Outside the Beltway

Outside the Beltway

One of These Is Not Like the Others

Dave Schuler
138

HCcostsbyAge

Yesterday in the comments of this post of Steven Taylor’s, “What’s Wrong With This Picture?”, I mentioned a bar chart comparing healthcare costs in a number of developed economies over at my place. Above, courtesy of a frequent commenter there and here, is an alternative representation of the information, sampled from an article at Forbes.

As you can see, one of these is not like the others and drastically so. There are multiple reasons the difference could be explained including

  • For some unknown reason old people are sicker in the U. S. than elsewhere.
  • Due to inadequate care earlier in life old people in the U. S. are sicker than elsewhere.
  • Old people in OECD countries other than the U. S. don’t get the healthcare they need.
  • The healthcare system in the U. S. is mobilized to potentialize the heavy subsidy we provide healthcare for old people.

I presume there are other explanations. I think it’s a combination of factors, leaning heavily to the second and last.

Whatever the underlying reason, it’s a graphic depiction of the point made in Steven’s post. What’s wrong with this picture?

138 responses to “One of These Is Not Like the Others”

  1. KM Avatar
    KM

    Considering I’m sitting in an office with a woman I’m trying to talk into going to the urgent care for a broken finger (from last week!!), I’m going to go with “Due to inadequate care earlier in life old people in the U. S. are sicker than elsewhere” for a $1,000, Dave. She’s demurring but it’s pretty clear she doesn’t want to rack up a bill this close to end of year. It’s already healing wrong and she’s in visible pain.

    I’m not surprised that a lifetime of ignoring health issues for money can and will catch up with you hard. An ounce of prevention is worth a pound of cure.

  2. DC Loser Avatar
    DC Loser

    Maybe the fact that all the countries except the US has some kind of universal health care coverage and we don’t is the biggest factor?

  3. john personna Avatar
    john personna

    I think you can add as a factor:

    “In the US, ‘slightly sick’ people are treated more expensively and aggressively than elsewhere.”

    I mean, my doctors actually consider me “in very good shape” (their words) but want me on lipitor and to get the requisite suite of blood tests every 3-6 months.

    I think 50 is the age where people start getting slight complaints, and in the US, that will get you lots of tests and/or permanent prescriptions for drugs-for-life.

  4. john personna Avatar
    john personna

    Perhaps I should go further and say that

    In the US, when you are not “healthy’, you are over-treated.

  5. john personna Avatar
    john personna

    @KM:

    That is a sad story, and if there is any sign of complications she should absolutely go to the doctor … but as someone who has healed a couple fractures before asking the doctor about them .. the old fashioned way actually works more than you’d think.

  6. SKI Avatar
    SKI

    From inside the industry, my perspective is that another huge piece is cultural – both societal and medical. We spend insane amounts of money in the last 6 months. 70+% of people don’t want to die in a hospital bed. 70+% do.

    The areas of the country (Pacific Northwest) that are more educated/informed/used to advanced directives (putting the patient, not their family or doctors, in charge of health care choices) have much lower ICU utilization and end of life costs.

    A major problem is the view that death can and should be beaten. Changing that starts with little things like renaming “Do Not Resucitate” or DNR to “Allow Natural Death” or AND. That simple switch starts to move the thinking from doctor-centric to patient-centric; from a presumption that death is a failure to a recognition that it is natural.

  7. Franklin Avatar
    Franklin

    @john personna: Get new doctors. Your current ones will believe anything a drug company rep tells them.

  8. anjin-san Avatar
    anjin-san

    My experience with my grandparents left me convinced that the system is set up to keep people alive long enough to drain them financially before they die.

  9. john personna Avatar
    john personna

    @Franklin:

    The interesting thing is that they are Kaiser. A non-profit, who even if they are not in it for me, should be in it to keep down their total system HMO costs.

    The LACK of a conflict of interest is what keeps me on the drug.

  10. grumpy realist Avatar
    grumpy realist

    Is it the doctors over-prescribing, or the patient being eager for anything that will “fix the condition”?

    For instance, I’ve got a wonky ankle. Luckily I’ve got a doctor who’s quite willing to follow the “wait and see” attitude and allow me to try to strengthen the foot muscles rather than stampeding me into hospitals for MRI tests, operations to tighten up the tendons, etc. We’ve basically decided that unless an operation has more than a 75% chance of helping me, no soap, which is why we’ve stayed away from a lot of the foot surgeries other, more aggressive doctors might be pushing on me.

  11. beth Avatar
    beth

    @SKI: Very intelligent view however, once you start talking about any kind of end of life care, cries of “death panels” go up and all rational conversation stops.

    I’m curious about the cultural differences between the US and European countries. Are there different levels of acceptance for suspending futile care in the cultures? Where are there higher percentages of people choosing not to take extraordinary measures at life’s end?

  12. john personna Avatar
    john personna

    BTW, remember that I met a freshly minted young pharmacist who was surprised that I as a 50-something was “only” on one prescription. “That’s good,” he said, leaving me to think “what have we come to in this country?”

  13. john personna Avatar
    john personna

    @grumpy realist:

    I have a friend who has slightly pinched spine, which gives her no pain, but has produced some atrophy in one calf. A doctor suggested decompressive surgery. And so my friend asked four of her friends whether to do it. Her friends all split 50:50, do it, don’t do it. Now, the punch line is that the four friends she asked are all top flight surgeons in various domains.

    Even they could not agree.

  14. john personna Avatar
    john personna

    @beth:

    I think the US would have been very open (still would be) to end-of-life planning, if the Republicans had not just decided to make it a wedge issue, and “irrationalize it.”

    Remember, there were a number of Republican Senators who had advised end-of-life planning before it became a “get Obama” issue.

  15. Dave Schuler Avatar
    Dave Schuler

    @DC Loser:

    Maybe the fact that all the countries except the US has some kind of universal health care coverage and we don’t is the biggest factor?

    Unless you presuppose that any imaginable system of universal care necessarily results in the allocation of care according to cost-benefit, universal care alone does not explain it. You need one or more of the other factors in my list.

    Don’t construe that as my opposing universal care. I don’t. I just don’t think that universal care alone is an adequate change.

    Note, too, that the apparent increase in spending per person per year at age 55 is an artifact of smoothing. The original numbers on which the graph is based which apparently come from the NBER show a sharp up-tick in spending at age 65.

  16. michael reynolds Avatar
    michael reynolds

    I think it’s philosophical: I think Americans fear death more and are willing to bankrupt themselves and their families (and the government) to hold it off for another year or month or day.

    I blame religion. We are far more religious than other advanced countries, and our religions emphasize fear of death in order to spread their influence. Be afraid, we can save you!

    The promise of heaven is balanced by the threat of hell, and neither is sufficiently believed at the deep, organic level, as to be taken seriously by adherents – otherwise, obviously they’d be perfectly happy to die. But with heads stuffed full of comforting nonsense, Americans lose sight of the fact that death is to be expected, is a normal part of life, and in the case of a septuagenarian or octogenarian, not a tragedy but just the inevitable end of one story.

    You don’t throw away a half million dollars in desperate measures on an 80 year-old cancer patient if you understand that death is a part of life.

  17. JohnMcC Avatar
    JohnMcC

    @john personna: Mr Personna, it might interest you to know that your Doctor is voicing a majority opinion, that ‘statin’ drugs extend the life expectancy of healthy people. There is a vocal minority. The ref I found to the issue is a WSJ article of 23 Jan ’12 (“Should Healthy People Take Cholesterol Drugs to Prevent Heart Disease) so you can obviously make a contrary decision and find someone to support you. I didn’t take them. Of course, I had a nearly fatal heart attack in July of 07. So consider the issue very very carefully.

