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Friday, September 26, 2014

Stop the Insanity

A few weeks ago I did a first rate job of lacerating one of my fingers on a broken piece of glass. Since, absent direct pressure, the thing wouldn't stop leaking at a rather dismaying rate, there was nothing for it but the ER.

Over the course of three hours, a nurse stared at it appreciatively for a few seconds. A med tech spent a few minutes setting up a tray of what was mostly clearly identifiable as medical paraphernalia; the rest like it belonged at a quilting contest. An actual doc took fifteen minutes to douse the wound with mercurochrome, which is exactly as painful as it sounds; jabbing the area with a novocaine loaded hypodermic, which made me forget about the mercurochrome; then putting in four stitches, one of which was outside the novocaine's sphere of influence, but did have the benefit of making me forget about the mercurochrome and the hypodermic.

Got the bill last week: $1,115.

YGBSM. There is no way the cost of goods and services my accidental experiment in self-mutilation got anywhere close to that. If the doc's cost of employment was $500 per hour, with the nurse and the tech coming in at $100 each, then the services cost at a half hour total time was $350. I'll round it up to $500. In any sane world, the thread, novocaine, mercurochrome, and that wrist band thing would come to approximately chump change.

Where the hel* is the rest of it going?

125 comments:

Annoying Old Guy said...

Cross subsidies.

We went skiing last winter and Boy Two managed to ski right in to a large wooden sign, giving him a concussion. He ended up being medivacced out on a helicopter. Cost of that ride - $15,000. But he got a free hat!

erp said...

... support/social services, insurance, legal fees, benefits, perks, physical plant updates, equipment, payola to politicians local, city, state, federal ...

ER physicians, like most physicians have seen their incomes go down while our costs go up.

My husband's recent hip replacement cost more than our first two houses and first four cars combined, but thanks to Big Brother (and the approx. ten thousand we pay for supplemental insurance and the "free" Plan D drug plan), it was just as free as aog, jr's free hat.

Bret said...

The rest of it goes to pay for all of those who can't pay.

Clovis e Adri said...

Simple question: would it be much different say, 2 years ago, before ACA?

erp said...

Bret, of course, but it was always (at least in my lifetime) that way even before the government stepped in and took their cut off the top to fund their massive bureaucracy.

Clovis, the ACA (which you may remember is about health insurance, not health care (something that's usually lost in the blather) isn't even up and running to any degree yet and when it will be in full operation, the differences will be major. Already nurse practitioners and physician assistants are taking over, especially in ER's where procedures, such as pre-screening and turning away people, are changing dramatically and in some doctor's offices, one doesn't get to see a doctor from one visit to the next, e.g., my husband's urologist only shows up for procedures.

Bret said...

Clovis asked: "...would it be much different say, 2 years ago, before ACA?"

No, it was the same.

Clovis e Adri said...

And why the main hypothesis is cross subsidies, as opposed to the much simpler explanation that the owner of the business is getting the rest as profit...?

Bret said...

Most ERs are not-for-profit type businesses.

Clovis e Adri said...

Now that's surprising.

Down here, in our private hospitals, every part of them, ERs included, are very much for profit.

How come that's not the case up there? I mean, why would you invest your money in building a hospital and not having profit with its ER? Makes no sense.

Bret said...

Legacy and philanthropic donations. For example, there was a $120,000,000 gift just last month to our local children's hospital by a fellow named Ernest Rady:

=====

http://www.rchsd.org/about-us/newsroom/press-releases/rady-childrens-to-establish-pediatric-genomics-and-systems-medicine-institute/

San Diego – August 4, 2014 –Rady Children’s Hospital-San Diego has taken a major step forward in the research of childhood diseases with the establishment of the Rady Pediatric Genomics and Systems Medicine Institute at Rady Children’s Hospital. Ernest Rady and family have made yet another extraordinary investment in the health and well-being of children by pledging $120 million to support pediatric research and innovation at the Institute.

=====

If you don't tax all their money away, America's rich tend to be fairly generous.

Bret said...

And generally the whole hospital is not-for-profit.

Peter said...

Canadians are considered certifiable if they cross the border without travel insurance.

Skipper, are you insured for this and did the hospital know that? In addition to the factors erp mentioned, the boys have a good gig going and take full advantage. I'd love to know what the bill would have been for an uninsured.

One of the downsides of opposing public healthcare is you find yourself advocating for private insurers. I'd rather pump for a more honourable profession, like used car salesmen.

Clovis e Adri said...


It looks like that, even though the Hospitals are officially non-profits, that only means they are profitting a lot more than others (since they pay less taxes) and using that money to make themselves richer indeed - only that it does not go to "the" owner of the business, but to the very many "co-owners" in practice (the people running the show).

At least that's what I understood from this:

http://www.nytimes.com/2013/12/03/health/as-hospital-costs-soar-single-stitch-tops-500.html?pagewanted=all

You were lucky enough, Skipper, for the people they used as examples had all higher bills for their stitches.

And I am really, really not convinced that the high prices are to pay for the uninsured. I've found this site interesting enough too:

http://www.truecostofhealthcare.org/summary

erp said...

Clovis, "non-profit" is merely an IRS classification -- it doesn't mean that the operation/entity/organization can't make a "profit." Without profits, there must be subsidies.

Your generation has been brain-washed that profits are bad, but confiscating workers earning to subsidize others is perfectly okay and even desirable.

Making a lot of money, even gazillions of dollars, isn't evil.

Socialism is evil.

Peter said...

erp's point is an important one. Non-profit doesn't mean the instituion can't make money, it means it can't be distributed to individual owners or shareholdres.

Annoying Old Guy said...

would it be much different say, 2 years ago, before ACA?

Worse, at least for me. Because of ACA our deductible was doubled and cost us multiple thousands of dollars more than had this happened before the ACA. I don't understand how people who aren't as well off as me are expected to cope with it.

Clovis e Adri said...

Erp,

It is not about profit being good or bad. And no, I don't think profit is evil - that's only you, as usual, projecting my arguments as opposed to paying attention to them.

The line of reasoning: I asked why higher prices could not be explained by higher profits. Bret answered they could not because ER's (and hospitals in general) are non-profit.

But his point is misguided, since they are indeed doing a lot of profit, and my NYT link above explicitly stated that ER's have been very profitable.

So, the more mundane explanation for Skipper's point - stitches are that expensive due to higher profits - is a good part of the explanation indeed. It looks to be a more important effect here than cross subsidies, as first suggested.

And BTW, before you interpret this as some defense of ACA (it is not, but you are going to project anyway), it looks to be the case also that private insurers are not taking the bigger piece of pie here. Their margin of profit is of 3,2%, way lower than the hospitals. So Peter's point also does not fit the picture here.

And one last remark for you Erp: I find profit great, even more so when they are transparent and clear to every part involved. There is not a free market here, because a good part of the participants are blinded and stuck to rules they did not willingly signed up for.

Bret said...

Clovis wrote: "Bret answered they could not because ER's (and hospitals in general) are non-profit."

As I wrote in Who's Non-Profit, "profit" doesn't necessarily mean much.

But given that owners and shareholders are not receiving any additional money from the high charges, the usual definition of profits does not apply.

So the high charges go to a number of different things. One of them certainly is aog's cross subsidies. Another is the high pay and benefits for doctors, executives, and other employees (as in Who's Non-Profit). Some of it goes into the bank, some of that is saved for "rainy days" (and hospitals do have those) and some goes to purchasing yet more expensive equipment and facilities.

Sometimes the ERs are a money sync, and sometimes they are a profit center (the Times article mentioned that).

But overall, in the long run, the organization as a whole will be roughly break-even or it will lose its non-profit status.

Harry Eagar said...

It's kinda like business class air travel, Skipper.

If you schedule and pay in advance you get one rate. If you wait to the last minute, you get the same product for a lot more.

That's what makes single payer so attractive: everybody gets the earlybird rate.

Also, as Bret says, somebody is paying for medical care for those who do not get paid enough at work to buy care. It's you.

Count your blessings.

Hey Skipper said...

[AOG:] Cross subsidies.

That seems the obvious conclusion. But is the default rate on emergency room care really that high?

If that was the only factor, then the rate of those appearing at the ER who are a) uninsured and b) default on the bill would have to be 50%. But I think something like 85% of Americans are insured.

And sometimes the numbers seem alarmist. For one example, the headline is: Uninsured patients costs [sic] emergency rooms millions

From the article:

In 2013, around 25% of the 64,631 patients treated in Onslow Memorial Hospital's ER were uninsured. These visits left more than $7 million worth of unpaid bills.

Sounds pretty bad, until you do some simple head math, and realize that the average loss amounted to $100 per uninsured patient. Re-distributing that to the 75% who are insured amounts to adding $25 each.

Presuming the same rate hold in Anchorage, that is no fricking where near accounting for what is seemingly at least twice what sanity would indicate.

Another potential reason is that ER care is supposedly very inefficient. It may well be, in the sense that my ratio of thumb twiddling time to cross-stitching time was about more than 12 to one. So yes, when thinking about my time, it was very inefficient.

However, looked at from the ER's point of view, their utilization rate was nearly 100%: all the nurses, med techs and docs were always doing something. Which is why my twiddle time was so high.

