Nicholas Kristof closes his column, touting the virtues of a ceremonial head of state for the United States, with the following summation, presumably his intended point all along:
So maybe we should just accept that we’re stuck with a presidential system — and with a ruminative and slightly boring president who tries to solve problems rather than fulminate about them.
Is President Obama really “ruminative and slightly boring”? Mr. Kristof may be confusing President Obama with former President Carter, something that’s become something of a national pastime recently.
To my eye the operative word in that sentence is “tries”. In all honesty I’d rather have a president that solves problems than either a president who fulminates about our problems or tries to solve them.
I’m sure that I will be chided for being unduly critical but I think that over the last year and a half we’ve seen altogether too much trying and all too little problem solving.
Here’s the score card so far. The massive stimulus package, touted as boosting the economy and preventing the unemployment rate from rising over 9%, failed in that objective. Housing and retail remain in the doldrums, the banks aren’t in notably better shape than they were a year ago at this time, the unemployment rate is now projected to hover around 10% for the foreseeable future, the stock market is in the midst of what may be a multi-year bear market, and only the permiest of perma-bulls are predicting a V-shaped recovery any more. PIMCO has just bought Treasuries. For those of you playing at home, that means that, rather than betting on inflation (and growth), the investment giant is now betting with real investors’ money on deflation and, presumably, contraction.
A Gordian knot of a healthcare bill was passed. It hasn’t started delivering anything yet and it’s already over-budget. Today I’m writing my Congressman and senators to urge them to repeal an onerous additional record-keeping provision in the bill that will raise my costs and those of millions of other small businesses by thousands of dollars a year, money that I’d rather spend on paying my bills, expanding my business, or saving for the retirement I have no real plans for but which old age and infirmity might force me into some day.
I can only assume that we’ll see more absurdities emerge from the healthcare bill in the fullness of time. Nearly every prediction of opponents of the bill is coming to pass and very few if any of the predictions of its advocates look very likely. Does anybody really believe that the healthcare reform bill will reduce costs any more?
President Obama’s efforts at wooing our foreign adversaries have largely come a cropper. Our enemies still hate us and our erstwhile friends aren’t sure any more.
We’re in the middle of what looks to be the greatest environmental catastrophe in the history of the country in the form of the Deepwater Horizon oil spill, which will presumably join the pantheon that now includes the Exxon Valdez and Three Mile Island. I don’t blame President Obama for the spill any more than I blame President Bush for Hurricane Katrina. I do blame both of them for the inadequate and frequently feckless federal response to both disasters. BTW I also blame state and local officials in both cases. I feel confident in predicting that some of the heroes of this catastrophe will be state and local officials who stopped waiting for directions from the federal government and started taking action to protect their beaches. As me auld mither used to say, it’s easier to ask for forgiveness than for permission.
Right now I’d like to see a lot less trying and a lot more succeeding.
Part of the problem is that we have made the position too big for any man, even a divinely ordained priest-king, to fill. There is no person in history who can be good at even most of the things the President is expected to handle, let alone all of them.
The solution I prefer is to split the role, into a head of government with domestic responsibility and very short times in office, and a head of state with international responsibility and long tenure in office. But absent a constitutional convention, I think we’re just doomed to being ill-governed and too often ruled.
Your last prediction is probably going to turn out correct.
Officials in Orange Beach, Alabama were barred by the Coast Guard from blocking Perdido pass, which is the entrance to the fish and wildlife rich back bays. Once oil came in, the Coast Guard changed its mind, but is having trouble keeping the oil out now.
In Magnolia Springs, in the same county, the community is placing barges across another pass, which leads to back bays containing at least 19 federally endangered species. They are doing so without permission, and risking serious jail time.
I’m personally familiar with Perdido Bay; it’s name comes from the Spanish for “lost.” It was a bay only accessible by a small pass that often closed up or shifted. It would close up today without constant dredging. The only boats going through the pass are local fishing boats. The hidden bay where fresh and salt water mix make great fishing, wildlife habitat and dolphin watching. I hope to return some day.
While differing on some details of your analysis, I agree with the conclusion. I apply the same standard to Mr. Obama that I did to Mr. Bush: get it done.
We don’t draft these people, they come to us begging for the job. So they don’t get much pity. Granted Mr. Bush left things in an awful mess, but Obama knew that before he applied for the job. Don’t tell me you can do it and then fail.