    Simlar decisions abound. A colonoscopy runs approx $8,000 and only takes the MD about 10 minutes. The statistics don’t show much advantage over the alternate method of early cancer detection (a smear of feces on a slide that a lab can search for intestinal blood). One of the MDs in my family recommends the alternative, other MDs in the family think he’s crazy to not have polyps discovered and removed until they become malignant and bleed. Many other examples…yadda, yadda.

    None of these will save the kinds of money that having everyone define in advance what kind of medical treatment we wish in our last days. Of course, this common-sense and merciful conversation with one’s chosen PMP became labeled a ‘death panel’ and so was removed (or the reimbursement to the Doc for having this discussion was) from the PPACA.

    I can’t begin to express my 30+ years of disgust at taking care of 80 and 90 year-old folks who have unfortunately ended up in my ICUs because no one knows if we should ‘do everything’ for someone experiencing the last days of this earthly travail. And I don’t say that because I wish them to die. I wish they could live without torture. Being a patient in an ICU is torturous, by the way. One is never allowed to sleep. Every oriface of your body has a tube made just for entering it; and we do it all day long and all night long. We probe people with needles, drill into their brains, bounce them through cold corridors for CATScans and “procedures”. And when their hearts fail we shock them back to function. When breathing stops — another tube and another machine.

    This is beautiful and inspiring when the recipient is the 50 year old who wants to live to see his grandson graduate or the 20 year old who was to be married last week. When the recipient is an 89 year old nursing home patient with dementia who undergoes our “care” for weeks we universally hate it, in my profession (ICU Nurse). We do it lustily and skillfully and more often that not it ‘works’. Then — at least in my case — I go home and pour a large slug of small-batch or single-barrel and sit on the patio in my pajamas thinking that the world is really a rotten place.

    And the whole time the bills pile up that produce Mr Schule’s graph above. Well done, Ms Palin with your ‘death panels’.

    Republicans delende est!

  18. KM Avatar
    KM

    @john personna:

    Normally I’d agree with that on smaller breaks like toes and such but this is a former cancer patient in remission only 2 months with a host of other health issues. And this is not a little break -it’s immediately obvious and very, very red. She does a lot of typing so that’s constant use of the finger and I can tell from a brief glance it’s not healing right. She does want to go but doesn’t want the bill on top of all the others she’s incurred this year alone.

    It’s very depressing to think she’s survived cancer but can’t/won’t get a break fixed based on monetary issues alone. This is what needs to be addressed – this is why healthcare needs an overhaul. In 2013, in one of the most prosperous nations on Earth, something like this shouldn’t even come to pass.

  19. Dave Schuler Avatar
    Dave Schuler

    @michael reynolds:

    I agree that religion is one cultural difference but I think the difference is somewhat more subtle than you’re suggesting. My mom, for example, was quite religious and steadfastly refused anything other than palliative care at the end. She was strongly opposed to “heroic measures” and she defined those rather broadly.

    It’s hard to come up with good data, at least in part because it’s hard to get studies along these lines funded, but if you use race as a proxy for religion, as it turns out American blacks are more likely to seek aggressive end of life care and and reject DNRs. It’s attributed to “religion, socio-economic strife, and distrust of the medical establishment”.

    I suspect that the contending forces of religion and secularism, much more drastic here than in most European countries of my experience, make it more difficult for many Americans to come to terms with mortality.

  20. john personna Avatar
    john personna

    @JohnMcC:

    Mr Personna, it might interest you to know that your Doctor is voicing a majority opinion, that ‘statin’ drugs extend the life expectancy of healthy people. There is a vocal minority. The ref I found to the issue is a WSJ article of 23 Jan ’12 (“Should Healthy People Take Cholesterol Drugs to Prevent Heart Disease) so you can obviously make a contrary decision and find someone to support you. I didn’t take them. Of course, I had a nearly fatal heart attack in July of 07. So consider the issue very very carefully.

    I did think about these issues, and tried to step up one meta level. I am certainly aware that “use statins” is a stock answer doctors give to a certain group. I am within that group. Now, as a 55 year old, who is 6′ and 145, who has blood pressure 120/80, who can run a mile in 8 1/2 minutes … am I really “within” that group?

    Maybe not, but I decided to, “trust expertise.”

    I have high confidence of myself in my domains of competence, but I am extremely skeptical of anyone who simply applies their confidence to a new domain.

    Ultimately, I take statins because my doctor(s) went to medical school, and I did not.

  21. john personna Avatar
    john personna

    @KM:

    That is very sad, and (despite this being outside my area of expertise) that does sound like something that warrants attention.

    (FWIW though, one of my self-healed fractures was a hip! I wasn’t even counting toes.)

  22. Gavrilo Avatar
    Gavrilo

    @KM:

    Your friend is probably worried that the Doctor will want to amputate her finger. After all, according to President Obama, doctors routinely choose to amputate because they make more money.

  23. john personna Avatar
    john personna

    @JohnMcC:

    A colonoscopy runs approx $8,000 and only takes the MD about 10 minutes.

    BTW, a friend told me that their bill showed insurance paying $20,000 for a routine colonoscopy recently.

    Part of the strangeness of our system.

  24. KM Avatar
    KM

    @michael reynolds :

    I think it’s philosophical: I think Americans fear death more and are willing to bankrupt themselves and their families (and the government) to hold it off for another year or month or day.

    You don’t throw away a half million dollars in desperate measures on an 80 year-old cancer patient if you understand that death is a part of life.

    OMG this!! Most of my family have worked in a prominent cancer hospital for the majority of our lives (myself only for 2 years). You would not believe the lengths terminal patients go to in order to stave off death for another week. One instance in particular stands out for me: a patient had a surgery that essentially removed almost his entire digestive track and had his esophagus stretched to try and replace it. Life expectancy: 2 weeks. My job was to explain the new BRAT diet he was on as digestion was not happening any longer. He kept talking about how he was going to have a steak and start up jogging again. This man was never leaving that bed again. When he finally realized that rib-eye wasn’t happening, he became violent. He thought he’d been cured when it was made clear this was to buy time at best.

    I have no idea what the bill for something like that would be but it had to be huge! He passed that along to his family or to us. His selfishness raked up an enormous bill just so he could delude himself for a few more days of pain and misery. It sounds cold, but there comes a point when enough is enough.

  25. PJ Avatar
    PJ

    @Dave Shuler:

    I presume there are other explanations.

    Socialized Death Panels.
    When people in Europe get old and really sick they are non-voluntary euthanized.

  26. KM Avatar
    KM

    @john personna:
    Thank you for your kindness. I’m taking her out for lunch and then offering to pay for the urgent care if she’s willing. It’s only $75 on our plan and frankly, I’d consider it money well spent. I can go without my Starbucks if it means she gets what she needs. Sorry for highjacking the thread – this is just really bugging me and that she still has to struggle like this in a country that can do so much better for its citizens. Healthcare reform is a dear subject to me and this just drove it home this morning. No one should have to count their pennies before seeing if they can afford medical care.

  27. john personna Avatar
    john personna

    @KM:

    In contrast, I read a little book, mostly about books, which told a story. The author, an American living in Wales, mentioned that a 92 yo relative was diagnosed with cancer. He says something like “in Britain that just means you are going to die,” and that heroic measures for 90-somethings are not justified.