Which also means that I wasn't paying for the ER maintaining excess capacity to be able to absorb mass casualty events.

So I don't think the subsidy thing sells.

(They were going to charge another $300 to pull the stitches. FT — did it myself.)

My daughter had to get an MRI a few years ago: $13,000 for a half hour in the machine and five minutes of a doc staring at the image. That could well be 10 times the actual O&M costs of the machine, plus the docs time.

Two and a half years ago I went to an ER with what was likely H7N9 flu — I had just gotten back from Shanghai, which was making news for fatal cases while I was there. $3300 for a chest X-ray, diagnostic nasal swab, blood work, and five mins of a doc's time. (They let me loose after determining I had a viral infection, but not a flu for which they could test. Which means I could have it, and they just released me into the wild. Considering how sick I got, and for how long, I probably did.) In no sane world does the cost of what they provided come to a third of that.

There could be other reasons.

Hey Skipper said...

The median ER physician's pay is $256,000 per year.

If the doc manages 25 billable hours per week, and gets two months off per year, that amounts to $256 per hour -- barely half my assumed total cost of employment.

Hey Skipper said...

[erp:] Clovis, the ACA (which you may remember is about health insurance, not health care (something that's usually lost in the blather) isn't even up and running to any degree yet and when it will be in full operation, the differences will be major.

erp is correct. In theory, what should happen is, through significant wealth redistribution, people who either would not, or could not, afford insurance will have it bought, to a greater or lesser extent, for them.

In theory, among other things this should result in fewer ER visits. I'm skeptical about that, and also about it's effect on cost. The ER requires staffing 24/7. It has to do that no matter how many people walk in the door. If the ACA results in significantly fewer visits, then the ER ute rate will go down, but the costs — the majority of which are employment costs — will not. So it is entirely possible that the ACA will make ER visits even more expensive.

[Clovis:] And why the main hypothesis is cross subsidies, as opposed to the much simpler explanation that the owner of the business is getting the rest as profit...?

Contrary to Bret, Clovis's NYT link above strongly suggests that ERs are profit centers no matter how "non-profit" the hospital might be. Those are scare quotes, btw.

Skipper, are you insured for this and did the hospital know that?

Yes, and yes. I have no idea how much difference that made, but if it was substantial, then insurance companies would be big bucks ahead by reimbursing me, instead of the hospital, for care.

Especially for non-emergent care. Planning a knee operation? Coordinate with the insurance company, negotiate a price with the health care providers, pay them the cash price, and then submit the total to the insurance company.

[Clovis:] So, the more mundane explanation for Skipper's point - stitches are that expensive due to higher profits - is a good part of the explanation indeed. It looks to be a more important effect here than cross subsidies, as first suggested.

I agree. Since 85% of the US population has medical insurance, even if the rest never paid a dime of their bills — which isn't the case — the cross subsidy couldn't possibly amount to 100%.

Hey Skipper said...

[Harry:] It's kinda like business class air travel, Skipper.

If you schedule and pay in advance you get one rate. If you wait to the last minute, you get the same product for a lot more.

That's what makes single payer so attractive: everybody gets the earlybird rate.


Ummmm, no.

First of all, your presumption isn't true. Many things that have a 100% perishable time value — hotel rooms, airline tickets — get a lot cheaper at the last moment.

Taking your example for example, the cost of a coach seat plus upgrade to business class is much less expensive than the price of a business class seat, even at the "early bird" rate. That happens all the time. Standby travel works the same way — those willing to wait for an empty seat will pay less than those who book in advance.

So, no, not like business class air travel.

Also, you completely fail to have accounted for the auction effect of airline ticket pricing. As seats fill, the supply of remaining seats goes down, which means at any point in time, the remaining demand is running a greater risk of not having a seat available. Taking even a cursory glance at airline webpages will make that point clear. Flights that are nearing capacity will prominently display "Only x available", where x is a small number.

So, again, not like business air travel.

And beyond that, ERs always operate on the standby model: they have a fixed, statistically determined capacity. Then they sit and wait. The cost of ER care is solely determined by how little waiting they do.

So, yet again, not like business air travel.

Clearly, the early-bird rate doesn't explain the "attractiveness" of single-payer. What does?

Peter said...

It's really a mug's game trying to apply market principles to this situation. As Skipper said in the post, there was nothing for it but the ER. In what sense was he a consumer deciding whether or not to purchase a service, and from whom, after informing himself of all his options? He may not have had any idea what services he needed until they were well underway, and he had no basis for critically assessing what was on offer. Plus he was dealing with highly protected professions in the sense of entry into them. I trust not even AOG would support individuals with B.A.s in English operating discount emergency care services from their garages.

erp said...

Skipper, the same thing that accounts for anybody buying into collectivity -- FAIRNESS. The school yard cry of children, “NOT FAIR” rattles around in their heads.

The reasons for much of the ridiculous costs in medicine is that non-medical people aka bureacrats make rules and regs, which require all kinds of non-essential tests, etc. paperwork, etc. to make sure they control everything and any deviation of outcome results in multi-million payouts when lawyers get into the act … and I hate to keep repeating myself, but a lot of it has to do with unions. A nearby private hospital which has rejected unionization has had multiple law suits and is at the verge of banktupcy even though it provides most of the services for the downtrodden in this area for FREE.

There is no longer competition among facilities. The family doctor on the corner we had as children can't exist because there is no way one guy can afford it anymore. Example: a friend managed a group of six surgeons in New Haven. They have nine (9) people who do nothing but deal with the required paperwork to feed the great maw of government. Let’s be conservative and say that make-work non-essential additional cost to the health care of their patients is probably upwards of half a million dollars.

Harry: It’s useful in a conversation for everybody to define their terms. I’m still waiting for your definition of right wing, but don’t hold out any hope for one, since you obviously change it to suit the whim of the day.

When you say Reagan destroyed the “middle class” by design, you don’t mean the middle class that made this country great, you mean the unions which destroyed the golden egg by their outrageous incessant demands leaving the working class, not middle class, devasted and unemployed. Mazel tov to them, however, like the carrion eaters they are, thanks to the sainted martyr, they moved on to the public sector to become an integral part of the crony capitalism/fascist government busy destroying what’s left of our country.

erp said...

Peter, there is probably more "private" doctoring going on now that the government has gotten into the act than in the bad old days when when medical profession policed themselves.

Bret said...

Peter wrote: "I trust not even AOG would support individuals with B.A.s in English operating discount emergency care services from their garages."

My wife had a vaguely similar experience to Hey Skipper recently. She managed to slice off the tip of her finger, just deep enough that as long as we kept pressure on it, it wouldn't bleed, but hours later, without pressure, it was still bleeding at a pretty good clip and didn't seem to be slowing.

So there was nothing for it except, umm, well, Urgent Care. Not sure why Hey Skipper had to go to a full on ER for stitches, but our Urgent Care networks are a small fraction of the cost of an ER for the same things.

First I would claim that neither Hey Skipper nor my wife were in an emergency situation. If you can stop the bleeding with pressure, you have all the time in the world. It's annoying, it's inconvenient, but it's not an emergency.

If my wife and I would've had to pay out-of-pocket, we would've shopped around. It turns out that you can actually negotiate with various medical organizations and get reduced cost service. And we would've called doctor and nurse friends. And we would've considered clinics in Mexico. Etc.

But we didn't have to pay out-of-pocket, so why bother? So we went to Urgent Care, which, again, is still a fraction of the ER.

At Urgent Care, they got this foam bandaid (not really foam, but it looked kinda like styrofoam), put it on the wound, put some tape over it, and off we went. The foam stuff basically attached itself to the wound but after the wound healed, it fell off of its own accord.

The foam stuff came in a package that said prescription only. I asked why I couldn't just buy this stuff over-the-counter and nobody had any idea why not. They were kind enough to give us an unopened (and therefore sterile) package for the next such urgency.

Because it was a fingertip, sutures really weren't a great choice.

But, if it was a stitches situation for me, and I was looking at $2,000, and I could keep from bleeding too much for 24 hours, and I didn't know any doctors or nurses who could help me out, I'd order a first aid kit with sutures from Amazon for overnight delivery, watch a youtube video or two, and I'd sew myself up. I've seen it done enough times (often to me), that I'd give it a shot. And if it didn't work, then I'd go to Urgent Care or the ER. What's the downside, really?

I might not do it in my garage, but close enough to Peter's comment.

Bret said...

To add to my last comment, note that people when people are injured in the wilderness while hiking, they have little choice but to stitch themselves or each other up. So it's not that unusual. I have friends who have taken wilderness first aid classes and they were taught how to do it.

Annoying Old Guy said...

Skipper;

If that was the only factor, then the rate of those appearing at the ER who are a) uninsured and b) default on the bill would have to be 50%. But I think something like 85% of Americans are insured.

You are making at least two non- proven assumptions.

First, that if 15% of the population is uninsured, they use 15% of medical care.

Second, that if a person is insured they do not get cross subsidies.

I think both of those are wrong. For the second, Medicare reimbursement rates are generally below costs so private parties (you, your private insurance) make up the difference.

You should also be aware that you saw "list price". Your insurance company almost certainly did actually pay that amount, but has negotiated some discount. Because of this, for non-emergency procedures you can frequently negotiate your own discount if you agree to pay cash.

