remove the filibuster and that will allow a real O-care repeal and replace bill to pass.

The question then is whether the conspiracy theories are correct.

Does Ryan really want to do this ?

Obamacare has really altered the whole structure of healthcare as I pointed out in another thread. Unwinding it will be complicated but the start has to be removing the mandates and making it optional. Those who want Medicaid can keep it but the funding should be restructured as block grants to the states, The blue states that are willing to go broke, can do what they want with the funding.

Reforming employer-funded health care will be another step but should not be required yet. It was the individual model that was destroyed by Obamacare. The Democrats never had the courage to enforce the employer mandate of O-care.

David Begley said...

Paul Ryan, from Wisconsin, failed his country and party. Why he didn't have those votes in the bag was all on him.

Sprezzatura said...

Doc, "Big Club" seems clunky.

I'd stick w/ "Deep State" and/or "Swamp" and/or "Special Interests."

robother said...

Sometimes you drain the swamp, and sometimes, the swamp drains you.

dreams said...

Paul Ryan is a lightweight it seems to me, I overrated him back in 2012.

Rusty said...

Paul Ryans tenure as speaker may be limited. Either way a replacement is comimg.
ARM. You ain't seen nuthin yet.
This is gonna get a lot more grimey before it gets clean.

Sprezzatura said...

"The blue states that are willing to go broke, can do what they want with the funding."

What is it that the Red states would be doing differently? Saving money by not subsidizing folks such that those folks can afford insurance, e.g. the 24 million who would lose coverage re the $880 billion funding cut of the Rs official plan?

Or, is it that the Red states would actually have everyone insured, it just wouldn't cost money because of the free market?

rhhardin said...

I don't see the catastrophe aspect. Just do something else so that you can get agreement on the right.

I'd suggest going specific in covering specific people who got sick while insured in their policy previous to Obamacare or in their policy in Obamacare. Those exact people get free coverage. There's no particular cost because they die off, because it's not general.

Those are the people Obamacare screwed out of their winning bets against insurance companies or who have current winning bets against insurance companies.

With those sob stories out of the way, just repeal everything and let insurance companies replace it with what they will.

traditionalguy said...

Aroundelay and aroundalay we go.

The Japanese Navy had their own roundelay circling back again and again on Port Moreseby to invade Australia next, until the American Navy blocked an invasion force and then drew the attention away to sink in Iron Bottom Sound over a slow 4 month continuous struggle for re-capture of a small airfield the USMC had stolen from them.

Jeff said...

Both the House and the Senate passed straight-up simple repeals of Obamacare several times when Obama was in office, but of course he vetoed them. It's very simple. Dust off last year's repeal and put it up for a vote. Anyone Republican who voted for repeal last year but not now will face the prospect of The Donald campaigning lustily for his primary opponent next year.

Repeal returns us to the status quo before Obamacare was passed. If you don't vote for it, you're saying that you think Obamacare is, on net, a good thing. And all your campaign rhetoric against it was a lie. How many Republicans want to run on that?

Marc said...

Surely roundelay is used in that headline in its literal meaning, not figuratively? 'Aussies sing a song to chase the mosquito blues away', basically? But I'm probably missing something, as would not be entirely unusual.

Beloved Commenter AReasonableMan said...

Good summary of the state of play by David Frum, helpfully reminding punters that the Republicans stubbornly refused to negotiate with the Blue team in the lead up to passing the ACA.

MayBee said...

I don't care about the ins and outs of the politics.

I just know the plans as they are are very expensive, and the deductibles are very high. Something needs to be fixed.

traditionalguy said...

As for Congress and the President Trump, it is now like Lincoln stuck with a General MacClellan who arranges to take an immense Army, and not fight the enemy with it. Funny how that works.

And of course copperhead MacClellan ran to defeat Lincoln in 1864 election so he could arrange a surrender to the Confederacy.

Trump must fire the copperhead Ryan, ASAP.

Michael K said...