    They might be more right than us.

  28. Mikey Avatar
    Mikey

    @KM: A broken finger can end up costing a boatload of money.

    My daughter (age 26, grad student, amazingly healthy and strong) had a pretty bad break of her right ring finger. It was a spiral fracture, and after consultation and X-rays her physician decided it would be best to surgically correct it. So, surgery, a couple titanium screws, and insurance was billed for nearly $20K…of which I was responsible for nearly $5K (thank you, high deductible health plan).

    And her finger’s still a bit wonky.

  29. JohnMcC Avatar
    JohnMcC

    @PJ: Can you cite something like proof for that? I can tell you from personal knowledge that many european MDs would be shocked to discover that this is happening around them.

  30. pylon Avatar
    pylon

    The correct answer is, of course, American Exceptionalism.

  31. JohnMcC Avatar
    JohnMcC

    @john personna: You know, my fellow John, a 92 year old who is diagnosed with cancer — depending somewhat on the particular cancer, of course — is going to die ANYWHERE!!!

    Would you prefer that that 92 year old have the gastric removal surgery that Mr/Ms KM described — for an intestinal cancer. Or come to my ICU (for a brain tumor) and have the NeuroSurgery resident take a bit-and-brace to drill a hole into the ventricles of his brain so I can measure his intercranial pressure?

    Would you prefer that 92 year old be assisted in whatever way keeps him comfortable and die with his family nearby?

    We really do not have much choice as to whether we’re going to die. We are.

  32. Mikey Avatar
    Mikey

    @john personna: Can you imagine many Americans who would accept that? I can’t. I don’t mean the acceptance of the inevitable for a nonagenarian cancer sufferer, I mean the government telling their family “Grandpa’s not worth saving.”

    Then again we had a DNR for my father, who died a year ago this month from Pick’s disease (a frontotemporal dementia). On his last trip to the hospital he had an infection that wasn’t responding to antibiotics. Docs gave him about a month, and us (his children) the choice: do we keep pushing, or just accept that his life is nearing its end? Even knowing how things would inevitably go, it was still one of the hardest choices we’ve ever had to make. We took him home, he returned to his “normal” life, was generally comfortable, and passed away in his sleep three weeks later.

    How much better was that than trying to drag out the inevitable, alone in a hospital with tubes connected half-a-dozen places? Immeasurably better, for him and for us.

    But Americans want that choice left to the patient and his/her family, and won’t accept the government making it. Hence, “death panels.”

    (I just realized today would have been Dad’s 77th birthday. Someone’s cutting onions in here…)

  33. rudderpedals Avatar
    rudderpedals

    @john personna: Part of the strangeness of our system.

    That sort of pricing disparity for identical procedures makes no sense. What possible justification is there for a $12,000 difference?

  34. john personna Avatar
    john personna

    @Mikey:

    I think JohnMcC covered this adequately.

    What we need is education, and not politicization of “death panels.”

    When I’m 92 and told I have bowel cancer, maybe I should be sent home with some morphine.

    Related: How doctors die.

  35. john personna Avatar
    john personna

    @rudderpedals:

    Obviously nothing justifies it, truly. I can only think that all the numbers we see as mere “patients” and “plan members” are fake, and the “real economy” is opaque to us.

  36. Edwin Perello Avatar
    Edwin Perello

    @KM: And I imagine a lot of that reasoning and reluctance is the same reasoning I am reluctant to get health care: I don’t have anything to fall back on because my income just doesn’t allow it and I don’t have any additional resources to help me get back on my feet if I falter.

    In many of those countries, the youth DO have something to fall back on thanks to social welfare.

    I don’t… Because even as I falter, I still make too much money to be eligible for any means tested programs.

  37. Gavrilo Avatar
    Gavrilo

    So, at precisely the time that the federal government takes over health care funding through Medicare, per capita spending on health care skyrockets? Hmm. Obviously, the answer is for the federal government to subsidize health care for more Americans. That’s a brilliant idea!

  38. john personna Avatar
    john personna

    @Mikey:

    BTW, on the personal content of your story, I feel for you absolutely.

    I can’t actually write well enough to say what I’d like for those who suffer with their families, at all the ages below “time to go.”

  39. Pinky Avatar
    Pinky

    There’s a difference between making the choice for/against treatment based on quality of life and likely time added, and making it based on money. Intestine-stretching guy might have made a different decision if he thought about how little time the surgery would gain him, how much risk there was, et cetera. He would not have made a different decision because of the money. He definitely wouldn’t have if he thought that the money wasn’t real, i.e. just some accounting between the government, insurance, and the hospital. What would he do if he was told that the neighborhood park wasn’t going to be built because he got intestine-stretching surgery?

  40. john personna Avatar
    john personna

    @Gavrilo:

    Perhaps you look at the correlation, but have the causation backwards?

    Why exactly was Medicare invented for “the elderly?”

  41. beth Avatar
    beth

    @Gavrilo: Yes, their health care costs go up only because the government is now paying for it, not because they’re over 65 years old. I guess old people never incur proportionately more health related expenses in your world. Must be a nice place to live.

  42. john personna Avatar
    john personna

    @Pinky:

    The Republicans politicized the “death panels,” remember?

    In real life those were the advisers who would help people with cost, quality of life, and length of life information.

    There is a whole discipline now, with certificates, in Health Care Ethics

    The Republican answer to that has been “the ethicists want to kill your grandmother!”

  43. James in Silverdale, WA Avatar
    James in Silverdale, WA

    Very useful discussion, thank you.

  44. michael reynolds Avatar
    michael reynolds

    I had a fun cancer scare a couple years ago. (Prostate, clean.) Currently in the middle of what I hope is just a repeat of same. (And even if it isn’t, it tends not to kill you any time soon). So I’ve been thinking a bit about dying. I’m 59, so, all things considered I’d rather not. But I’ve searched myself as honestly as I can and I don’t find any fear of death. My concerns on that have mostly to do with feeling as if I’d be running out on my responsibilities to my kids, my wife, my publisher, etc…

    I am however afraid of being slowly, expensively hacked apart. I can afford the heroic measures, but if it comes to that, what’s the point? Maybe because my thinking is so much tied up with books, I get that life has a beginning, middle and end, and that the end is necessary or the rest of the story is all build-up with no pay-off. Tell me I’ve got a 50/50 chance of some more good years? Then you may hack away, doctors. Tell me it’s months or weeks of pain and degradation for no real purpose? I’ll pass. (Hah, see what I did there? Pass?)

    We’re all the heroes of our own stories. I’ll do what I can to make a decent end of it. But I also feel very lucky to have had this life and if I drop dead tomorrow I’ll be grateful not resentful. Life treated me better than I deserve. Hopefully will go on doing so. But I wonder how many people fear the end because they’re unhappy with life, disappointed, can’t believe it’s over. It would be interesting to do a study comparing perceived quality of life experience with heroic measures. Do you fight more desperately if your whole life was a disappointment?

  45. Gavrilo Avatar
    Gavrilo

    @beth:

    Look at the graph, genius. Per capita healthcare costs in the U.S. are right in line with the other countries up until age 55. And, while they increase in all countries, it is only in the U.S. that the cost skyrockets. How do you explain that? The only reason why the U.S. spends more in health care than other countries is because we spend a vastly disproportionate amount on those who are covered by the federal government. The federal government clearly doesn’t do a very good job.