My overall point would be that you should be a bit more cautious with your numbers.

Annoying Old Guy said...

As for single payer, remember when proponents would laud the Veteran's Administration's system as an example? I would like Mr. Eagar to explain why we shouldn't expect to get something like that.

Harry Eagar said...

I don't know if ERs are profit centers in all hospitals, but they could be in some.

There are definitely some treatments that return waaay more to the hospital than costs. Our hospital built a one-bed cardio surgery center estimated to return $3.5 mil a year. That's $100K a day, which helps support the areas that are big money losers -- notably mental health.

(There was a huge fight here over whether to allow a private hospital to open; the only hospital is operated by a corporation that is a state creature. It generates huge revenues -- enough to support 11 money-hemorrhaging rural hospitals at no cost to taxpayers.

(The proponents of the private hospital said it would be "no-cost." It was also going to be no-mental-health.)

These disparities in rates of return are not, despite erp's fantasies, the result of government diktat but of private insurance reimbursement schedules (usually higher than government schedules; don't let your head explode, Skipper).

It is interesting that in erp's example of support staff, she imagines that the paperwork is required by government. Not true.

erp said...

Harry, the information is from the horse's mouth. The truth is more dreadful than anything I could conjure up.

... the only hospital is operated by a corporation that is a state creature. It generates huge revenues -- enough to support 11 money-hemorrhaging rural hospitals at no cost to taxpayers.

Harry: Is the above statement a typo? A state creature not paid for by tax payers? Who then, do you imagine foots the bill?

Clovis e Adri said...

Bret,

---
I might not do it in my garage, but close enough to Peter's comment.
---
Oh no, no way it is close to Peter's point.

Stitches are really easy. Nurses are supposed to do it with no help from doctors. Anyone can indeed learn it with a bit of practice.

Actually, if the cut is not too wide you can make without stitches or new gadgets: your wife's wound probably would be OK if you had placed bandaids in ways that it would both protect and apply pressure to her wound. You change it everyday, cleaning the area well, and after a week it is fine.

But you don't really want Peter's B.A.s in English making a call about an internal injury, or a head accident, or how sick you little kid is.

erp said...

Clovis, you're right, but neither do I want an affirmative action doctor, nor a nurse nor a physician's assistant, nor do I want a bunch of bureaucrats deciding on what the treatment should be taking away the doctor's traditional autonomy.

Before Harry decides I'm hallucinating, my husband's hematologist thinks he needs a particular treatment, but Medicare guidelines say no-can-do because his numbers are borderline and don't measure up to some faceless genius's computer models.

So we can wait until he deteriorates further or pay for it ourselves after paying a bundle for the great "free" health care insurance we neither wanted nor needed instead being able to buy the insurance we did want and need.

Harry Eagar said...

More anecdotes, please. I will unpack them as they come.

Query: How comes a helicopter ambulance to a ski resort? Is this a superior allocation of rare resources?

erp, the Hawaii Health Systems Corp. was set up to support the rural hospitals with excess income from state-owned Maui Memorial Hospital, which supports itself. Sorry, you lose again.

erp said...

Harry,

Where did the excess income come from? Price gouging? Good thing you're into words and not numbers. You have only the most hazy notion of how they work. If over-charging hospital customers paid for rural hospitals, why did the state need to get into the act?

You want more anecdotes. Here's another true one. My kids were helicoptered from Falmouth MA to Boston hospitals after their accident and the cost was also $15,000 for each helicopter. Getting them to the burn units any other way would have taken precious time, same thing for accident victims in hard to reach places like ski resorts.

Annoying Old Guy said...

How comes a helicopter ambulance to a ski resort?

It flies through the air.

How comes a helicopter ambulance to a ski resort

Medivac helicopters are common through out the US. I think it plausible that, over all, they are more cost effective than maintaining a sufficiently large number of distributed ambulances to provide equivalent response times.

Still waiting on the VA explanation, in reasonable reciprocity. But not in expectation - Eagar does not care to have any of his anecdotes, statements, or claims unpacked.

Peter said...

Bret:

C'mon, self treatment or even helping a friend in an emergency is hardly analagous to setting up shop and offering services commercially.

erp:

You try much too hard to find the evil hand of government at the bottom of all problems. Medicine in the "good old days" didn't consist of prescribing a battery of tests of questionable utility (or undertaking "protective surgery") with tort lawyers lurking in the wings. Doctors, like lawyers, are self-regulated monopolies and have been since long before the New Deal was a glint in FDR's eye. There are some good reasons for that, but that's what they are.

As I've said before, the Europeans must be doing some things right with their combination private/public schemes. As long as the debate in North America consists of trading anecdotal horror stories from the U.S. and Canada (both of which provide first class care when you can afford or access it), we'll all just keep spinning our wheels.

Hey Skipper said...

[Bret:] Not sure why Hey Skipper had to go to a full on ER for stitches, but our Urgent Care networks are a small fraction of the cost of an ER for the same things.

My wife the RN called the urgent care clinic first. Between the two of them, they decided that due to the depth of the laceration, most, if not all the way, to the bone, the possibility of nerve damage required an actual MD.

First I would claim that neither Hey Skipper nor my wife were in an emergency situation.

Strictly speaking, we weren't, and got triaged appropriately. On a Sunday afternoon, there aren't a whole lot of option.

But, if it was a stitches situation for me, and I was looking at $2,000, and I could keep from bleeding too much for 24 hours, and I didn't know any doctors or nurses who could help me out, I'd order a first aid kit with sutures from Amazon for overnight delivery, watch a youtube video or two, and I'd sew myself up.

That stitch I got outside where the novocaine had taken effect was a real attention getter.

[AOG:] You are making at least two non- proven assumptions.

First, that if 15% of the population is uninsured, they use 15% of medical care.


Good catch. I made that assumption without a thought for its validity.

Second, that if a person is insured they do not get cross subsidies.

Another good catch.

I didn't think about Medicare. The practice for which my wife work will no longer accept medicare/medicaid (without supplemental coverage) patients due to the low reimbursement rates.

[Harry:] … enough to support 11 money-hemorrhaging rural hospitals at no cost to taxpayers.

That, in a sentence, is progressives' sparkly-pastel-unicorn-manna-from-heaven theory of economics.

We went skiing last winter and Boy Two managed to ski right in to a large wooden sign, giving him a concussion. He ended up being medivacced out on a helicopter. Cost of that ride - $15,000.

That is (probably) a lot less extreme than it appears at first glance. The operating cost of the helicopter is probably about $500 per hour. Call it $1000. Figure a pilot and EMT at a combined cost of employment at $500 per hour. Two hour flight and … wait … $3,000 is nowhere near $15,000.

But that analysis leaves out utilization rate. If the medevac helo is rarely used, say once a day, then its total annual cost must be amortized over 356 flights. Suddenly, $15,000 sounds not entirely out of bounds.

[Peter:] It's really a mug's game trying to apply market principles to this situation.

Well, yes, that is rather a problem. In retrospect, we should have gone to an urgent care clinic first, then gotten kicked to the ER if it seemed necessary, since we didn't have a bona fide emergency.

However, for those who do, virtually every aspect of what constitutes a functioning market is out the window and en route to the ER due to blunt force injuries.

Hey Skipper said...

[AOG:] Medivac helicopters are common through out the US. I think it plausible that, over all, they are more cost effective than maintaining a sufficiently large number of distributed ambulances to provide equivalent response times.

In much of the US, particularly west of the Mississippi, population density is low, and distances to hospitals great. Medevac helicopters and airplanes are the only way to keep response time from being less than hours.

[Peter:] As I've said before, the Europeans must be doing some things right with their combination private/public schemes. As long as the debate in North America consists of trading anecdotal horror stories from the U.S. and Canada (both of which provide first class care when you can afford or access it), we'll all just keep spinning our wheels.

+10

erp said...

Peter, unfortunately I don't have to try much too hard to find the evil hand of government at the bottom of all problems. Government intrusion in our lives and its collusion with public sector unions are evil. I'm glad you're satisfied with the Canadian health system and hope you are never given reason to be disappointed by it.

In my experience, physicians on the whole are highly moral, sorry I can't say as much for bureaucrats and politicians especially those on the left and that includes practically every Republican as well.

Here’s another anecdote about the vaunted French system with apologies to Harry and Clovis’ sensibilities. My French granddaughter has been suffering from an undiagnosed illness for 8 years (she’s 22 now) and all they offer is more of the same ineffective drugs and another hospitalization. Her parents wants to bring her to the U.S., but costs here are prohibitive thanks to the aforesaid government intrusion and la Belle isn’t willing to pay for it and even though both her mother and father are university professors, they couldn’t possibly afford it. Where √©galit√© rules, the fruits of my son’s work which is considerable belongs to the state. Apparently the cry of socialism, “From each according to his ability, to each according to his need,” like everything in a socialist state, is determined by the elistists in power.

Skipper, your grade of +10 -- Does this mean you agree that we should follow the Canadian and European health care models? I doubt very much they have a network of helicopters blanketing their geography as we do. I have no problem with paying for such a system no matter the cost. I do have a problem with Harry’s lunatic version of who pays for what in Hawaiian hospitals. I found his explanation past parody.