"Repeal returns us to the status quo before Obamacare was passed. "

Unfortunately, that may not be the case. A lot of hospital administrators and executives of "nonprofits" anticipated lots of profit from building vertically integrated systems with all the doctors on salary and total control by the admin.

It's interesting to me to see lots of "Urgent Care" facilities in Tucson, more than Orange County. There are a lot more cash practices in Tucson than I saw in California. This is what independent medical practice is evolving into. The next step is to end the contract insurance model where only doctors that sign contracts and agree to abide by the "rules" are signed up.

There will probably be some experimentation if repeal actually passes.

Can Of Cheese for Hunter said...

All you need to know is that the DNC Media (the media) are giddy.

Why didn’t the GOP try to pass last year’s vetoed health-care bill?

Progressives do not care about ordinary Americans and their exploding health insurance costs. Leftwing progressives only care about their teams economic Gruber nonsense.

Once written, twice... said...

Trump promised that he had a plan that could deliver healthcare to everyone that would be better, cheaper, and would get rid of the individual mandate. Of course, only idiots would fall for such a demagogic appeal. Ann was one of those idiots.

Now that we see that Trump was obviously bullshitting, Ann has developed a new disinterest of politics and government. How convenient that is for her.

rehajm said...

Paul Ryan is a lightweight

Right. Just like that Boehner guy. Of course the next speaker in line will be chosen for his obvious mastery of goat ropes, cat herding, manufacturing wine from water and blood from stones.

Michael K said...

Frum is an angry lefty masquerading as a Republican. Hint:

the great mass of conservatives and Republicans had turned on the double in the other, toward an ever more wild and even paranoid extremism.

I used to correspond with Frum who told me he quit National Review because he was not invited on the annual cruise. He is no REpublican any more than David Brooks is.

Big Mike said...

Pelosi managed to convince a number of her Dumbocrats to vote for Obamacare even though it meant their sure defeat in the next election. Ryan wasn't able to do the same, and I don't think emulating the Dumbocrats of 2009 is a good move for the Republicans of 2017. That said, they could have written a better bill and picked off some centrist Democrat congress critters ( if there are any left after Pelosi and Obama). They'd have done a lot better to re-pass the bill they submitted for Obama's veto or done nothing at all and let it collapse.

Can Of Cheese for Hunter said...

Gruber - the author of the Democrat's ACA.

"Lack of transparency is a huge political advantage,” said Gruber. “Basically, call it the stupidity of the American voter or whatever, but basically that was really, really critical to getting the thing to pass.”

Why would anyone with an ounce of integrity work with the democrats and their lies?

Frum is a hack.

tcrosse said...

This shows Trump how many friends he has in the GOP congress should an impeachment resolution come up. Food for thought....

GAHCindy said...

Perfect word for it. Nice!

traditionalguy said...

As for the Ryan/Preibu/Koch team, they are committed defeatists solely because they want the Presidential power back that think Trump stole from their slimy hands. Nothing that Trump lets Ryan handle for him will end in anything but a defeat.

Anonymous said...

Big Mike: That said, they could have written a better bill and picked off some centrist Democrat congress critters ( if there are any left after Pelosi and Obama).

Well, that's just it, isn't it? They didn't write a better bill because they really don't want to do a damned thing about health care. They're still hoping it all just goes away, and Trump with it.

It won't all just go away, but that's a different story.

Beloved Commenter AReasonableMan said...

"The American Health Care Act is a truly horrendous piece of legislation. But it did not become the vehicle for the Obamacare repeal effort because Trump, or Ryan, or anybody insisted on it over some other option. It became the repeal bill because nobody in the Republican Party had a better idea."

For seven years people on this forum have insisted that the Red team had a plan. This belief has been exposed as nonsense. Ryan is the emptiest of empty suits, but the entire party lacks a coherent ideology that is consistent with the world as it is.

Can Of Cheese for Hunter said...

trad-guy -

The Koch brothers are AGAINST Ryan-Trump-McConnell Care.
Get your facts straight.

Unknown said...