  46. john personna Avatar
    john personna

    @michael reynolds:

    The “death panels” need to help the people who should fight, who can have more good years, to fight. And then yeah, they need to help people who only have a year or two, no matter what, to deal with it.

  47. john personna Avatar
    john personna

    @Gavrilo:

    We’ve given explanations above. Mine is that the US excels at billing slightly-sick people, and getting more out of sick people, without appreciably increasing their life expectancy.

  48. john personna Avatar
    john personna

    @Gavrilo:

    BTW, you do know that you are defending the status quo here, while faulting it, right?

    You don’t actually want a better system, do you?

    If so, name it.

  49. grumpy realist Avatar
    grumpy realist

    @PJ: Maybe we’re going to have to get to that point for people who insist that their lives be preserved at all costs–with the costs getting laid on the taxpayer. Bluntly–we can’t afford it. I’d rather spend money on a young individual who has a chance of growing up and becoming a tax-paying citizen. If you’re at the end of your life and aren’t going to be able to contribute anything back–why should taxpayers continue to pay for your every medical desire?

    At some point, being a part of the community means not being too much of a burden on everyone else. I hope that when my time comes, I will have the dignity to go out with courage and a smile on my lips, rather than insisting on life No Matter What.

  50. Gavrilo Avatar
    Gavrilo

    @john personna:

    No, the explanation is that the federal government excels at paying huge health care costs for people on Medicare. Employer-based insurance (which the vast majority of Americans have until age 65) in the U.S. somehow manages to keep health care costs in line with single-payer, government run systems in several European countries.

    No, I don’t want a system that gives the government more control. Our government obviously can’t handle Medicare!

  51. SKI Avatar
    SKI

    @Gavrilo:

    The federal government clearly doesn’t do a very good job.

    Except that the Federal Government doesn’t actually provide the care, just the payments. And when the experts want to limit choices to save money, get killed and overruled by the taxpayers (via Congress). Heck, the Feds aren’t even allowed to use its purchasing power and scale to get better deals on drugs.

  52. john personna Avatar
    john personna

    @Gavrilo:

    Pfft. That is a weak argument, and one specially tailored not to look at solutions, isn’t it?

    We know from the graph that Steven and I use that our costs are way out of line from other more governmental systems.

    Your argument is, well, “exceptionalism” again, isn’t it?

    We can’t be better, we can’t be like the others, because we’re “special.”

  53. JohnMcC Avatar
    JohnMcC

    @Gavrilo: I swear I really try to be polite and dispassionate and to remember that those who disagree are not enemies but fellow passengers on this long strange trip. You are making this difficult, my dear.

    First of all, no one in a hospital knows how much is charged for the services and products we render. The simplest thing in the world, a bag of Normal Saline for IV use was tracked by a reporter covering an outbreak of food poisoning that sent victims to a couple of local hospitals in NY state. The article was in the NYTimes and is titled ‘How to Charge $546.00 for Six Liters of Saltwater’. Before exposing any more ignorance, you should read it:
    http://www.newyorktimes.com/2013/08/27/health/exploring-salines-secret-costs.html

    This same rule of no one knows extends to EVERYTHING we do. Back in May the CMS released the charges various hospitals charge for 100 particular procedures, surgeries and DRGs (Diagnosis Related Groups — if you don’t know what DRGs are, heaven help you and you have a great deal of study ahead before you can speak intelligently about hospital costs).
    At various hospitals around the country. They showed that because insurers make deals with hospitals, the cost billed to insurer A is completely different from that billed to insurer B and completely different from what Medicare is billed and again different from what they would charge a self-pay (uninsured) patient. There is no way to discover in advance what that billed amount will be for a procedure/surgery/illness before you present yourself to a hospital. And even if you discovered what the ‘official’ price tag is at a given hospital, it might not apply to you because your insurer has made a deal with them.

    It gets more absurd! There are huge price differences between hospitals merely blocks apart for identical care. This was well covered in the NYTimes and WaPo and, really, everywhere. For a summary of the media coverage go to the Kaiser people.
    http://www.kaiserhealthnews.org/daily-reports/2013/may/09/hospital-cost.aspx

    There are many financial winners in the healthcare business. My BA got me as far as being a competent roofer. My Associate Degree in Nursing has given my the chance to make a damn fine living and drink real fine whiskey. Some MDs work real hard to make much above $100K (really — a pediatrician in the hills-n-hollers of Tennessee for example) Some plastic surgeons and orthopedic sugeons have their brokers on speed dial and ALWAYS get through.

    But the biggest winners are executives in the insurance and hospital administration line. One hospital I worked at had a retiring CEO receive a $1Million bonus. After the new guy took over it was discovered that during the previous year the hospital had been so slow in it’s billling to Medicaid that the state was actually out of money when the bills arrived. So sorry, better luck next year. And the hospital had to eat some $24Million because of that delay. But I’m sure that the boss got to keep his bonus.

    That was another day I had a large slug of single-barrel and sat on my patio in my pajamas brooding about what kind of world I live in.

  54. Rob in CT Avatar
    Rob in CT

    But the biggest winners are executives in the insurance and hospital administration line. One hospital I worked at had a retiring CEO receive a $1Million bonus. After the new guy took over it was discovered that during the previous year the hospital had been so slow in it’s billling to Medicaid that the state was actually out of money when the bills arrived. So sorry, better luck next year. And the hospital had to eat some $24Million because of that delay. But I’m sure that the boss got to keep his bonus.

    That triggered a memory. We recently got a bill from a hospital for care given in mid-2012 (!). Thankfully, BCBS went ahead and paid it (to be clear, we received the explanation of benefits with $0 due from us, so we didn’t actually ever see the hospital’s bill). They’d have been within their rights to refuse, I believe.

    That’s the second time in the past few years I’ve had a healthcare providing bill more than a year after the time of service. Even the ones that get handled semi-properly are shockingly late. Why would you sit on a large (tens of thousands of $) bill for six months? Of course, who handles the billing for the hosptial? An outside contractor. I have a sneaking suspicion that has a little something to do with it (no proof, though. Could be the hospital can’t get its act together and the contractor is tip-top).

    Hospital billing is immensely f*cked up. I have to think that most health care workers would be appalled at what their billing departments are up to. And these are all private business. I have employer provided insurance.

    So, while I think there is some truth to the “medicare caused medical inflation” line, it’s very incomplete. The portion that *is* due to Medicare can be fixed without tearing the whole thing down. Medicare needs to be able to bargain, which in turn means it needs to be able to say “No.” And there has to be rationale for saying no, which in turn means Medicare needs expert guidance, which in turn means “Death Panels.”

    [There is a conflation between the end of life planning thing – very much a commonsense and, pre-Obama, Republican, idea and the idea of an advisory board that recommends pay/not-pay. I think both are good ideas, but they really aren’t the same thing]

  55. Gavrilo Avatar
    Gavrilo

    @JohnMcC:

    A. Nothing I wrote is worth you getting all upset. Remain calm and dispassionate. I was simply pointing out what the graph shows.

    B. What the graph shows is that from age 0-55, when most Americans get their health insurance from private companies, either through an employer-based plan or on the individual market, per capita health care costs are very much in line with the other countries. Regardless of what deals insurance companies make with hospitals or how much hospital CEO’s make, our private health insurance spends roughly the same amount per capita as government health insurance in the other countries on the graph.

    C. It is only when the federal government takes over at age 65 that we see a huge disparity among what health care costs in the U.S. relative to the other countries.