Clovis e Adri said...

Skipper,

---
[AOG:] You are making at least two non- proven assumptions.
[AOG] First, that if 15% of the population is uninsured, they use 15% of medical care.
[Skipper] Good catch. I made that assumption without a thought for its validity.
---
Actually no, it was not an important catch.

Your arguments were about orders of magnitude. Even if the 15% of uninsured use way more than their share of medical care, they can not explain the 400% to 600% of overpricing on those stitches' bill.

---
[AOG] Second, that if a person is insured they do not get cross subsidies.
[Skipper] Another good catch.
---
Nope, another irrelevant one.

Suppose 50% of US population was uninsured and used 50% of medical services. The present situation (of 15 uninsured plus others semi-insured) is very probably less drastic, so that's a good bound to make a simple back-of-the-envelope estimate: every paying customer would pay double the price to compensate for the non-paying ones.

Then we check the prices being billed at that NYT article and... they are usually N times greater than market price, with N far greater than 2. So redistribution can only be a second order effect to explain price dynamics here.

Now you can make the argument that those calculations are for the ER alone, and maybe the hospital is using profits in ER to close for holes in other parts. But that's not the picture we get from the articles referenced above either.

Annoying Old Guy said...

Clovis;

Then we check the prices being billed at that NYT article and... they are usually N times greater than market price

How can a market price be N times larger than the market price?

Skipper's rough estimates are in the 2-5 range over presumed costs, which is well within the range of cross subsidies, particularly if you consider these are strongly discounted for people with insurance.

erp said...

Clovis, you may have missed the numerous comments made on numerous posts here in which the NYT has been exposed as not a reliable source. Your citing it as some kind of authority is silly.

Annoying Old Guy said...

Ah, the New York Times, the newspaper whose foreign policy expert did not know that then President Bush assembled a coalition of nations for the invasion of Iraq.

Bret said...

Peter: "C'mon, self treatment or even helping a friend in an emergency is hardly analagous to setting up shop and offering services commercially."

I disagree. What difference does it make if I help a friend for no money or a non-friend for money? In either case I helped someone who solicited or at least consented to that help.

Bret said...

Clovis wrote: "Oh no, no way it is close to Peter's point."

Hmmm. Apparently, given Peter's response above.

But since I don't understand his response, I don't understand his point. It seems to be that NO emergency services should be performed by someone (non-doctor/non-nurse/etc.) in their garage.

But why shouldn't emergency stitches be performed by anyone that's willing to do it and who is chosen to do it by someone in need? What's wrong with an interaction that's completely voluntary by both parties?

Let me ask exactly where it breaks down. Where does it start to become wrong and why?

1. While hiking in the middle of the wilderness, someone need's stitches, I stitch them up, no charge.

2. While hiking in the middle of the wilderness, someone need's stitches, I stitch them up, no charge, but they volunteer to pay for the supplies.

3. While hiking in the middle of the wilderness, someone need's stitches, I stitch them up, but I ask them to pay for the supplies after I've finished.

4. While hiking in the middle of the wilderness, someone need's stitches, I stitch them up, but I ask them to pay for the supplies before I start.

5. While hiking in the middle of the wilderness, someone need's stitches, I stitch them up, no charge, but they volunteer to pay me which covers more than the supplies.

6. While hiking in the middle of the wilderness, someone need's stitches, I stitch them up, but I ask them for a fee which somewhat more than covers supplies before I start.

Okay, now 1a through 6a are the same as above EXCEPT the setting is my house or garage.

Which, if any, are okay, and which are wrong, and why?

Peter said...

I doubt very much they have a network of helicopters blanketing their geography as we do.

erp, how do you imagine Canada handles critical and emergency care in the north, which in many parts of the country starts about 150 miles from the border? Believe me, our medivac services could beat up your medivac services any day.

Clovis e Adri said...

Bret,

If your questions are on what your Laws allow or not, I am not qualified to answer.

But if this is a test on what I (and others here) think about it, I'd say at no point from 1 to 6 there is a problem.

In small cities with little access to doctors, it is rather usual for the people at the local pharmacy to do stitches, shots and prescribing medicine. But this is also a setting where chances of a tort due to malpractice and bad handling of medical issues is null. It is also a place where chances are greater that, if the person doing this stuff is bad at it, word will spread and he won't have many clients.

Now, in a bigger city, it is easy to think of cases where dishonest/incompetent people could affect way too many people with impunity. So I don't think the restrictions against lay practitioners here are absolutely uncalled for.


Clovis e Adri said...

AOG,

---
How can a market price be N times larger than the market price?
---
In order to have meaning in our discussion, your question should be "How can a market circuit price be N times larger than the same product in another market circuit?", and in such light I hope you'll see the answer is, trivially and again, about margins of profit.

Bret said...

Clovis,

Definitely not a question regarding laws (or rather legislation), but just a feeling of right and wrong.

Which you answered. Which I'll sum up as you think (and I agree) that none of the cases is inherently wrong, but there may be a case for restrictions based on public health or public good.

I'm inclined to minimize such restrictions, others are much more likely to endorse such restrictions. My belief is if such restrictions are minimized, a society is far less likely to end up with $2,000+ charges for a couple of stitches which has a substantial adverse impact on society.

But as another answer to Peter's quip, I'm all for people offering SOME emergency services (such as stitches) in their garage.

Clovis e Adri said...

Bret,

---
My belief is if such restrictions are minimized, a society is far less likely to end up with $2,000+ charges for a couple of stitches which has a substantial adverse impact on society.
---
I don't think you are addressing the root of the problem in this case.

It does not look like, IMHO, that regulation is to blame on these stitches price. We can ask ourselves why 20 or 30 years ago they were much more affordable, while regulations against lay practitioners were basically the same (or so I believe - am I wrong here?)

From my far away point of view, it looks like that Hospitals, just like big Pharma, learned very well how to explore your insurance pool.

Down here most private health insurance companies have strict upper limits to many procedures. If a hospital started to charge so much for a stitch, most insurance companies would take them out of their portfolio.

That NYT article mentioned on how the Hospital conglomerates have been using their near monopoly status (at least in California, their main example) to force their will on insurance companies.

Those conglomerates, even though they may be classified as non-profit, look to be agressively practicing the same game that any other for-profit business would do. But with less restrictions, since they won't have competition from for-profits (who, paying taxes, are hindered in any competition).

I propose a simple solution: take out their status of non-profit and make this an easy market for new investments of for-profit groups.

Peter said...

Bret: You've given me a great idea for an idyllic post-retirement career. Gonna' get me some cat gut and sharpen up the ol' compass set and set up a stand outside the nearest national park. I'm thinkin' of offering weekday discouts on stitches and post-traumatic stress counselling after encounters with bears.

erp said...

Peter, delighted to hear you have helicopters covering the vast geography north of the Queen's Highway, which BTW we drove from Montreal to Calgary and then continued north to Jasper, stopping for a night in Moose Jaw where we had one of the best meals ever -- cooked by a charming renegade French couple … but I digress.

Considering your sparse and scattered settlements, it would pretty impressive if your national health delivery system maintained helicopters at the ready to cover it all. I think what you mean is that residents in the hinterlands routinely come and go by air and that would include emergency transport, not that those are routine functions of your national health care.

Do you think the same services are available in Europe? I remember a few years back we had to send in helicopters when France had nary a one to use for some rescue mission.

erp said...

Clovis, much simpler solution would be to take government out of health care and every other part of our lives and let the free market figure it out. Non-profits are in cahoots with government. It's called crony-capitalism and it's not only non-profits but publicly held corporations as well.

Peter said...

erp, I am NOT going to spend a day Googling to learn all the details of comparative medivac services. In the North, if they can wait to reserve space on commercial they will (it's quite an experience flying for three hours beside someone in a hospital bed hooked up to oxygen and attended by two nurses), but if they can't, they will charter, and not just helicopters. But it isn't just in the North. Our son's good friend was very seriously injured playing hockey last year (spinal cord)about fifty miles from Ottawa. The local hospital couldn't handle it and within two hours he was airlifted to the renowned children's hospital in Ottawa. There is no regular service between the two places. He's disabled, but alive and mentally together as a result.

I know you are a proud American but you have to get over this belief that everyone else makes do with Mao's barefoot country doctors.

erp said...

Peter, you are again putting words in my mouth. Thank you, but I assure you there is no need, I have plenty of my own.

I said that helicopter service is not a routine service provided by your national health system and as your example clearly establishes, that statement is correct.

I have never alluded to Mao's country doctors. In fact, didn't even know they existed, shod or unshod.

I am proud to be an American and am also proud of my Canadian neighbors, quite a few of them winter down here and we met quite a few on our various trips to Canada when we lived in Vermont.

Why are you taking offense where none was offered nor intended?

Peter said...

Offence? erp, you know me well enough to know I love a good argument much too much for that. I was responding to your statement that we don't have a network of helicopters blanketing their geography as we do by showing you that we do have extensive medivac services as needed. A discreet, unified national service? No, we don't have that, but neither do you, so what are we arguing about?