Moving past that I don’t think our problem is that the job is too big. Our problem is the American people. Their heads are stuffed full of mismatched bits and pieces of ideology, prejudice, superstition and distortion, and their state of mind is childish, resentful and self-centered.
A juvenile, ignorant electorate was probably never a good thing, but a juvenile, ignorant electorate that defers to no party, is paranoid and mistrustful toward all authority, and insists on its right to jump with both feet into every issue and controversy is disastrous.
I have mixed feelings about all this. I don’t know if chiding you on the merits of what you wrote is appropriate, because through my lens it is largely factual, but perhaps the chiding should be “what did you expect?”
Perhaps my prism is too PE/Board oriented, but this man – had he sent a resume to us for a CEO position – would have been rejected out of hand. He had completely inadequate qualifications and experience for an executive position. If there is a search function for “Drew” here or at OTB people would see multiple comments to that effect. But political momentum being what it is, ludicrous promises, combined with media fawning and a slick tongue, can get one elected in this day and age.
Hence, you might suspect I strongly disagree with Mr. Medcalf’s observation. There are plenty of complex executive positions filled by people who fulfill those roles successfully everyday. The notion of splitting the job only comes about because we have a guy not up to the task.
That all said, my criticism of Mr. Obama on the oil spill is more tempered than some. The wild eyed sycophants probably expected him to be barking orders from a shrimp boat, if not don a scuba outfit and plunge to the depths to fix the leak. More sober, but misguided, observers who truly believe in the competence of central government, appear to be surprised at the ineffectiveness of the response. Me? I’m not sure why we expect Mr. Obama to “solve” the problem, any more than we should have expected Mr. Bush to “solve” the Katrina mess. The enormity of the problems seems to be missed.
I think the central problem is the arrogance and inexperience – my words – of Mr. Obama’s response. Specifically, there were requests to build barriers and an offer from the Dutch which were rebuffed. No competant executive would do that. But a career community organizer/politician might. It is this same arrogance and inexperience that lead people to thing central govt can fix poverty problems, health care problems etc. The track record stinks; its an empirical fact.
No, no. I have thought that since at least the first President Bush. (For reference, I became politically aware at the end of the Carter years, and was first eligible to vote in the 1992 election.) The job has just become too big for one person. (And yes, many companies are in the same position, when their business activities become too large for one person to encompass at a level where they can guide those activities towards a common corporate goal.) It has nothing to do with Obama’s incompetence; he just highlights the problem more than most do. There is literally not a single person in human history who could competently and efficiently manage the mess that the US government has become. if our expectation were that the President would provide moral and policy guidance, first principles, we’d be OK. But we expect that the President will be conversant with the minutiae of everything the government does, and that’s simply beyond human capacity. Any human.
“But we expect that the President will be conversant with the minutiae of everything the government does, and that’s simply beyond human capacity.”
Perhaps that is our point of departure. I don’t expect that. In fact that is really my point – anyone who does is a fool. (Not aimed at you) This reliance-on-government worldview is what I rail about all the time. Its naieve beyond all sensibility. And yet pols promise, and the electorate continues to look to, government for solutions to our ills.
Its all a straw man argument. When markets have failures a contingency rises up and cries for government. But government produces precious little and is not held up to the same standard.
I used to have a better facility with the numbers. But I believe the US budget rivals the GDP for the 3rd or 4th biggest economy in the world. I defy anyone to make the case that the US government provides as much utility as the GDP of the 3rd or 4th largest economy in the world.
I happen to think Obama is in completely over his head. But I also think the solution to your concerns isn’t to carve up the office into bits, but to carve down the scope and expectations of government.
“But I also think the solution to your concerns isn’t to carve up the office into bits, but to carve down the scope and expectations of government.”
I guess the next step in the argument is to invoke the automagic properties of the market to correct and head off problems like the Gulf. The political problem with that is that folks, quite reasonably, think, “Oh, the market, you mean that entity consisting of companies like BP and folks like Bernie Madoff. That market?” The most compelling argument against the market philosophy, as a governing philosophy, is the character of many of the participants. I would rather be ruled by the first one hundred people listed in the New York phone book than have my fate be entrusted to a market consisting of companies like BP. The invisible hand would all too quickly be replaced by the invisible fist.