    How is it that our primarily private insurance based system competes (in terms of per capita costs) with other countries’ government based systems, yet our government based system (Medicare) spends exponentially more than those countries?

  56. PJ Avatar
    PJ

    @JohnMcC:

    Can you cite something like proof for that?

    I pulled that straight out of Sarah Palin’s behind.
    Also, Europe had Nazis. All who were socialists and had concentration camps.

  57. Hal 10000 Avatar
    Hal 10000

    I don’t think the second explanation works because there is a growing body of research showing that while preventative care may save lives, it does not save money (preventative care is expensive; dying is cheap). I think the fourth explanation is the most accurate because I’ve seen it. People on the verge of death getting the last full measure at $10,000 per day to stave it off another day. This is rarely their choice. It’s that the didn’t realize that this would be the default if they were unable to give orders. Families aren’t willing to “pull the plug” because they don’t want to kill gramps. Doctors demur on the wise choice because they don’t want to get sued.

    One piece of legislation that could address this: anyone who enrolls in Medicare has to fill out a living will. The contents of that will are not controlled. if you want the last full measure, you get the last full measure. But I guarantee you that millions of people would shy off from extraordinary measures and save us billions.

  58. Andy Avatar
    Andy

    For some unknown reason old people are sicker in the U. S. than elsewhere.

    Alternatively, people in the US generally are sicker. It certainly seems like we live, on average, a less healthy lifestyle.

    Due to inadequate care earlier in life old people in the U. S. are sicker than elsewhere.

    Makes me wonder if there is a study somewhere that examines how a lack of access to care or coverage affects medical spending once on Medicare. If a large portion of that money was spent on those people, then that would be a real factor. Here’s a tidbit I found from a recent Medicare trustees report:

    Medicare FFS spending is concentrated among a small number of beneficiaries. In 2008, the costliest 5 percent of beneficiaries accounted for 38 percent of annual Medicare FFS spending and the costliest quartile accounted for 81 percent. By contrast, the least costly half of beneficiaries accounted for only 5 percent of FFS spending.

    Costly beneficiaries tend to include those who have multiple chronic conditions, are using inpatient hospital services, are dually edligible for Medicare and Medicaid, and are in the last year of life.

    Continuing with your points:

    Old people in OECD countries other than the U. S. don’t get the healthcare they need.

    Alternatively, old people in the US get much more healthcare than they actually need.

    The healthcare system in the U. S. is mobilized to potentialize the heavy subsidy we provide healthcare for old people.

    Doc fix, FFS, “keep your hands of my medicare” anyone?

    Certainly a lot more study is required to determine exactly where the money goes.

  59. john personna Avatar
    john personna

    @Gavrilo:

    I can’t believe I missed the big flaw in your reasoning!

    All of those countries have government provided health care for seniors.

    We just do it especially badly, how do we fix that?

    Obviously we did do not need to discard government because of other countries did not.

  60. Tony W Avatar
    Tony W

    @Gavrilo:

    So, at precisely the time that the federal government takes over health care funding through Medicare, per capita spending on health care skyrockets?

    Surprised you didn’t mention the reduction in the number of pirates worldwide as the cause of increased health care spending.

    Just in case my snark is too lofty to comprehend – association does not equal causation.

  61. Pinky Avatar
    Pinky

    @Hal 10000: How does a non-professional determine whether a treatment is $50 or $50,000? Whether it’s going to add a painful week to a dying patient’s life or save that life? We can’t expect the non-professional to come up with a good answer if he doesn’t have at least an approximation of the necessary information.

  62. john personna Avatar
    john personna

    @Andy:

    Alternatively, people in the US generally are sicker. It certainly seems like we live, on average, a less healthy lifestyle.

    You can try to show that, with numbers.

    But for what its worth, the colonoscopy numbers above show how slightly ill, or even healthy people are overcharged in our system:

    Colonoscopies Explain Why U.S. Leads the World in Health Expenditures

    That is a data driven argument.

  63. john personna Avatar
    john personna

    @Pinky:

    Someone (death panel) has to explain the survival chances *with* treatment, and when they are not good.

  64. Ron Beasley Avatar
    Ron Beasley

    @KM: My uncle who died at 80 was diagnosed with cancer 2 years before. Over $200,000 were spent to keep him alive for those two years and most those two years were a hell on earth for him.

  65. Rob in CT Avatar
    Rob in CT

    @john personna:

    In addition to this, you can see clearly on the chart that our expenditures start skyrocketing not at age 65, but around age 55.

  66. Mikey Avatar
    Mikey

    @Rob in CT: Per Dave Schuler:

    Note, too, that the apparent increase in spending per person per year at age 55 is an artifact of smoothing. The original numbers on which the graph is based which apparently come from the NBER show a sharp up-tick in spending at age 65.

  67. Mikey Avatar
    Mikey

    @john personna:

    When I’m 92 and told I have bowel cancer, maybe I should be sent home with some morphine.

    You probably should. That’s the choice my late grandmother made–age 82, cancer she’d been treated for several years previously had returned. She was given the option of chemo and other treatment, but basically said “I’m 82, I’ve had a good long life, no need for any of that.” She died a few months later, at home, with my grandfather at her side. The only expense she incurred was a weekly visit from a hospice nurse (who didn’t do much besides listen to Grandma talk about the grandkids). I can’t imagine Grandpa having to deal with all the other crap that could have been done.

    That’s the thing, too–we end up paying a great sum of money to extend life a few months and it’s not even GOOD life, a lot of times. Grandma could have had chemo, but how miserable would that have been for an old lady? As it turned out, she actually felt pretty good up until very shortly before she passed away. Maybe her life was a few months shorter, but the months she had were so much better.

    When you talk about “education,” maybe that’s the direction we should go–let people know exactly how expensive it will be to add a few low-quality months to the inevitable end, and ask them “is it really worth it?”

  68. john personna Avatar
    john personna

    @Mikey:

    Gosh, if only someone could chart the raw NBER data, eh?

    But really, that shouldn’t matter, because the meat of this comparison is between us and those other countries. They exhibit minor variation. If we didn’t have the US flier, we might make more of the German take-off at 40, and the Swedes at 30. The graph for those is compressed, because our data is so outrageous.

    And that outrageousness isn’t simply explained by “we use the government and they don’t” !!!

  69. Mikey Avatar
    Mikey

    @john personna:

    And that outrageousness isn’t simply explained by “we use the government and they don’t” !!!

    Because they use the government, too, of course–they just do it dramatically better than we do.

  70. john personna Avatar
    john personna

    @Mikey:

    Of course, that’s where I’ve been coming from all through this thread.

    And … I think we can lay that blame squarely on that US party which seeks to demonstrate the inability of the Government to solve problems, in every single issue.

    In a two-party system you can’t fix anything with a single “fix it” party and a permanent “I told you so” party.

  71. john personna Avatar
    john personna

    @this:

    So, shy (and idiot) down-voter, what IS the Republican plan to bring our spending in line with those other countries?

    I forgot, the “plan” is to nothing and complain about government.

  72. PJ Avatar
    PJ

    About that chart…

    There wasn’t a link to the Forbes article, so I googled and I found this from a year ago:

    UPDATE: Chart deemed bogus. See comments. Rest of post altered to reflect that fact, including a big red “X” through the chart. I’ve left this post up to document the problems with the chart. If you use the chart and don’t mention those or refer readers to the comments below, you’re acting irresponsibly.

    Fully agree. Read the comments.

    This chart is crap.