My point is that there are strengths in the American healthcare system, but obviously problems too or it wouldn't be such a political lightning rod. I suggest denigrating willy-nilly the quality of everyone else's healthcare when facts show otherwise may be polemically appealing in the moment, but not a winning tactic in the end. Maybe it's ok with France, though. Not because there is anything wrong with French healthcare, but because it's always fun to trash France.

Bret said...

Clovis wrote: "I don't think you are addressing the root of the problem in this case.

You and my wife, always worrying about root cause. Sometimes it's easier to just cut the tree off at the ground and not worry about the roots. If the tree grows back from the root, just cut it off again!

Clovis wrote: "It does not look like ... regulation is to blame on these stitches price. ... it looks like that Hospitals ... learned very well how to explore your insurance pool. ..."

And yet without regulation, the insurance pools wouldn't (IMO) look like anything like they do. So I think that regulation specifically has caused "these stitches prices" and that over the decades, specifically because of restricting who is allowed to perform services based on credentialing and licensing, the prices for some awfully straightforward stuff is awfully expensive.

Clovis wrote: "I propose a simple solution: take out their status of non-profit and make this an easy market for new investments of for-profit groups."

That would, IMO, be insufficient because the FDA is such an onerous bureaucracy and the AMA coupled with insurance companies and hospitals is such a powerful lobby, that efficient for-profit companies are not really possible on any sort of significant scale.

Bret said...

Peter wrote: "I'm thinkin' of offering weekday discouts on stitches and post-traumatic stress counselling after encounters with bears."

And since you're a lawyer, you can also help them sue the bears. :-)

Clovis e Adri said...

Bret,

---
You and my wife, always worrying about root cause. Sometimes it's easier to just cut the tree off at the ground and not worry about the roots. If the tree grows back from the root, just cut it off again!
---
I don't know about you and your wife, but I think right there we see the difference between the Engineer and the Physicist (that, and a huge gap in paychecks :-)

---
specifically because of restricting who is allowed to perform services based on credentialing and licensing, the prices for some awfully straightforward stuff is awfully expensive.
---
But there again, why there are places where same restrictions on who is allowed to perform services did not lead to so expensive stitches? In pretty much all the world the medicine profession is strongly regulated, Bret.

Regulation is partly to blame in your expensive health care, but it is not really the professional regulation the one to blame here.


---
[...] that efficient for-profit companies are not really possible on any sort of significant scale.
---
Oh, so much hope in your heart.

A few decades ago your system was not like it is now. At some point you went off the rails. As with much other things in US public life nowadays, I think you don't take it back to track only due to general political paralysis.

Harry Eagar said...

'That, in a sentence, is progressives' sparkly-pastel-unicorn-manna-from-heaven theory of economics.'

Bingo! You win he prize, except for the minor point that this was not a progressive but a regressive measure.

I favored -- still do -- using the general fund to pay for rural hospitals, as the social part of government. Foisting off the public duty on the Maui medicine-using minority was classic rightwing economics.

As it turned out, over the course of two decades, the siphoning of excess income from the money-making hospital starved it of capital funds, so that the state will have to supply them anyway. TP economics at its most obvious.

Harry Eagar said...

'they are more cost effective than maintaining a sufficiently large number of distributed ambulances to provide equivalent response times.'

Why would anyone expect equivalent response times in sparsely populated backcountry with urban environments -- erp's examles amusingly is set in the most densely hospitaled area in the world?

Oh, yeah: rich people expect urban services even in the country. If you were to, you know, check, you would discover that helo ambulances are not so common in rural areas full of poor people: we may take the example of North Florida Regional Hospital, which has a catchment area of about 5 thinly populated counties. It gets its patients by ambulance, on trips that, in some cases, must take about an hour.

This is not a treatment issue, since modern ambulances are little rolling hospitals and the handlers can stabilize the injured/sick as readily as happens in the ER.

Annoying Old Guy said...

Clovis;

Now I don't understand your question at all and have no idea what two market prices you are comparing.

I would also note that regulations are not the only way the government interferes with market prices. You must consider subsidies and purchasing power as well.

Mr. Eagar;

Why would anyone expect equivalent response times in sparsely populated backcountry with urban environments

I don't know, but I do know that has nothing to do with the quoted statement, which makes no mention on response times in urban areas.

erp said...

Clovis, we went off the rails a long time ago, approx. 100 years ago, when Wilson took over, but we had such strong people and immigrants who came to find their dreams, it took this long for We, the People to descend into the hell of fascism we have now.

Young people have been taught that our country is to blame for everything wrong with the world and that we're all equal in outcome instead of we're all equal under the law, I despair it'll change until some day many years from now when an errant throw-back gene wakes up some new leaders and they reconstruct our founding documents.

erp said...

Harry, hospitals are not a public duty anymore than confiscating funds from private citizens to run health insurance scams.

erp said...

Harry, you may be unfamiliar with the traffic on the Cape at any time of the year, but on a summer holiday weekend it is a nightmare, so Boston and its surrounds may be the most densely hospitaled area in the world, it is also legendary in its densely packed traffic jams.

A 40 mile trip by ambulance from Falmouth to Boston could take up to 5-6 hours or even longer.

You should read newspapers once in a while to inform yourself about how the rest of the country is not like Maui.

Clovis e Adri said...

Erp,

---
[...] Clovis, we went off the rails a long time ago, approx. 100 years ago [...] I despair it'll change [...]
---

I sense your despair indeed, it is a profoundly pessimistic worldview you expose time and again.

I would like to invite you to read this piece, please. Yes, it is in the NYT, but it happens to be written by one of a few conservatives among them. Please take a look at the message, and think a bit about all this pessimistic view again.

Maybe others here could use it too.

erp said...

Clovis, there are no conservatives among those writing in the NYT and as I've said many time, I prefer to save whatever is left of my eyesight for kitten videos.

Hey Skipper said...

[erp:] Skipper, your grade of +10 -- Does this mean you agree that we should follow the Canadian and European health care models?

My grade of +10 means that Peter, as usual, is talking sense.

The US healthcare model, pre-Obamstrosity Care, was a shambolic mess. His Obamaness has only made it worse.

So let's start there. The US healthcare system, at one remove, gives every appearance of having been designed to be a life support system for tort lawyers. From another direction, a lot of what it does doesn't appear to do much good. Court decisions greatly expanded those conditions that insurance companies must cover: infertility treatments? gender reassignment? Really? Technology has made possible at great expense what before couldn't be done at all, and to which we can't say no: preemie ICUs, for just one example. It suffers a serious free-rider problem, which accounts for at least some of why each fricking stitch cost close as dammit to $280. The seemingly brute fact that no matter how effective and efficient healthcare becomes, it will still be beyond financial reach of some people, and strain a good many more.

Slanging horror stories doesn't even begin to touch any of that.

Even if the 15% of uninsured use way more than their share of medical care, they can not explain the 400% to 600% of overpricing on those stitches' bill.

You are also right. AOG really had two points (I think): first, I didn't even think of it. True. Second, there is some good reason to suspect that the 15% of the uninsured do, in fact, consume much more than their per capita share. However, many of the uninsured are young free-riders who don't get insurance because they think, and in the main are right, that they don't need it.

But, like you say, it takes a heroic amount of a) consumption by the uninsured and b) defaulting on bills to get anywhere close to wealth transfer alone to account for the monetary hemorrhaging attending four stitches.

Also, on re-reading, I have to admit confusion over AOG suggesting that the insured might themselves get cross subsidies.

Not in my experience.

To wit:

[AOG:] Skipper's rough estimates are in the 2-5 range over presumed costs, which is well within the range of cross subsidies, particularly if you consider these are strongly discounted for people with insurance.

The first part assumes a great deal, consider there is no information at all to suggest how great cross subsidies are. The one example I was able to find, given I wasn't going to devote more than three minutes to the task, suggests that the cross subsidy at one hospital would virtually disappear within the rounding error of my bill.

And if my bill was discounted for people with insurance — I have one of those morally indefensible gold-plated employer "provided" plans, thank you very much — then I'd have blown an aneurysm for how much cash would have ended up on the barrel head.

[erp:] Clovis, you may have missed the numerous comments made on numerous posts here in which the NYT has been exposed as not a reliable source. Your citing it as some kind of authority is silly.

I disagree. Sometimes its straight reporting deserves scare quotes the size of hot air balloons. However, even accounting for the Gell-Mann amnesia effect, much of the NYT's straight reporting is quite good; moreover, for anyone with any sort of analytic bent, it is quite easy to see where there is axe grinding.

Hey Skipper said...

[Clovis:] We can ask ourselves why 20 or 30 years ago they were much more affordable, while regulations against lay practitioners were basically the same?

Excellent question.

Here is another way to pose it. From the webz: A dog runs into a fence, suffering a deep cut, through the muscle, about 4" long. Requires sedation before stitches to fix the muscle, then more to close the skin.

Cost? $250.

Or a fifth what I paid for a tenth — if that — of the work.

Why?

Or an even better question: Why the hell didn't I go to a vet?

[Harry:] You win he prize, except for the minor point that this was not a progressive but a regressive measure.

You were the one who made the fatuous statement that it didn't come as a cost to taxpayers. If not them, then who?

As it turned out, over the course of two decades, the siphoning of excess income from the money-making hospital starved it of capital funds, so that the state will have to supply them anyway.

You need a whole heck of a lot more substantiation then you are providing.