That was, with all due respect, sam, idiotic commentary.
You did just what I cited: invoke the straw man of a perfect world. There is no perfect world; there is no perfect market. No one in their right mind claims an “automagic” market.
Then you invoke Madoff or BP, yet you implicitly seem to take comfort in the alternative of government, with crooks, waste, fraud and failed programs in spades. But its a fact, government’s record is just awful. Government is running us into the cliff of insolvency. Its a fact.
Here is a simple question: our state , local and federal governments are basically bankrupt. How many private (market) companies are bankrupt? Who is doing better? Market, or government?
The sad thing about it, Drew, is that if governments operated under the GAAP under which virtually any company operates many at all levels would have been declared insolvent long, long ago.
Dave –
They would have been forced to put an actuarily calculated liability on the balance sheet. Like a pension fund must. Can you imagine?
There has been no “sinking fund” or “rainy day fund” concept in government for decades (like 5 decades) and so now we have this mess. Many, many observers, not just me, have made this point to no avail.
And so here we are. As the current President’s pastor says: the chickens are coming home to roost. I’ve got an awful lot of money with PIMCO.
Drew:
You’re a guy who starts with an idee fixe and fits reality to support it.
Denigrating Obama as just a community organizer is stupid. Lincoln was a railroad lawyer. Grant was a firewood salesman. Truman was a haberdasher. Jefferson was a farmer.
Now, I understand that in your case “community organizer” is code. But you might try a bit harder to disguise your shall we say pre-conceptions?
Who was the president who fit your personnel department notions of a well-qualified president? Was it the former cheerleader George W. Bush? How about the nuclear engineer Jimmy Carter?
You know who was qualified? Nixon — a criminal. Who else would have passed muster with the human resources department? George H.W. Bush — a mediocrity.
Your core concept, your central premise won’t stan up to te seconds’ worth of application to the historical record. But you jump on that “community organizer” crap at every opportunity.
Let me make one thing very clear: Obama has not succeeded. But he has not yet wreaked one tenth of the damage on this country that his MBA, former oil man, former governor did. Our last human resources department-qualified president is the one who dug the f–ing hole the community organizer is now trying to get us out of.
“Here is a simple question: our state , local and federal governments are basically bankrupt. How many private (market) companies are bankrupt? Who is doing better? Market, or government?”
And who blew up the world economy? A bunch of banks and insurance companies. It was worldwide remember. Who has to try to fix things so that we dont end up in a depression? Without intervention, it was likely that all of the investment banks would have cascaded under, plus AIG, Citi, BoA along with the wents that went anyway like WAMU. Across the pond, Barclays, UBS etc. go under. AND, there is no JP sitting around to bail things out. Of course, the Fed was created when the limits of private bailouts was reached.
For my money, very big business and government both have problems and neither should be completely trusted. We should decide what government is good at, what business is good at, then try to keep the two apart. For example on health care, I see absolutely no evidence that the private side has any solutions to offer for reform. Maybe I am too close to it, but I read extensively also, and just do not see it. The industry is very good at expanding, not controlling costs. OTOH, I do not want government running businesses or allocating resources that can be placed transparently on a market.
So taking Dave’s list. #1 is a strawman. The unemployment rate was over 9% before stimulus money was in circulation. They suck at forecasting. #2. Nearly every prediction? Such as? I can personally and confidently tell you that I am not working for a death panel and medicine is not now functioning like the NHS. What was the alternative? The parts that are working won’t get any press. Government program worked doesnt make the press. Most of the cost savings come later if that is what you are concerned about.
Oil spill? The plans for handling this should have been made years ahead of time. I will agree with you on this one not being handled well by government. Giving carte blanche to drillers never made any sense.
Steve
Drew:
I fail to see what’s idiotic about what I said, since I believe I was only responding to what you, in your heart of hearts, believe: government is altogether bad, bad, bad (” the alternative of government, with crooks, waste, fraud and failed programs in spades”). So, given that animus, what would one expect such a person to believe? That market-based solutions are the best solutions, obviously. We disagree.
Does your spleen feel better, Michael?
First, please tell me your comment: “Now, I understand that in your case “community organizer†is code.” isn’t what I think it is – your usual racist screed.
Second, I stand by my position 100%. This guy simply has no background to recommend him; and no results so far to alter that point of view.