  73. PJ Avatar
    PJ

    Some excerpts from the comments:

    The underlying data on countries’ age-spending profiles were obtained by Kotlikoff and Hagist from 10 different country-specific studies. The authors do not report having done anything to confirm that the various studies all cover the same types of spending. In fact, as nearly as I can tell, they do not even acknowledge the possibility that the figures from different studies might not have comparable coverage.

    The chart is misleading. Kotlikoff et al.’s paper looks at PUBLIC spending only. There is very little public spending on adults in the US until they enroll inMedicare (mostly at 65, but quite a few disabled enrollees in the 55-64 age group). That’s what produces the dramatic leap in the US data.

    It’s crap.

  74. john personna Avatar
    john personna

    @PJ:

    As I think the ability to draw a crooked red “x” shows much mathematical prowess (sarc), I decided to look for a second source.

    This Carnegie-Mellon Chart has a different format but seems to show the same thing, the US as a huge outlier.

  75. PJ Avatar
    PJ

    @john personna:
    Read the comments.

    The other chart shows the same thing because it’s the same source. Paul Fischbeck.

  76. Gavrilo Avatar
    Gavrilo

    @john personna:

    If spending more money on per capita health care costs in the U.S. is an example of a broken system in need of reform, then the federal government broke it.

  77. PJ Avatar
    PJ

    @Dave Schuler:

    What’s wrong with this picture?

    Bad data.

  78. john personna Avatar
    john personna

    @PJ:

    I don’t have the patience, if all it is, is a bunch of “I don’t like this data for a bunch of reasons I just pulled out of thin air.”

    For me, you disprove data, with better data.

    Anything else is too likely “I don’t like your data because it doesn’t tell me what I want to hear.”

  79. john personna Avatar
    john personna

    @Gavrilo:

    Explaining slowly, for the slow members of the audience:

    If the US healthcare system were fully nationalized, then sure, 100% of the blame would lie with the government. For that you’d need government hospitals and doctors employed directly by the government.

    Of course, when you have a public-private partnership, which enriches the private part, surely blame can be spread?

  80. Andy Avatar
    Andy

    Yep, looks like the chart has some serious problems – Since I’m the one that originally posted a link along with the paper the data came from, I take responsibility for not reading the details of the data used for the analysis prior to posting the link.

  81. PJ Avatar
    PJ

    @john personna:

    I don’t have the patience, if all it is, is a bunch of “I don’t like this data for a bunch of reasons I just pulled out of thin air.”

    The chart was disproven almost a year ago.
    The reasons are not pulled out of thin air, read the comments.

    For me, you disprove data, with better data.

    In this case, you disprove the chart by, for instance, pointing out that the chart is based on a number of country specific surveys that don’t seem to be coordinated…

  82. john personna Avatar
    john personna

    @PJ:

    Really, I’m trying to give you a chance here.

    Do you have actual numeric errors for this chart? Numbers?

    Or just hand-waving?

  83. john personna Avatar
    john personna

    @Andy:

    I know, someone scrawled an “x,” with all the skill of a 4 year old!

    For that reason, and because it tells us something uncomfortable, let’s throw it out.

  84. john personna Avatar
    john personna

    Seriously, the idea that someone MIGHT do a better study has merit. There might ALWAYS be a better study.

    That DOES NOT mean that this study does not tell truths.

  85. john personna Avatar
    john personna

    I mean, you could knock $20K PER YEAR off the US numbers at age [80], just give that much up as a fudge factor, and we’d STILL look foolish compared to all the others.

  86. Andy Avatar
    Andy

    Ok, followed some links on this topic to find this which is official, comprehensive data from HHS.

    Someone more clever than I should build a chart based on the data.

  87. john personna Avatar
    john personna

    @Andy:

    Insufficient data, particularly in age resolution. It is only over/under 65, and only “[median] and mean” for those sets.

  88. PJ Avatar
    PJ

    @john personna:
    You have been arguing in this thread about a picture of a chart that was posted without a link and with no information whatsoever about what data was used to create it.
    And now you can’t even take the time to read the comments detailing why the chart is crap.

    (83 comments in this thread so far, of which 31 are written by you…)

    Time well spent?

  89. Andy Avatar
    Andy

    @john personna: Hmm, that’s not what I see.

    It has over and under 65, but it also has under 5, 5-17, 18-44 and 45-64 and it includes median and mean. It also breaks it out by a lot of other metrics.

  90. john personna Avatar
    john personna

    @PJ:

    I at least got a mountain bike ride in today. Felt glorious. Heart and lungs working wonderfully. Legs … well, I’ve been off the bike a bit, and could use some leg work.

    @Andy:

    We are concerned with graduations over 65, aren’t we?

    And note in the top chart at [pardon me, at 90] the US spends about 43K, the others average around 8K.

    What do you really have to wave away a multiple of 5?

    This isn’t some 10% difference that could easily be fuzzy data. This is a 500% difference.

    What have you got?

  91. john personna Avatar
    john personna

    Really dudes, “we don’t like that chart anymore, it doesn’t say what we want.”

  92. Pinky Avatar
    Pinky

    John, there’s no data presented here. Just a chart. It’s Dave’s or your duty to present the underlying data, or link to it, if you want it to be taken seriously. You can’t say:

    Do you have actual numeric errors for this chart? Numbers?

    because there’s nothing here to refute. The link to the “Carnegie-Mellon chart” is just a link to a Denver Post chart, with no underlying data, credited to the same original source, so you can’t use that as confirmation. Please provide the data.

  93. john personna Avatar
    john personna

    @Pinky:

    It was trivial to find the Carnegie Mellon page, with links to research:

    The current health care debate in the United States is complicated. Trade-offs between heath care expenditures, lifestyle choices and life expectancy have been suggested but seldom clearly demonstrated. The U.S. spends on average more than $45,000 per year on health care for every 80 year old, while the Europeans spend $12,000 for the same age group. U.S. octogenarians have a 20 percent less chance of dying than Europeans in the next year. But, more than 30 percent of the U.S. population is obese, compared to less than 10 percent of Europe’s population.

  94. PJ Avatar
    PJ

    @john personna:

    For me, you disprove data, with better data.

    You don’t need always need better data to disprove bad data, a lot of times the only thing you need is to be able to show why the data used is bad.

    Ponder this, someone decides he wants to compare the median income of different countries, so he uses a number of different studies.
    Problem is, one study only looks at the median income of dentists in a certain country, another only looks at median income of those living in the capital, and so on.
    The comparison done is obviously not correct and you can prove that without having better data.

  95. john personna Avatar
    john personna

    @PJ:

    But Fischbeck’s data is entirely consistent with every single cross-country comparison on health care costs, is it not?

    Every single study shows our total spending much, much, higher than other nations.

    The only contribution here, from Fischbeck, is the age breakdown, the “take-off years.”

    But those don’t even provide more than framing.

    The main thing, our unusually high healthcare costs, is uncontested.

  96. PJ Avatar
    PJ

    @john personna:

    It was trivial to find the Carnegie Mellon page, with links to research

    As pointed out by Pinky, it’s the same data. And it’s faulty.

    I like your shovel, but I think you should stop digging and instead ride your bike some more.

  97. PJ Avatar
    PJ

    @john personna:

    Every single study shows our total spending much, much, higher than other nations.

    I’m not arguing about that.

    The only contribution here, from Fischbeck, is the age breakdown, the “take-off years.”

    But I’m arguing about that. Fischbeck’s chart is based on bad data.

  98. john personna Avatar
    john personna

    @PJ:

    Shovel? Maybe I need a broom to sweep up the bs.