Why would anyone expect equivalent response times in sparsely populated backcountry with urban environments …

You seem not have lived out West at all. No one expects "equivalent" response times, but rather times somewhat less than near as makes no difference to never. Where I live, there are a lot of places where air medevac is the only game around.

It gets its patients by ambulance, on trips that, in some cases, must take about an hour.

You should learn more about US geography — it is a really fascinating place. West of the Mississippi, there are a lot of places where an hour doesn't even begin to get the job done.

If you were to, you know, check, you would discover that helo ambulances are not so common in rural areas full of poor people:

I did. You are wrong.

erp said...

Skipper, the NYT's axe has been grinding out lefty propaganda for decades and as straight-forward news is readily available from reliable sources, why would anyone want to waste time separating their occasional wheat from their preponderance of chaff.

Our health care system, as you state, has been corrupted by government interference, collusion with unions and insurance companies, etc. so why would we opt to give the whole shebang over to the government as they've done in Canada and Europe in order to fix it? Isn’t the VA is proof enough that health care in the hands of bureaucrats, like everything else in the public sector, turns into a self-perpetuating entity that promotes the welfare of the agency, not those it was created to serve.

erp said...

Skipper, it's called the Inclusionary Zoning Affordable Housing Program.

Peter said...

erp:

To put it simply, the U.S. has by far the most expensive health care in the world. The statistic I like quoting in these debates is that, even pre-Obamacare, the U.S. government spent more per capita on healthcare than the Canadian government. When it comes to access, wait times, bureaucratic delays, an ever-expanding definition of "elective" treatment, etc. Canada is the worst in the West. Both rank high on the quality of the actual care, but so does Northern Europe.

Not surprisingly, these issues are political flashpoints in our respective countries. Whenever debates come to the fore, negative comparisons are made about the other by defenders of the status quos, largely based on anecdotes of people who suffered in some way in the other country, and there is no shortage of those.

Wouldn't it make sense for both countries to get off that treadmill and start asking why and how the Europeans have managed to avoid the worst of either world?

erp said...

Peter, I disagree that Europeans have solved any problems, but since neither of us can know for sure, we can continue to "argue" our perspectives as friends and neighbors. :-)

However, my son has lived in France as a French citizen (don't ask) and from the little he's said, there are problems aplenty.

Clovis e Adri said...

Skipper,

---
A dog runs into a fence, suffering a deep cut, through the muscle, about 4" long. Requires sedation before stitches to fix the muscle, then more to close the skin.
Cost? $250.
---
To which we may ask:

1) Are Veterinary Hospitals a near monopoly of a few non-profits?

2) Are there cross-subsidies (or each animal pays his own)?

3) Are there restrictions for B.A.s in English to stitch dogs in their garages for a profit?

4) Are there health insurances for dogs? If yes, are they used by how much of the population?

I guess - only a wild guess, I did not google about it - the first three questions have "no" for an answer, and the fourth may have a yes but with irrelevant levels of such an insurance being bought for.

Now let's play a game: imagine each (alone or in various combinarions) of the above suddenly getting a "yes" for an answer (or, in the case 4, dogs start to massively buy insurance, with exception to 15% of them who live in the streets).

Which combination would have greater potential to drive prices up?

Annoying Old Guy said...

Clovis;

A column by David Brooks? The guy who thought Obama's perfect pant crease would save us? Seriously?

I also have to agree with erp, Brooks is not a conservative.

Skipper;

The insured who get cross subsidies are those insured by the government. It's certainly not the only factor in that pricing, but it is a major one.

Here is an example quote

"Cost shifting from Medicare to private payers and employers is seen as the number one impetus for higher medical costs in 2011. Medicare, which is the single largest payer for hospitals, will reduce payment rates to hospitals in 2011 for the first time after seven years of increases that nearly matched or exceeded inflation increases. Some hospitals that benefited from higher payments in 2008 and 2009 might be able to manage this type of cut by tapping their reserves, but many are likely to shift more costs to commercial payers during their negotiations"

erp said...

Clovis, if the government doesn't get involved, dog insurance would be competitive and insurance would have different levels of care, etc. People would then buy the level of care they prefer and don't forget when dogs become too ill to treat, their owners have them put to sleep. That's still not an option for humans, but they're working on it and it'll happen within your lifetime if we don't put a stake in the heart of fascism.

erp said...

I was not surprised to read this morning that George Soros' "Generous" Electric also the owner of Comcast/TWC, NBC and other crony capitalist companies too numerous to mention, has dropped health care coverage for retirees. It's nice to be one of the king's troubadors.

We lived within the orbit of G.E.'s Fairfield CT headquarters for many years and are good friends with many of these retirees. I wonder if they are regretting their staunchly leftwing politics about now.

Clovis e Adri said...

AOG,

I have no intent to defend Brooks, but this kind of selective quoting out of context is too low even for you.


Erp,

It is indeed interesting to live in different worlds. I, for example, have no idea why you think any Company should keep paying health care for anyone after that person got retired. I'd say you need to be quite a socialist to expect that.

erp said...

Clovis, you perhaps don't know the history of how and why company's started to pay for their employees’ health insurance. Check it out.

My comment was not that I think company's should pay for retirees’ health insurance. I don't think they should pay for health insurance of the current employees either, but those GE retirees voted through their unions to push up the costs of GE products including in the end losing many thousands of jobs by sending their operations out of the country didn't care about that or about maintaining high standards for GE products, so now they are getting their just deserts, but unfortunately we are all paying the price for their greediness.

erp said...

... sorry I didn't finish.

Management were complicit with the unions to forestall strikes so are no less to blame.

erp said...

er ... that's I don't think companies should ... , not what the previous comment shows.

Clovis e Adri said...

Erp,

I find it amusing how you keep lashing fire onto unions even after we agreed they are nowadays close to irrelevant among private companies workforce.

Look, very probably those jobs would be shipped overseas anyway, union or not. It is called globalization and it was pretty much advanced by you guys.

So good for them if they were able to extract some pennies more before those jobs vanished. I hope it helps them to pay for their health care now.

erp said...

You're right that unions killed the goose that laid the golden eggs, but you're wrong if you think globalization would have had anything to do with our exporting jobs if costs weren't going outta sight. You have no idea what went on and you surely won't find out consulting the leftwing media. You're also wrong if you think workers made a few pennies to help them out now.

Again, what you think you know about the U.S. is largely wrong, but I'm glad that ignorance is keeping you amused.

Clovis e Adri said...

Erp,

Right, if they accepted wages at the level of the Chinese ones, sure the jobs would stay. It wouldn't help them much anyway, but your point is granted, isn't it?

erp said...

I can't tell if you're kidding or not, but they weren't getting coolie wages. That's the rewriting of history ala Harry.

Now they're getting $0.00 in wages, but are sitting pretty on the dole.

Annoying Old Guy said...

Clovis;

If you don't think Brooks is worth defending, why recommend reading one of his columns?

this kind of selective quoting out of context is too low even for you.

That's rather weak coming from someone who never hesitates to deliberately misquote me.

Whatever. Brooks wrote it, I consider it sufficient to demonstrate he's a superficial sheeple who's dumb enough to hero worship Obama, which makes anything else he writes a waste of time to read.

Clovis e Adri said...

Erp,

What you'd prefer, no job at $0,00 per hour or full job at $1,00 per hour?

Clovis e Adri said...

AOG,

---
If you don't think Brooks is worth defending, why recommend reading one of his columns?
---
I don't check everything a writer wrote before linking to him. Do you?

I've recommended one particupar piece, and I'd welcome you take it at its face value to discuss it here. If not interested, you can just let it go instead of depreciating the guy because he did not share your view on Obama in past.

---
That's rather weak coming from someone who never hesitates to deliberately misquote me.
---
Going ad hominem so soon?

---
[...] he's a superficial sheeple who's dumb enough to hero worship Obama, which makes anything else he writes a waste of time to read.
---
Ironically, one reason I've linked him was because he addressed a bit this excessive partisanship you readily exemplifies here.

erp said...

I prefer a job where there may be chances to learn things and move up than to be kept in custodial care as a burden on the tax payers.

FYI, my first job was $0.65 an hour working in a Five & Ten Store during the Christmas vacation from high school. It taught me a lot that I wouldn't have known about from my home or school life. One of the main things I learned is that the permanent staff couldn’t have cared less about their jobs and spent all their time complaining to each other instead of organizing their merchandise, sprucing up their counters and being pleasant to customers and were very annoyed when I, a 16 year old kid, did so, increasing sales considerably.

Contrary to leftwing thinking, we are not all equal cogs in the great wheel of socialism looking longingly at our betters in their Valhalla for handouts.

Clovis e Adri said...

Nice try Erp, but your salary back then would be the equivalent of $6.42 an hour today.

I can redraw the question for you: would you work at that Five & Ten store for $0.1 an hour when you were 16? Comparing to Chinese, that would still be a privilege, for $0.1 would be, in dollars of 1950 ($1 in dollars of today), roughly what many Chinese adults gets now for an hour.

erp said...

Still worth it if only to learn stuff.

Annoying Old Guy said...

I don't check everything a writer wrote before linking to him. Do you?

I try to have a general sense of the writer if I recommend a piece of his for analysis rather than facts.