It is hilarious to see the Trumpies defend the indefensible or trying to change the subject

In case the Trumpies have forgotten:

Trump on the campaign trail:
"We’re going to win so much, you’re going to be so sick and tired of winning"

Trump, February 9, 2017
"We will immediately repeal and replace ObamaCare - and nobody can do that
like me. We will save $'s and have much better healthcare!"

David Baker said...

Ryan delivers:

Obama: 1

Trump: 0

(Was/is Trump naive?)

Unknown said...

The Republicans/GOP control the White House, the House and the Senate ... and Trump still couldn't deliver on the PROMISE he made to his Trumpies.

Obama fought for years to get his bill passed. Borscht-eating surrender monkey Trump fought for a few weeks and gave up. #coward #gutless #sad!

The buck stops THERE. Yep, Trump blamed failure of Trumpcare on Dems. What a loser.

Can Of Cheese for Hunter said...

Sorry ARM - nothing tops Gruber when it comes to an empty suit.

exhelodrvr1 said...

November 9th the Repub Sens and Reps should have started working on this. Initially take a simple approach that addressed some of the major flaws that everyone could support, with the expressed intent to address the other issues in later legislation. That could have been ready to be voted on Jan 20th.

This was a major screw-up.

buwaya said...

Dr. K is right, the would-have-been system of Obamacare was meant to suit a consolidated corporate-managed system, which is of course a set of special interests.

Obamacare is broken already, just ramshackle, partly built, partly abandoned parts left over.

Simplification should lead to lower costs, even for employers medical insurance.

I suggest, and suggested in the past, that the bloody thing be fixed in parts, or salami sliced. This would have worked just as well for the Democrats if they had not been so greedy in 2009, and they would have gotten into far less trouble.

Unknown said...

Trump: "We’re going to win so much, you’re going to be so sick and tired of winning"

Trump scorecard:

Muslim ban: FAIL
TrumpCare: FAIL

David Baker said...

Maybe a better question would be: Can Trump be a conservative socialist and still succeed?

William said...

Epidemiologists claim that the endless agita associated with the health care debate is now America's fourth leadinging cause of death. The numbers are growing rapidly, especially among Republicans.

Can Of Cheese for Hunter said...

Ryan-Care kept all the so-called provisions you leftwingers like.

And now you mock him? Disingenuous twats.

buwaya said...

Nobody has a coherent ideology consistent with the world as it is, ARM, because the world is too messy.
Empiricism is a non-ideology, and the only way for rational people to operate.

buwaya said...

Conservative socialist = Otto von Bismarck

Yes, I think its been done.

Michael K said...

" the bloody thing be fixed in parts, or salami sliced. "

Yes. Just make it optional so the Medicaid group can stay in but block grant Medicaid to the states.

Ritmo asks what the red states would do differently. They could prioritize spending and maybe require work for able bodied.

Welfare reform was done in similar fashion and worked. At least until Obama gutted the work requirements.

Medicaid was originally intended for women and children. Women with small children or pregnancy.

Beloved Commenter AReasonableMan said...

Chait said...
"The political miracle of Obamacare was its ability to design a way to cover the uninsured and to pay for the coverage in a politically viable fashion. The law found a way to solve a political problem that had frustrated would-be reformers for decades. And they accomplished it against the ruthless opposition of a united party that has used every demagogic method to undermine it — in Washington, in the states, and in the courts.

As the Congressional Budget Office found last week, the exchanges are not in a death spiral. Insurers have found a stable price point.

Republicans have spent eight years fooling themselves about Obamacare. They have built a news bubble that relentlessly circulates exaggerated or made-up news of the law’s shortcomings and systematically ignores its successes. The federal government is now spending less money on health care than it was projected to spend before Obamacare passed, medical inflation is at the lowest level since the government began recording it 50 years ago, and 20 million more Americans have insurance."

Unknown said...

Healthcare is a single industry and represents 6% of the economy. Trump failed.