Third, “But he has not yet wreaked one tenth of the damage on this country that his MBA, former oil man, former governor did.” Your wild eyed, erroneous assertion is duly noted.
The rest of what you wrote was just drivel.
Oh, and lastly. In what year of his Presidency do you stop blaming the predecessor, and ask what has Obama done? Its a year and a half now, and lot’s of policy has been implemented. In my business you don’t get to put forth perpetual excuses. But of course, my business is not government. Maybe perpetual excuses work for book writers.
steve –
“And who blew up the world economy? A bunch of banks and insurance companies.”
Its always a problem to start off an argument with a false and simple minded assumption. You forgot the Fed, Fannie and Freddie, Congress etc etc. The Congress has appointed a 10 member panel to attempt to sort this out. I don’t know if the work product will be useful or not. But if I were you I might withhold such assertions until a full vetting is completed. My views have been clear, and expressed here. I still think I’m right. But I will review the commissions report with due respect.
“For my money, very big business and government both have problems and neither should be completely trusted. We should decide what government is good at, what business is good at, then try to keep the two apart.”
Now this is a concept we could completely agree upon, although you might suspect my leanings. I simply trust far more the results of a profit driven, but competitive, market, than a government. I think the empirical evidence is clear.
“For example on health care, I see absolutely no evidence that the private side has any solutions to offer for reform.”
Because you have ignored my obvious, fundamental, Econ 101 point that the price mechanism must be reintroduced into the healthcare arena. If you reject that, then you are into a world of government control, committees, panels, “experts” and useless masterbation that will go nowhere. Healthcare expenses took off when the market was basically eliminated from consumer choice. Shouldn’t that be a hint? Jus a lil bit?
sam –
“I believe I was only responding to what you, in your heart of hearts, believe: government is altogether bad, bad, bad (†the alternative of government, with crooks, waste, fraud and failed programs in spadesâ€).”
Well, you believe wrongly. And to come to such a monolithic conclusion may indicate a certain lack of intellect on your part. No fool would conclude that government is always “bad, bad, bad.” Further, even if it was so, there simply are certain activities in a society that only a central government can take on, for example, national defense. (Hence Milton Friedman’s quip – paraphrased – “I know I have to pay $3 for every dollar of defense I get, but what’s the alternative?”) There are obviously a number of legitimate functions of government. The question is the appropriate limits of government, and the economic tradeoffs of government vs private enterprise. Given the near bankrupt state of governments: fed, state and local, how do you think things are going? And that is what I am observing. Are you pleased with the financial management and the with the utility received from your state, local and fed government??
I’ll repeat: I think the feds have a budget about the size of the 3rd or 4th largest economy in the world. Anyone want to take up the banner for the relative utility provided by the US government and, say, the German economy?
That would be good for a belly laugh.
Drew:
I’ll pass over the certain lack of intellect remark and ask you what conclusion you would draw about a person’s attitude toward government, in general, on the basis of these two remarks:
“It is this same arrogance and inexperience that lead people to think central govt can fix poverty problems, health care problems etc. The track record stinks; its an empirical fact.”
and
“But I also think the solution to your concerns isn’t to carve up the office into bits, but to carve down the scope and expectations of government.â€
What is one to think of this person’s attitude toward government vs the market? Is it so far out of the realm of possibility to infer that such a person might prefer market solutions to government solutions? I think not, and I said as much — and registered my disagreement — and then when the person in question goes on to flat assert the position I attributed to him (and seems to object to my having done so, straw man and all that):
” I simply trust far more the results of a profit driven, but competitive, market, than a government. I think the empirical evidence is clear.”
Well, what’s a body to think? Empirically, I mean.
“Healthcare expenses took off when the market was basically eliminated from consumer choice. Shouldn’t that be a hint? Jus a lil bit?”
They took off when we could diagnose stuff accurately for the first time. When technology started to drive costs. Insurance was introduced during WWII.
Your Econ 101 is trumped my Medical Reality 101. The information asymmetry is too large. No, not for the kinds of people who post here, but for the kinds of patients I see everyday and at night. They are frightened and not well informed. Most barely know their own medical history. I took the liberty of looking at the early numbers on a small study we have been doing. Only about 1/3 of patients with an artificial heart valve knew which one had been replaced. I can see pricing mechanisms making a difference at the fringes, but not on the big ticket items.