Going ad hominem so soon?

Just following your lead.

excessive partisanship

Thinking a particular columnist is worthless based on his own writing is now "extreme partisanship"? That's not my definition of that phrase.

What you'd prefer, no job at $0,00 per hour or full job at $1,00 per hour?

I'd prefer to make that decision for myself, and not have it made for me by a union or the government. I would also note that erp specifically disputed that the alternative was wages at Chinese levels, yet you persist in presuming that without providing the slighted bit of evidence to the contrary.

Clovis e Adri said...

AOG,

---
[Clovis] Going ad hominem so soon?
[AOG] Just following your lead.
---
Oh no, I usually wait a good number of iterations before ad-homining you.

---
Thinking a particular columnist is worthless based on his own writing is now "extreme partisanship"? That's not my definition of that phrase.
---
You look to judge him worthless because he once had respect for Obama. Am I wrong? I do think that's quite a lot of partisanship, but we can disagree on that too. I promess I won't mark you as useless for having such a difference of opinion.


---
I'd prefer to make that decision for myself, and not have it made for me by a union or the government.
---
I can't possibly see where this affirmation fits with my previous exchanges with Erp but, well, I guess every brain is its own world.

---
I would also note that erp specifically disputed that the alternative was wages at Chinese levels, yet you persist in presuming that without providing the slighted bit of evidence to the contrary.
---
The bigger point I am trying to convey to Erp is that no thing anyone in the US would do - be it politicians, unions, workers, whatever - would protect them from China taking those jobs away, unless US workers were to accept the same wages practiced in China (which is not a possibility).
As for evidence, I am presenting the same as hers (nothing). I've learned in time that analytical proof means very little to Erp, so why to bother?

Annoying Old Guy said...

Clovis;

With regard to ad hominems, this - "this kind of selective quoting out of context is too low even for you".

You look to judge him worthless because he once had respect for Obama. Am I wrong?

Yes, you are wrong. It is the stupid shallowness of that respect, not the respect itself.

This is related to a more fundamental problem in that there's really nothing about Obama, then or now, to respect so any one doing so is effectively forced to make such stupid arguments. That this doesn't cause some introspection is just another indicator.

no thing anyone in the US would do - be it politicians, unions, workers, whatever - would protect them from China taking those jobs away

I don't believe that's true, and I would expect neither does erp, who pointed out something she thinks would have prevented it.

As for your question, it's not a matter of evidence, but of basic respect for rational argument. If you are going to provide a hypothetical as a counter argument, it should embody her assumptions, not disregard them. It's like my making a claim about low temperature matter and you point out that the solar corona doesn't work that way. Even if true, it's irrelevant.

Annoying Old Guy said...

I read the Brooks column, it was as worthless as I expected.

Brooks once again demonstrates why his columns are even more of waste of time to read than to write. I was tempted to say "demonstrate he should be locked up other delusional types, but he writes for the New York Times, so he's already there.

His latest column is panglossian fluff which rarely dares get near any sharp facts for fear of bursting. The few times it does demonstate why that's necessary.

New York City apaprently better than ever, despite a big spike in shootings and murders. He claims better parks, more businesses, etc., without any evidence to support such claims. Given the general economic state, such claims seem rather dubious. "hen I think about the 15 or 20 largest American cities, the same thought applies" - like, say Detroit? Or the not so slowly going bankrupt cities like Chicago, which is simultaneously riven by violent crime? Of course, Brooks is simply parroting the White House messaging line, which is "the economy is good even you peasants are too dumb to realize it". But, I'm sure, the timing is surely just a coincidence.

===
there hasn’t been a time in American history when so many global cultures percolated in the mainstream, when there was so much tolerance for diverse ethnicities, lifestyles and the complex directions of the heart, when there was so little tolerance for disorder, domestic violence and prejudice
===

Perhaps Brooks should inform major newspapers like, say, the New York Times about this, who report on quite a different America. One need merely look at its reporting on the Martin/Zimmerman case, the unrest in Ferguson, the rape crisis in American colleges, or criticism of Obama (driven primarily if not solely by racism). One is left wondering what newspapers Brooks actually reads. As for his comparison of the 1970s, I don't see what on his list isn't the same or worse, except perhaps violent crime outside of those beautiful cities he praised.

As for external enemies, for such weak tea they do seem to be doing very well. I would think this would actually be a serious argument against Brooks' view but he's too caught up in dismissing threats (in line, once again, with the White House spin) to notice this.

Brooks gets the "non-use" vs. "abuse of power" wrong as well. We have no shortage of abuse of power by our current ruling class. The real problem is that our ruling class views the American Street as the enemy, not foreign actors like Russia or the Islamic State and have lead major efforts to defeat its own citizenry. The essence of ruling class is to carry out unpopular efforts against the citizens (e.g., the ACA, immigration reform, affirmative action, etc.). Why Brooks thinks this or even his imagined problem is easy to solve is unexplained. Apparently in his view, he need merely state the ruling class should do better and whomp! there it is. No incenties or motives needed, just unanchored dreams. On the way there, Brooks of course displays his inner fascist, declaring that the idea of personal liberty (as exemplified by Cruz's policies) is not liberty but simply "power" wielded by another group. He can't even imagine a nation of independent citizens, only a subjugated mass for which the only question is "who has hold of the controls?".

erp said...

aog, I wasn't going to bother trying yet again to make Clovis understand that he doesn't know what he's talking about. All he knows is what he's read in the leftwing media, what he learned in his leftwing schools, what he's seen of our television dreck and movies all with leftwing propaganda running through them. Imagine suggesting that we be schooled by a pompous jerk like Brooks.

His analysis of why industry fled the country is so jejune it reminds me of an acquaintance (my age) who still harbors resentment against “rich” Jews like the one her Irish immigrant mother worked for as a housemaid when she was a young girl fresh from the auld sod.

She can't see that no matter how kind or generous the mistress of the house might have been, the girl was resentful that she didn't have the same level of material things and had to do unpleasant housework while to her mind, the mistress had a life of ease.

What my friend refuses to understand is that any work no matter how menial and low paying opens up windows into the world that would be impossible if her mother had come here and been given a credit card, a phone, free rent, free ... and lived with others also in custodial care penned like animals in a zoo and apparently Clovis can’t see it either.

Annoying Old Guy said...

Thinking of columnists who should be mocked instead of read, we have Paul Krugman reminding us why he is one

Harry Eagar said...

An additional difference between people hospitals and veterinary hospitals:

Vets collect up front and if you do not or cannot pay, they send you and your dog away untreated.

Harry Eagar said...

My first job (other than mowing lawns and painting fences etc.) paid 75C an hour, plus a plate of stew and a glass of tea if worked 8 hours.

I picked up garbage and killed rats. cannot say that I learned anything worthwhile from the work, although I learned something about people from watching -- there was no time to talk -- the people working around me.

One lesson became apparent only quite a long time after. All -- every single one -- of the people I worked with were adults, I was the only high schooler there. What I learned was, later, is that rightwingers will lie, lie and lie again -- no matter how many times the facts are laid out in front of them -- about how minimum wage jobs are entry points for young people.

This is not true now, it was not true 50 years ago and it was not true when Pultizer Prize-winning rightwing editorials Bill Fitzpatrick got his first minimum wage job in 1937. (I may have told Bill's story before, I think I have, but if anybody would like a pluperfect example of hateful Republican hypocrisy, I'll be happy to tell it again on request.)

erp said...

Harry as a scion of southern aristocracy I find it hard to believe that you had to work at killing rats while in high school and I bet if nothing else, you learned you didn't want to make it your life's work.

You are exactly right that rightwingers aka fascists lie and lie again just like our president and his handlers.

erp said...

Harry, I guess you don't know any more about vets than you do about things in general because your statement about animals being turned away untreated is not true.

Peter said...

Vets collect up front and if you do not or cannot pay, they send you and your dog away untreated.

Harry, I understand that, as a good leftist, you think that government officals sing with the angels and are all honest, diligent and 100% committed to the public good. But the more I see you argue, the more you leave me with the impression you think they are the only people who are.

Clovis e Adri said...

AOG,


---
Yes, you are wrong. It is the stupid shallowness of that respect, not the respect itself.
---
Now you are believing your own fakery. This is the problem of practicing too much selective and manipulative quoting.

You go back there and read Brooks properly, and you see that first and foremost he was impressed by Obama's knowledge, nos his pants:

“[...] but usually when I talk to senators, while they may know a policy area better than me, they generally don’t know political philosophy better than me. I got the sense he knew both better than me.”

The comment about his pant is risible, and easy target for ridicule, but it makes only a good joke for teenanger's level of discussion. Please stop using your father's account, AOG's son.

---
New York City apaprently better than ever, despite a big spike in shootings and murders.
---
Gee. A 26 days statistics? Really? Please teach some math to your son before he types here again, AOG.

---
With regard to ad hominems, this - "this kind of selective quoting out of context is too low even for you".
---
Well, I will not exempt you from personal criticism when duly deserved. If you can't take it, just give me once again that ad-hominem phrase you use to run from arguments.


BTW, thank you for your take on Brook's column. It gets down to a half-full or half-empty view of things, I guess. You could consistently disagree with him without invoking paranoid conspiracies of him trying to help the Govt line: had you paid attention last election, you'd see he was one of a few voices defending Romney at the NYT. (Yes, I think he usually votes Republican).