Trump now wants to address tax reform which impacts every industry, the whole economy and every person. Yeah, go on big boy, show us what you're made of.

Trump is a con-man and the Trumpies fell for him hook, line and sinker. Tee Hee.

Unknown said...

Trump: The WORST first 50-day record of any President. It will also be the WORST 100-day record of any President pretty soon.

tcrosse said...

Muslim ban: FAIL
TrumpCare: FAIL

Hilllary elected President: FAIL

Can Of Cheese for Hunter said...

Chait - another hack.

Tell everyone who is paying 30-60% more and getting less that it's all made up.

Beloved Commenter AReasonableMan said...

Chait said...
instead of comparing Obamacare to what it replaced, they compared it to the plan Republicans would have passed, if only they had the chance. The existence of the mythical Republican health-care plan was the foundation for every serious critique of the law. And now that that plan has finally appeared, virtually the entire conservative intelligentsia has been forced to admit that it is worse than Obamacare.

Anonymous said...

ARM @9:17 AM:

Chait writing for Tractor Production Monthly now is he?

Meade said...

David Baker said...
Maybe a better question would be: Can Trump be a conservative socialist and still succeed?

Good point. Now would be the perfect moment for Trump to bring in Senator Sanders to spearhead single-payer BernieCare.

Unknown said...

Keep going Trumpies with your blaming Obama, Pelosi, Schumacher, Democrats, Liberals, Progressives, Hippies, Dippies, Moonies ... but guess what?

Trump: "We’re going to win so much, you’re going to be so sick and tired of winning"

Trump is a LOSER. #SAD but true.

buwaya said...

Chait is a dickhead ARM.

Obamacare escalated employment costs by loading coverage and benefit mandates, via the insurance system, on the employer, suppressing labor demand and wages. This is not controversial, it is clearly visible in the BLS data.

Beloved Commenter AReasonableMan said...

Angel-Dyne said...
Chait writing for Tractor Production Monthly now is he?

Since they brought back the centerfolds circulation has been way up.

Original Mike said...

Insurance providers are fleeing. "If you like your ObamaCare, you can keep your ObamaCare" will come to the same end as "If you like your doctor, you can keep your doctor."

Beloved Commenter AReasonableMan said...

Frum said...
It seemed to me that Obama’s adoption of ideas developed at the Heritage Foundation in the early 1990s—and then enacted into state law in Massachusetts by Governor Mitt Romney—offered the best near-term hope to control the federal health-care spending that would otherwise devour the defense budget and force taxes upward. I suggested that universal coverage was a worthy goal, and one that would hugely relieve the anxieties of working-class and middle-class Americans who had suffered so much in the Great Recession.

Can Of Cheese for Hunter said...


It’s not exactly the Ems Dispatch (the diplomatic cable Bismarck doctored to provoke the 1870 Franco-Prussian War). But what the just-resurfaced Gruber Confession lacks in world-historical consequence, it makes up for in world-class cynicism. This October 2013 video shows MIT Professor Jonathan Gruber, a principal architect of Obamacare, admitting that, in order to get it passed, the law was made deliberately obscure and deceptive. It constitutes the ultimate vindication of the charge that Obamacare was sold on a pack of lies.

“Lack of transparency is a huge political advantage,” said Gruber. “Basically, call it the stupidity of the American voter or whatever, but basically that was really, really critical to getting the thing to pass.” This was no open-mic gaffe. It was a clear, indeed enthusiastic, admission to an academic conference of the mendacity underlying Obamacare.

First, Gruber said, the bill’s authors manipulated the nonpartisan Congressional Budget Office, which issues gold-standard cost estimates of any legislative proposal: “This bill was written in a tortured way to make sure CBO did not score the mandate as taxes.” Why? Because “if CBO scored the mandate as taxes, the bill dies.” And yet, the president himself openly insisted that the individual mandate — what you must pay the government if you fail to buy health insurance — was not a tax.

Worse was the pretense that Obamacare wouldn’t cost anyone anything. On the contrary, it’s a win-win, insisted President Obama, promising that the “typical family” would save $2,500 on premiums every year.