“You forgot the Fed, Fannie and Freddie, Congress etc etc. The Congress has appointed a 10 member panel to attempt to sort this out.”
I have read almost everything I could get my hands on about the GSEs. Russ Roberts’ piece is probably the most readable and one of the best. They were a factor, but not a necessary one. They were losing market share as the subprimes ramped up. The shadow banking system did not need them. Having some way to securitize the loans and rate them AAA were much more necessary.
Steve
sam –
“I’ll pass over the certain lack of intellect remark”
I don’t think you should pass it over, it was intended to be inflammatory and to elicit a response. You made an unwarranted and broad assertion. You should be held to account.
“and ask you what conclusion you would draw about a person’s attitude toward government, in general, on the basis of these two remarks:
“It is this same arrogance and inexperience that lead people to think central govt can fix poverty problems, health care problems etc. The track record stinks; its an empirical fact.â€
I would conclude that you can’t defend government’s track record and prefer to make broad generalizations. Get back to me when you have a coherent argument/defense of government intervention.
“But I also think the solution to your concerns isn’t to carve up the office into bits, but to carve down the scope and expectations of government.â€
“What is one to think of this person’s attitude toward government vs the market?”
One is to think that a rationale person’s observation is that the private sector has a robust track record of improving the human condition, and that government, although necessary for some functions, has a pretty dismal track record.
Again, if you care to make the case for government with some specificity, please do. Else climb back in your cage.
“Is it so far out of the realm of possibility to infer that such a person might prefer market solutions to government solutions?”
That’s not what you said or inferred. You are lying now.
†I simply trust far more the results of a profit driven, but competitive, market, than a government. I think the empirical evidence is clear.â€
“Well, what’s a body to think? Empirically, I mean.’
That you are unable to make your case.
steve –
There’s alot going on here……..
“They took off when we could diagnose stuff accurately for the first time. When technology started to drive costs.:
I have no doubt, or quarrel,with this. But its only a piece of the puzzle. As are malpractice insurance issues.
“Insurance was introduced during WWII.”
Yes, and employer based, one of the root causes of our problem, and one of my central points. The consumer/health care provider price equation was broken, with tax advantage, and with predictable results. And as this benefit grew (naturally) so did the problem. No one eats hamburger on an expense account.
“Your Econ 101 is trumped my Medical Reality 101.” ” The information asymmetry is too large.”
Only in your mind. The same information asymmetry exists for people don’t know the details of how to rebuild their tornado destroyed homes, prevent flooded basements, fire damaged kitchens, crashed cars etc. They don’t know how to fix them, or to truly evaluate the insurance need. Medical treatment is not special; Your argument is a red herring. Proper insuring medical treatment (or anything) is the issue, and different from making making medical treatment decisions.
“No, not for the kinds of people who post here, but for the kinds of patients I see everyday and at night. They are frightened and not well informed. Most barely know their own medical history. I took the liberty of looking at the early numbers on a small study we have been doing. Only about 1/3 of patients with an artificial heart valve knew which one had been replaced. I can see pricing mechanisms making a difference at the fringes, but not on the big ticket items.”
The red herring continues. I bet the average person doesn’t know what the plumber did to their sump pump last year either. That doesn’t mean they shouldn’t have water damage insurance. I get very agitated at these red herring arguments that a person – in a desperate life or death medical decision moment – is at a loss with respect to insurance issues. That’s too late. You can, with proper guidance and in the peace and unhurried time of your home, make your insurance decisions. No gun to your head. People don’t do it because they are divorced from the insurance process – my central point. What you are really invoking is the notion that people are underinsured out of stupidity, or in a moment of crisis may have to make adverse economic decisions. I say they have abrogated a fundamental responsibility because of the rise of the third party payer system. And this brings me back to a point I always make: people should buy medical insurance for all manner of catastrophic events, so that the issues you cite are not relevent in a moment of crisis. But rather, our system has resulted in them buying (or being employer provided) all encompassing health care maintenance contracts, which are by definition expensive. As a result, to whittle down premiums, certain coverage limits exist for the catastrophic events. And then the awful decisions you cite occur. Pardon my French, but that’s a system that’s all fucked up. Its simply not insurance, and its a terrible malformation in the health care system. We want everyday health care expenditures to be free, but then we bitch when the no-free-lunch reality of cost containment elsewhere raises its ugly head. In effect, we have a system where people play the lotto with respect to catastrophic health care coverage.