    This has become a denialist thread.

    You are denying a study on comparative costs, which is entirely consistent with ALL studies on comparative medical costs across countries.

  99. Pinky Avatar
    Pinky

    http://www.nber.org/papers/w11833

    Here’s the actual report. The CMU page doesn’t have data. This report does. It’s labelled in Table 2 as “healthcare age-benefit profiles”, which appears to refer to the government benefits, not healthcare spending overall. So the graph doesn’t show what you’re saying it does, at least not in any way I can figure.

    (note – links to same study as Mikey)

  100. Mikey Avatar
    Mikey

    Since we seem to be arguing about the numbers from the Kotlikoff study, here’s the Kotlikoff study.

  101. john personna Avatar
    john personna

    @Pinky:

    So what, the US actually has lower healthcare spending than all the others?

    You guys are lost in your bs.

    You really missed that to deny this study as much as you’d like, you have to deny ALL the studies.

  102. Pinky Avatar
    Pinky

    @john personna: John. Step back for a moment. We’re not denying anything. We’re not trying to refute all the studies in the world about health care costs. We’re saying that this particular graph appears to be based on data about comparative government health care benefits, not comparative health care costs.

  103. Mikey Avatar
    Mikey

    I think the overall point, which remains valid, is that regardless of whether one counts up all health care spending or just government health care spending, the US still spends dramatically more than anywhere else. The OECD average excluding the US is (off the top of my head) about 11%-12% of GDP. Here, it’s nearly 18%, of the world’s largest GDP. We spend nearly twice as much per capita as the second-place country (France). And we don’t get nearly twice the benefit.

    We can get lost in the weeds nitpicking the numbers, but let’s not lose sight of the forest because we’ve got our lips pressed firmly to the trunk of a single tree.

  104. JohnMcC Avatar
    JohnMcC

    @Andy: Well done, sir. I’ve been trawling through various medical expense websites looking for comparative data on expenses for the U.S. vs OECD and comparing state to state. (The latter because I thought the question above — does poor coverage/care in younger years translate into higher expenses after 65; it occurred to me that a comparison of medicare rates for — say — Mississippi vs Massachusetts would shed light on that.)

    As I mentioned above this is pretty tightly held information for private insurers, for obvious reasons. And the medicare information is there but it is encoded — literally — by the procedure code that billing & insurers & CMS use. (A chest XRay is a 7 or 9 digit number; no explantion or breakdown. Unusable information for me.)

    I was happy to stumble into an organization called the “International Federation of Health Plans”
    (www.ihcp.com) who do an annual survey of 100 procedures in various OECD countries and show the cost.

    Here are a few:

    Angiogram — Spain — $125
    Angiogram — France — $264
    Angiogram — U.S. — low-173/avg-914/high-2,430

    CT Abdomen — Spain — $118
    CT Abdomen — France — $183
    CT Abdomen — U.S. — low-243/avg-630/high-1,737

    Hospital per day — Spain — $476
    Hospital per day — France — $853
    Hospital per day — U.S. — low-1,514/avg-4,287/high-12,537

    CABG — Spain — $17,437
    CABG — France — $22,844
    CABG — U.S. — low-46,547/avg-73,420/high-150,515

    I chose Spain and France because they seemed to represent the low end (Spain) and the approx middle range (France) in all 100 listed. If you are curious about South African or Norwegian medical prices, it is there.

    Please to remember that all these other nations have universal coverage and very high levels of gov’t involvement compared to the US.

    Listening, Gavrilo?

  105. PJ Avatar
    PJ

    @john personna:

    So what, the US actually has lower healthcare spending than all the others?

    I’m not arguing that. My sole point is that the chart posted by Dave Schuler is based on bad data.

    I’m in total agreement about the US spending way more per capita on health spending, please don’t call me a denalist.

  106. michael reynolds Avatar
    michael reynolds

    @JohnMcC:

    Listening, Gavrilo?

    He never was.

  107. Pinky Avatar
    Pinky

    @PJ: Yeah, I don’t want to pile on John, who seems like a decent chap, but that “denialist” accusation was pure fascism. I don’t know about anyone else, and I try to keep a level head about this stuff, but that kind of comment makes me want to deny everything the writer says. It can’t be productive with anyone.

  108. Grewgills Avatar
    Grewgills

    @john personna:
    John, you are arguing past each other. The only thing you need to know from PJs post

    The chart is misleading. Kotlikoff et al.’s paper looks at PUBLIC spending only.

    When does the US inject most of its PUBLIC spending. Yes we are the outlier. Given that bit of info above, we are likely the outlier well before we hit 65 since only public spending was counted and our public spending comes late.

  109. Rob in CT Avatar
    Rob in CT

    @Mikey:

    Oh, missed that. My bad.

  110. Rob in CT Avatar
    Rob in CT

    Wow, JP. Just wow.

    People were pointing out the chart is misleading, and you assumed they meant the chart falsely showed that US costs were higher. That’s not what they were saying at all. Any of them. The point was that US costs are dramatically higher, yes, but they don’t suddenly spike at ~65. *Governmental* expenditure does, duh, because of Medicare (I assume that most of the governmental expenditure pre-65 is medicaid?). The chart leaves out a massive pile of private spending, which makes the US system even worse (if you were to graph that properly, the result would be to raise the USA line far above its level in the chart, particularly pre-65). Which blows Gavrilo’s argument to shreds, btw.

    Pinky said it best: step back. You had the wrong bone between your teeth, and you gnawed the sh*t out of it.

  111. john personna Avatar
    john personna

    I think I pushed back on people who said “this chart is wrong (based on little), and so we don’t have to talk about it.”

    That was foolish, and probably a deflection. The Carnegie Mellon page I linked above links to:

    Death Risk Rankings

    That page has a wealth of information on cross country comparisions.

    Basically, these knuckleheads waved it all away as “false.”

  112. Pinky Avatar
    Pinky

    @john personna:

    Basically, these knuckleheads waved it all away as “false.”

    I don’t think that’s a fair accusation. I haven’t memorized this thread or anything, but as I recall it was a pretty serious, non-partisan discussion of end-of-life issues. Then someone questioned the graph and everything fell apart. But I didn’t see anyone wave away the issue, just the graph.

  113. john personna Avatar
    john personna

    @Pinky:

    Well, did anyone, with numbers, show how this chart was so horribly wrong that the 500% difference between the US and the others could truly be waved away?

    Does different accounting actually close the gap?

    Because, if not, what was it all for?

  114. john personna Avatar
    john personna

    @Mikey:

    We can get lost in the weeds nitpicking the numbers, but let’s not lose sight of the forest because we’ve got our lips pressed firmly to the trunk of a single tree.

    Exactly.

  115. Gavrilo Avatar
    Gavrilo

    @Rob in CT:

    Actually, it doesn’t. My argument was that the federal government does a terrible job at controlling health care costs as evidenced by the graph showing per capita healthcare spending in the U.S. dramatically higher than the other countries. I assumed that the per capita spending for the U.S. included private insurance pre age 65. If it does not, that means that our government (federal and state) does an even worse job.

    It is unimaginable that our government spends as much or more per capita covering the relatively small number of Americans on Medicaid (pre age 65) as the other countries spend covering their entire populations. If that is true, then anyone advocating a government funded healthcare system in the U.S. is not only stupid, but crazy as well.

  116. john personna Avatar
    john personna

    @Gavrilo:

    Gavrilo, Gavrilo, Gavrilo.