Skeptics like me pointed out the obvious: You can’t subsidize 30 million uninsured without someone paying something. Indeed, Gruber admits, Obamacare was a huge transfer of wealth — which had to be hidden from the American people, because “if you had a law which . . . made explicit that healthy people pay in and sick people get money, it would not have passed.”

Can Of Cheese for Hunter said...

Obama raided the treasury to pay the failing mega insurance companies. Leftwingers like Frum and Chait are cool with it.

Roger Sweeny said...

"... health care is 1/6 of our economy, but nobody wants to spend 1/6 of their income on it." tweeted Josh Barro. Which is why so much of the politics is about making the payments indirect, making it impossible to see how much anyone is paying.

Of course, that makes people less cost conscious and--surprise!--costs go up and up.

Rance Fasoldt said...

Ok then. Obamacare still owned by Democrats. Republicans tried to fix it, Democrats didn't. So, still a valuable club for Republicans to use in 2018, as Obamacare gets more unhealthy.

dreams said...
This comment has been removed by the author.
Michael K said...

It seemed to me that Obama’s adoption of ideas developed at the Heritage Foundation in the early 1990s—and then enacted into state law in Massachusetts by Governor Mitt Romney

This lie is why Frum is totally unreliable. I'm not sure if you are just trolling or you really don't know the story.

The original concept was for an individual mandate for catastrophic care and was based on "the free rider" theory. Heritage later dropped the idea for several reasons.

Heritage policy experts never supported an unqualified mandate like that in the PPACA [ObamaCare]. Their prior support for a qualified mandate was limited to catastrophic coverage (true insurance that is precisely what the PPACA forbids), coupled with tax relief for all families and other reforms that are conspicuously absent from the PPACA. Since then, a growing body of research has provided a strong basis to conclude that any government insurance mandate is not only unnecessary, but is a bad policy option.

I have provided the link so you can read the story if you were not just trolling.

In Massachusetts, Romney supported the individual mandate concept and the Mass Legislature, 90% Democrat, passed a more burdensome bill than he supported. He vetoed the bill and it was passed over his veto. Deval Patrick later expanded it again. The employer mandate was never supported by Romney or by the Heritage Foundation.

I was mystified why Romney did not explain this in 2012 but he defended the law that he had vetoed. I think this added to his defeat and maybe made it inevitble.

Anonymous said...

AprilApple: Obama raided the treasury to pay the failing mega insurance companies...

The mega insurance companies weren't failing, April. They had sized up the state of the existing, and probable future, "health care" landscape, the opportunities for expanded business and profit therein, and responded accordingly.

Michael K said...

health care is 1/6 of our economy, but nobody wants to spend 1/6 of their income on it.

Yes, I think it was P.J.O'Rourke who said, "If you think healthcare is expensive now, just wait until it is free."

The fundamental flaw in all government health plans is the desire to make it "free."

There is an infinite demand for anything that is free. That is what basic economics is about. There used to be an expression "Land Office Business," meaning that free land was a huge draw. Everyone wanted some. Even the Homestead Act of 1862 required a filing fee and the homesteader had to improve the land and live there for five years. My grandmother's parents had a homestead in Illinois. It was finally sold when she died. It had been in the family over 100 years.

Politicians try to make things seem free and that is the root of all the trouble we have seen since Roosevelt.

Roger Sweeny said...

"I just know the plans as they are are very expensive, and the deductibles are very high. Something needs to be fixed." said commenter MayBee.

In American, doctors are taught not to consider cost (most have little idea how much anything in the system costs), and Americans want "the best care" for themselves. Since few are paying out of pocket, they go along with most anything the doctor recommends and may even push for treatment the professionals are not gung-ho on.

In a system like that, the only way to lower premiums and deductibles is to make someone else pay. Period. Politicians know voters don't want to hear that. And the media would prefer to cover it in their accustomed sports way--focusing on which team is winning and which team is losing. Oooooh, was yesterday a big loss or a long-term win for Trump? Etc.