Clovis e Adri said...

Erp,

---
His analysis of why industry fled the country is so jejune it reminds me
---

Actually, Erp, that's not my analysis. Contrary to you, I do not believe to know all about everything from my high chair.

I do look for more informed opinions, and the one I expressed is close to the consensus for most economists.

I lose my time, because you are an anti-intelectual who can only answer rational arguments with derision for people who look for numbers, or by announcing how much you only care for your kitten videos. But since AOG asked for, I can recommend these articles about the subject:

There is this, this and this.

Nowhere US labour unions are counted as a relevant factor. And for obvious reasons: they've been declinig frantically from the 70's, around the same time the curves of productivity and average earning on wages have completely decoupled. IOW, you defend companies desperately fled the US to China exactly when they have been spending less and less with labour. It must make sense in your twisted worldview.

erp said...

As I've already pointed out, unions are only in decline In the private sector. They are thriving in the public sector.

As for numbers, they are my favorite thing. I was math major in the dim dark past, but what you present are not numbers, they are studies and analyses of statistics of IMO questionable personages.

See the difference?

Harry Eagar said...

'Harry, I guess you don't know any more about vets than you do about things in general because your statement about animals being turned away untreated is not true.'

I did a news story about 10 years ago about an eager young vet who provided free care to a dog that had been dragged by a truck. He explained that he would feel compelled to treat helpless animals even if no one could pay. (After my story appeared, he received contributions from strangers big enough to cover his expenses on the dog.)

I also interviewed veteran vets on the subject of uncompensated care, and they were unanimous in saying his practice would soon fail. I also have a fund of horror stories about vets who did break the rule and operate on the cuff.

But your objection begs a question: these vets are operating as the free market requires -- as skipper keeps telling us -- so why do you want them to do otherwise?

Peter said...

these vets are operating as the free market requires

OK, Harry, you win. I'm prepared defend market principles for human healthcare, but if it means sick puppies, I'm converting to socialism.

erp said...

Socialized vet care would certainly solve the sick puppy problem and stop people from wasting their time taking videos of their adorable kittens' antics, not to mention saving what's left of old ladies' eyesight.

Annoying Old Guy said...

Clovis;

vI will not exempt you from personal criticism when duly deserved.

Go right ahead, just remember such comments are not arguments nor facts and therefore ignoring them is not avoiding an argument.

Brook's column. It gets down to a half-full or half-empty view of things

No, I cite data, Brooks cites his personal anecdotal impressions. Not quite the same thing.

P.S. Claiming I have a math problem because the data I cited is not of sufficient quality for you is rather risible as well.

But even more bizarre is "paranoid conspiracies of him trying to help the Govt line".

I think you would do better to, whenever you are about to write such a hyperbolic epithet, you stop and think "why do I have to do that, instead of providing facts and reason?". Because, frankly, it's quite reasonable to presume you do it precisely because you have neither facts not reason. In this case, you provide not the slightest of either to argue Brooks isn't carrying water for the Obama Administration just like most of the rest of Old Media (the latter being a opinion you claim to share).

Annoying Old Guy said...

Eagar's argument is an excellent demonstration of his not so inner fascism. In his world view there is no individual morality or conscience - *society* will decide what is good and all will be coerced to obey and do spend themselves on that societally defined "good".

Harry Eagar said...

Well, yeah, I am OK with compelling people to be taxed for health care for all, unless, of course, it could be done by the market.

But we've seen that doesn't happen.

Just in the last few days we've learned that America has an extensive infrastructure system for dealing with diseases that have not been known here, as well as a system of developing prophylaxis/prevention against them.

All coerced out of the taxpahyers. But I'm open to an explanation of how a free-market health system would have provided all that. (Going out for popcorn, this should be good.)

Annoying Old Guy said...

As far as I can tell, you are OK with compelling people to do whatever you think would be "good", of which taxes are simply the smallest manifestation. I can provide a link to a successful free market response to Ebola against massive government failure. In this country, I have yet to see that infrastructure actually be used for something useful. Care to provide any evidence?

But let me try to understand the logical chain you are yanking here - if there exists one aspect, no matter how small, the government does well, this justifies and validates government control over everything. In this specifically, if te government can do a better job at one facet of emergency preparedness, it's unreasonable to oppose an entirely government run medical system. Is that your view?

Clovis e Adri said...

AOG,

---
I think you would do better to, whenever you are about to write such a hyperbolic epithet, you stop and think "why do I have to do that, instead of providing facts and reason?". Because, frankly, it's quite reasonable to presume you do it precisely because you have neither facts not reason.
---
Well, sorry if I am not sufficiently objective sometimes. It is mostly not for lack of "facts and reason" though, but for lack of faith that to present them will change your mind.

Take for example this answer you gave me: "No, I cite data, Brooks cites his personal anecdotal impressions. Not quite the same thing. P.S. Claiming I have a math problem because the data I cited is not of sufficient quality for you is rather risible as well."

You believe to have presented facts, but of what quality? I mean, if you can't recognize how a statistics of murder in 26 days shouldn't be directly compared to one in 365, what else can I say so you can see "reason"? Either you are arguing in bad faith, or you are just too blinded by political bias to recognize the blatant error in your reasoning here. [I am discarding a third option - that you have no training in basic statistics - due to your alleged academic background]

Analogue comments apply to other of your points, e.g. Brooks says 15 to 20 other US cities look to be improving fine, then you believe to be disproving him by citing one single outlier (Detroit)?

Now, I suppose I could argue ad infinitum over all those points, but my experience is that a mix of pride and bias will make it hard for you to recognize those errors, so my last shot is to hope my "hyperbolic epithets" may help where reason is slow and innefective to communicate.



---
In this case, you provide not the slightest of either to argue Brooks isn't carrying water for the Obama Administration just like most of the rest of Old Media (the latter being a opinion you claim to share).
---
Hmm, I see, guilty until showed innocent in a tribunal made of your own mind alone?

Harry Eagar said...

Address the question, Guy, don't duck it. What Firestone shows is that resources beats no resources. Who knew?

I have not said government should control everything. What I explicitly said was when the market has demonstrated failure, as it has repeatedly, we look to government. As Margaret Humphreys showed so elegantly in her history of the control of yellow fever.

Furthermore, the areas where gummint should step in are not those that I think are good; we vote.

I would vote against municipal tennis courts, for example.

Annoying Old Guy said...

Clovis;

You believe to have presented facts, but of what quality?

Higher quality than Brooks.

guilty until showed innocent in a tribunal made of your own mind alone?

Not at all. You are the one who claimed I was guilty of "paranoid conspiracies". You find it improper for me to object to such declarations of my guilt?

Mr. Eagar;

Address the question, Guy, don't duck it

Just following your lead. I would point out that the governments involved hardly had "nothing". Why don't we compare the budgets of those goverments to the revenue of the local Firestone company and see if the government side is "$0".

Because you look to government after market failures, but never the market after government failures*, eventually government will controle everyhing. Any such one way process inevitably and eventually results in moving everything to the same side. Morever, any human endeavor will have failures, the market is human endeavor, therefore your formula will in time apply to everything.

Why would you vote against municipal tennis courts? If people want to play tennis but don't have courts, how is that (in your view) not a market failure?

* presuming you consider a government to ever fail

Clovis e Adri said...

AOG,

---
Higher quality than Brooks.
---
Actually, lower. Mathematically false statements are wrong in a way that general subjective impressions can not be.

---
You are the one who claimed I was guilty of "paranoid conspiracies". You find it improper for me to object to such declarations of my guilt?
---
Ha, nice one. Good joke.

Annoying Old Guy said...

Clovis;

What was "mathematically false"?

The other matter was not a joke, simply scroll up to your comment on October 4, 2014 at 5:34 AM (since the comment links have disappeared once again).

Bret said...

aog wrote: "...since the comment links have disappeared once again..."

Yes and no.

I'd bet that this takes you to the comment you just made.

Unfortunately, when you're on the page with the "Leave your comment" box, they don't show up. They only show up on the post page.

I'll add trying to fix that to my list of things to do.

Bret said...

Bret wrote: "I'll add trying to fix that to my list of things to do."

And Bret replies to his own comment:

Scratch that. I took a look at blogger's html for the blog these days and there's no way I'm going to have time to figure out why comment links work on the post page but not the "Leave your comment" page. It's gotten a lot more complicated than last time I looked.

Clovis e Adri said...

AOG,

It was an invalid statement, within the data provided, that NYC had a big spike in shootings and murders.

And yes, the other matter was a joke from you, intended or not.

Annoying Old Guy said...

So, 28 is not 33% greater than 21? Huh.

And didn't write that I was bringing up "paranoid conspiracies". Huh.

Clovis e Adri said...

AOG,

Yes, 28 is greater than 21 (hey, congratulations!), but it does not represent a "big spike in shootings and murders". An no, that's not subjective as long as you are comparing a 26-days murder distribution to the initial part of a 365-days one.

Annoying Old Guy said...

So, it's not actually "mathematically false", we simply have different views of what is a "spike". Also, the 21 to 28 comparison is month over month, equal time periods.