    You keep saying that our government programs can’t be as good as their government programs.

    A natural law or something?

    Or should we just fix them?

  117. Gavrilo Avatar
    Gavrilo

    @john personna:

    Fix them? Are you serious? Find me one Democrat who would support cutting Medicare or Medicaid. Find me one Democrat who would support cutting any entitlement. Democrats would demagogue the shit out of any Republican who advocated limiting Medicare payouts or capping benefits. In order to bring costs down, the government would have to do exactly what the eeevil insurance companies do. The only difference is that people would have zero options.

  118. john personna Avatar
    john personna

    @Gavrilo:

    We have the prime example of Democrats trying to fix the end-of-life spending, right?

    That was about a reduction in spending, and Republicans demagogued it as “death panels.”

    Indeed when the Democrats have talked about reforming Medicare, the Republicans demagogued again, saying “the Democrats want to cut your benefits.”

    Man up.

  119. David M Avatar
    David M

    @Gavrilo:

    Find me one Democrat who would support cutting Medicare

    Given that Obamacare cut some $700 billion from Medicare over 10 years, the list is fairly large.

  120. Grewgills Avatar
    Grewgills

    @Gavrilo:

    I assumed that the per capita spending for the U.S. included private insurance pre age 65. If it does not, that means that our government (federal and state) does an even worse job.

    How on earth do you come to that conclusion? Pre 65 government spending in the US is primarily MedicAid and military and the rest is private. Post 65 in the US government starts paying most medical costs with some private supplemental spending. The graph is missing the bulk of our pre 65 spending and a small minority of our post 65 spending. If we include all spending, that would raise the pre 65 spending well above the other countries, while only raising the post 65 bit slightly. That would flatten out out line considerably. There would still be an increase with age, but not the spike at 65. Do you understand how math works?

  121. Mikey Avatar
    Mikey

    @Gavrilo: So what makes America so “special” that our government can’t control health care costs, while every other government in the world can?

  122. Grewgills Avatar
    Grewgills

    @john personna:

    I think I pushed back on people who said “this chart is wrong (based on little), and so we don’t have to talk about it.”

    NO, that is what you assumed the point was. The chart only looks at PUBLIC spending, which actually supports the point you were trying to make. If you would have read what was being said instead of reflexively attacking what you perceived as an argument against yours, you would have seen that.

  123. Gavrilo Avatar
    Gavrilo

    @john personna:

    Exactly when did Democrats call for a reduction in end-of-life spending? Please give me one example.

  124. David M Avatar
    David M

    @john personna:

    did anyone, with numbers, show how this chart was so horribly wrong that the 500% difference between the US and the others could truly be waved away?

    Does different accounting actually close the gap?

    Because, if not, what was it all for?

    The chart isn’t so much wrong as useless. I don’t think anyone disputes the idea that health care costs are much higher here in the USA than elsewhere, but that chart doesn’t help anyone understand the issue. The chart would need to be total health care spending to be helpful. For all we know the actual gap shrinks after age 65.

  125. Mikey Avatar
    Mikey

    @David M:

    The chart would need to be total health care spending to be helpful. For all we know the actual gap shrinks after age 65.

    If it did, it wouldn’t shrink much, because there’s very little difference between “government health care spending” and “total health care spending” in all the other countries on the chart. The UK and Sweden have single-payer, Germany has multi-payer but 90% of the population is in the public system. Not sure about Spain but it’s likely quite similar.

  126. Gavrilo Avatar
    Gavrilo

    @Grewgills:

    I would encourage you to read all the comments. The graph does not specify that per capita health care costs is limited to government spending. That fact was only brought out by other commenters who researched the study that the graph was based on. It was my assumption that a comparison of per capita health care costs between the United States, where only a small percentage of people under 65 receive government funded healthcare, and the other countries where all people receive government funded healthcare would naturally include private insurance. I didn’t realize that our government was so inefficient that it would spend as much or more per capita as other countries while only covering a fraction of the citizenry.

  127. Gavrilo Avatar
    Gavrilo

    @Mikey:

    I don’t know. You tell me why our government spends $35000 per year on healthcare for 80 year-olds while other governments spend less than $10000.

  128. john personna Avatar
    john personna

    @David M:

    For all we know the actual gap shrinks after age 65.

    Seriously?

    We know that the US spends most money in end-of-life situations.

    Patients’ Last Two Months of Life Cost Medicare $50 Billion Last Year; Is There a Better Way?

    Again, this graph is entirely consistent with what we know from other studies.

  129. Mikey Avatar
    Mikey

    @Gavrilo: Probably because the government has to access a system that’s already pushed costs dramatically higher well before recipients start turning 65.

  130. john personna Avatar
    john personna

    (It should be obvious to the reader that in any age-by-age sample, the older segments will contain a higher percentage of “dying this year” members. And so, we, 95 costs more than 85, 85 costs more than 75, 75 costs more than 65, because in each of those contrasts the older group contains more receiving end-of-life treatments.)

  131. David M Avatar
    David M

    The graph is consistent with what we know, but does not contain useful information. How total health care expenditures compare between countries would be worth talking about, but this chart by itself probably leaves people with a worse understanding of the issue.

    This graph tells us that people are eligible for Medicare at age 65. That’s not really newsworthy.

  132. john personna Avatar
    john personna

    @David M:

    Let me ask you this, is there anything in the chart, which “does not contain useful information” which you can say is actually wrong?

    We know that we spend more than other countries.

    We know that our spending centers on end of life.

    It seems to me that this chart confirms things we should know, and should talk about.

  133. john personna Avatar
    john personna

    Of course that’s going to be the shape of the graph, and the shape is the issue.

  134. David M Avatar
    David M

    @john personna:

    Total spending matters, public spending only matters as a component of that. If we reduce public spending on health care by X and private health care spending increases by 1.5X, the total is the important number. Without the rest of the picture, the public spending portion isn’t useful.

    The chart doesn’t have to be wrong to be completely worthless.

  135. john personna Avatar
    john personna

    @David M:

    So now we can’t even say how this chart is wrong. It just isn’t the chart you’d use.

    OMG, right?

  136. David M Avatar
    David M

    OK then, the chart is actually wrong. Not including private health care costs is an error.

  137. Pinky Avatar
    Pinky

    Let’s make this easier: the chart is mislabeled. For the sake of clarity, no one should use a chart that’s mislabeled.

  138. JohnMcC Avatar
    JohnMcC

    @Gavrilo: Oh for Pete’s sake. Do you have dementia — where only long-term memory of reading Conscience of a Conservative as a child exists and the short-term memory of long rants by me about 90yr old people being tortured in ICU scoots right away from you? We had a fairly long discussion about this just yesterday, honey.

    But in the spirit of the holidays, full of love and joy:

    “….(F)or common benefits, Medicare spending rose by an average of 4.3% each year between 1997 and 2009, while private insurance premiums grew at a rate of 6.5% each year.”
    http://healthaffairs.org/blog/2011/09/20/medicare-is-more-efficient-than-private-insurance/

    “Since 2010…inflation-adjusted health care spending has been rising at an annual rate of just 1.3%…”
    http://www.newyorker.com/online/blogs/johncassidy/2013/11/the-good-news-on-healthcare.html

    Now help me out here, Mr/Ms Gavrilo; didn’t something happen in 2009 that would affect healthcare? I’m trying to remember…. Something, I don’t know what….

    OH YEAH! The Kenyan Socialist took over healthcare and destroyed freedom!!!

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