Can Of Cheese for Hunter said...

I don't think so, Angel-Dyne.
The numbers are wrong. People were not signing up, as planned and promised by the gamed CBO.

How The Obama Administration Raided The Treasury To Pay Off Insurers

Clark said...

Here's a delightful Roundelay (from Schumann, Album for the Young, Op. 68, No. 22). Going round and round doesn't always end badly. (Sorry for the Youtube ad--you can skip it after a few seconds.)

Can Of Cheese for Hunter said...

Obama administration may use obscure fund to pay billions to ACA insurers

Can Of Cheese for Hunter said...

U.S. Paid Insurers Funds Meant for Treasury, Auditors Say

"U.S." is a code word for "Obama".

Michael K said...

"The mega insurance companies weren't failing, April."

Yes and no. They make their money from processing claims. Someone once said, "Even the handling of money can be profitable."

They want no part of health insurance since it morphed into prepaid medical care about 1965 with Medicare.

Traditional health insurance was like fire insurance. You paid a premium and when an insurable event occurred, the company paid out the insured amount of coverage. That was called "indemnity insurance" and it paid an agreed upon amount for each claim. For an appendicitis, it might pay the surgeon $150. plus more for the hospital. The hospital rates were also agreed and specified in a policy.

This all changed about the time I began in Practice. Doctors made a big mistake by demanding higher payments called "Usual Customary and Reasonable" fees. Blue Cross did not pay individual claims. It paid hospitals an annual amount based on their share of the year's claims.

Commercial insurance companies began to enter the market selling policies to employers. They did not do business like Blue Cross but paid individual claims. They set off the fire by demanding that each item by specified in the claim. That;s where 20 dollar aspirin tablets began. Hospitals just did not track costs as efficiently as a normal business did.

If you want to know more, read my book on it.

Insurance companies thought Obamcare would be like employer plans and they would just process claims but they got into the paying claims side and that has been a disaster for them.

Can Of Cheese for Hunter said...

Is it any wonder the leftwing media ( the media ) are giddy over the current Trump fail!

Trump fail! they had 8 years! blah blah blah

Nevermind the original sin

How Obamacare Execs Broke the Law and Cost Taxpayers Billions

Anonymous said...

AprilApple: I don't think so, Angel-Dyne.
The numbers are wrong. People were not signing up, as planned and promised by the gamed CBO.

OK, I misread you. I thought you were talking about the financial health of mega-insurance companies before Obamacare was enacted.

(That they weren't making the extra coin they were hoping to be making off Obamacare, and got bailed out, is a different matter. My misreading.)

Can Of Cheese for Hunter said...

Frum - the agony. What an idiot.

Anonymous said...

Michael K @10:06 AM:

Thanks. Wish your book was on Kindle.

320Busdriver said...

The HC market is completely distorted due to the inability to determine a price for any aspect of health care. No one can be a be an intelligent user of health care when you are unable to compare products and services. They tell you we all need to use our benefits wisely, but make it impossible for you to do so.

It would be like going to the grocery store and everyone getting charged a different price for a gallon of milk. Mostly based on what the store has determined is the most they can extract from you. How would that work for you?

320Busdriver said...

The whole purpose of Ocare was to reduce the excessive amount of money spent on american healthcare and thereby save our budgets from being swamped by entitlements. Ocare did NOT do anything to reduce the excessive amounts spent in the USA. And our debt is forecast to continue its climb, mainly due to medical entitlements.

John Wennberg had input into the O care process mainly from the work being done at Dartmouth and the Health Care Atlas. It was summarily rejected, left out of the bill,and the wasting of health care resources continues unabated. All the more reason that the Dems gloating yesterday are considered despicable creatures in my eyes.

Jeff said...

If you want lower prices for healthcare, you either have to reduce the demand for it or increase the supply. If you just increase the demand for care by mandating and subsidizing the purchase of health insurance, basic economics tells you the one thing you can be sure of is higher prices.

Decreasing the demand for care by making people pay more of their own costs is not ever going to be politically popular. Making pricing transparent would help, but only if the people making the decisions on what care to consume are the ones paying the bill. And pricing transparency will be opposed by the providers who benefit from the opacity of the current system.

The only real solution is to increase competition by increasing supply. There are several ways to do this. We could start by letting non-MDs do a lot more than they are allowed to today, and by immediate FDA approval of drugs that have already been approved by other countries with rigorous testing requirements, like Japan and most of Western Europe. Let anyone who wants to open a hospital, without requiring them to demonstrate a need for the facility. It is often the case that people associated with existing hospitals are the same people who can withhold approval of new hospitals. This is rather like letting GM and Ford decide whether or not there is a need for Toyotas.

But the biggest thing we should do is vastly increase the number of doctors allowed to practice here. Right now, you cannot practice medicine in the US unless you have completed a residency here. Foreign-trained doctors, even from countries where the training is every bit as rigorous as it is here, and with years of experience, still have to do a residency here. And of course, the number of residencies is sharply limited by both the Congress (which funds residencies at VA and some other hospitals) and by the states. It is almost always the case that the state boards that determine the number of residencies in a state is dominated by doctors. Of course they always err on the side of limiting competition with themselves.

In his 1776 masterwork The Wealth of Nations Adam Smith pointed out that:

"People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices."

Doctors and pharmaceutical companies are not exceptions to this rule. We need to stop pretending that doctors are all saints and treat them like the businessmen they are. Stop helping them limit competition and let the market actually work.

Michael K said...

"Thanks. Wish your book was on Kindle."

I'm working on it. Have to get busy.

John Wennberg had input into the O care process mainly from the work being done at Dartmouth and the Health Care Atlas.

Jack Wennberg is a great guy and thankfully still alive. The faculty at DMS had input into Hillarycare but they don't have a lot of experience with in the trenches care delivery. When I got there in 1994, they had almost no input about surgery.

The Atlas was developed while I was there and is very useful. Outcomes research was just getting going in anything but Epidemiology. The Maine Medical Assessment Foundation was doing great work with David Wennberg there. Then HMOs arrived and cut off all data to the group studying outcomes.

When I came back to California, I tried to do a study of Medicaid outcomes when MediCal (the Medicaid version in CA) switched from fee-for-service to an HMO. I had the support for the study, and the UCI Statistics Department was enthusiastic about studying the outcomes using the claims data from the FFS days and comparing to how patients did under an HMO.

The Medicaid people refused to let us see any of the data. They did not WANT to know how people did.

In fact, I had visions of a second career studying how to measure and improve quality in healthcare delivery. I had had to retire after back surgery. I learned that NO ONE wanted to know how their patients/ subscribers were doing.

The insurance companies and HMOs all assumed that better quality meant higher cost and I could not convince anyone otherwise.

All we needed for the Medicaid study was the data. The rest was funded. Nothing doing.

LA_Bob said...

I lived on Roundelay Road in Lynchburg, Virginia from age 2 to age 5. It is a large circular cul-de-sac. When I lived there it was a dirt road. When I went back for a visit many years later I was astonished to see how small it really is.

LA_Bob said...

Michael K.

"The Medicaid people refused to let us see any of the data. They did not WANT to know how people did."

I wonder if this is related to the story of the two studies done during the Obamacare debate suggesting that having medical insurance did not improve outcomes, especially for common metabolic diseases like hypertension and diabetes. I suppose if much information like that became conventional wisdom, people might make less use of medical services. That would have a beneficial effect on medical costs, at least for patients.

Roger Sweeny said...

I learned that NO ONE wanted to know how their patients/ subscribers were doing.

Interestingly, the situation is almost the same in education. Nobody does long-term studies of what people have actually learned and retained after a course is over. Even though everyone knows that knowledge "decays" if it is not used and reinforced.

Far easier to just assume passing a course = knowing the material. For some unspecified amount of time.