With all due respect, the rest here is subject to much more debate later. BTW – F&F had most of the subprime volume:
“You forgot the Fed, Fannie and Freddie, Congress etc etc. The Congress has appointed a 10 member panel to attempt to sort this out.â€
I have read almost everything I could get my hands on about the GSEs. Russ Roberts’ piece is probably the most readable and one of the best. They were a factor, but not a necessary one. They were losing market share as the subprimes ramped up. The shadow banking system did not need them. Having some way to securitize the loans and rate them AAA were much more necessary.
Steve
Drew
“That’s not what you said or inferred. You are lying now.”
Ah, c’mon. That’s not true. I said that what would come next after the dumping on the government move would be the invocation of market solutions move. And it did, in the end, as I showed. But no matter. I shan’t be arguing with you again or reading your posts again.
“people should buy medical insurance for all manner of catastrophic events, so that the issues you cite are not relevent in a moment of crisis.”
It has long been part of my thesis that it is insurance which is part of what makes pricing mechanisms not work well in medicine. As long as people are insured for it, they will have it done (whatever IT is). Providers will tailor their care to the insurance payments. It is also difficult to insure separately for every contingency, so you need comprehensive insurance. You need to find a way to more directly link costs to the consumer. You also need to think carefully about different levels of insurance and different levels of care. It will make keeping accurate stats, already difficult, more complicated.
You also grossly underestimate the emotional aspects to medical care and the time constraints. On routine care, the part of medicine that might respond better to market mechanisms, those are not issues. On the big ticket items, the emotional component is a driving factor. They are usually diagnosed by their family doctor, whom they know and trust. He/she recommends the specialist. They recommend the procedure. Most people do not question the need for the procedure. Most people are not willing to go shop around, especially as it means going to some place new or seeing someone they dont know or their family doc cannot vouch for. What you want would take a huge cultural shift.
Then, you aways forget the provider side. Hospitals and providers have learned how to work insurance for maximum returns. Without insurance, people are at the mercy of whatever they are charged.
Throwaway, since most people dont work in medicine. Most cities with two or three heart programs should have just one. Volume makes a difference. However, heart programs pay well so many hospitals want one. In the ideal world, that drives down costs, but in insurance world and referral world, it does not. Now, suppose we manage to instill price competition. In theory, the program with the best ROI, outcome for dollar spent, should win out. Then you are left with one program, and no ore price competition. Entry costs are high to start a new program, so the remaining program can charge much higher prices than a competitive market would allow for until they reach the trade off on entry costs. Even then, the newer competition will likely have worse outcomes until they build adequate volumes.
Steve
sam –
sniff, perchance you have a tissue
So steve –
“It has long been part of my thesis that it is insurance which is part of what makes pricing mechanisms not work well in medicine. As long as people are insured for it, they will have it done (whatever IT is).”
So I’m confused about a disconnect between us; this is exactly my point. Maybe I make it clumbsily. (Is that a word?) We don’t really have health insurance for catastrophic events; we have maintainence insurance for all events. This distorts price discovery and reaction. The results are obvious to any thoughtful person, and empirically evident, and so different from insurance results in other settings.
“Providers will tailor their care to the insurance payments. It is also difficult to insure separately for every contingency, so you need comprehensive insurance.”
I simply cannot tell you how completely I agree with you on this. Hence, if insurance is paying for every piddly ache and pain that motivates a doctor visit, we will have health care cost escalation, and insurance premium escalation. Its axiomatic.
“You need to find a way to more directly link costs to the consumer.”
From your lips to God’s ear.
“You also need to think carefully about different levels of insurance and different levels of care. It will make keeping accurate stats, already difficult, more complicated.”
I’m not sure I totally understand where you are going here. I’m squarely in the camp of comprehensive care for all catastrophic (read: expensive) events, and for zero coverage of routine care. Just as I don’t think auto insurance should cover buying gas or replacing tires.
“You also grossly underestimate the emotional aspects to medical care and the time constraints.”
Perhaps, but I don’t think so. My father, grandfather and uncle were all doctors. My mother a nurse. So I grew up in a medical family and all the table talk that was attendant. I made the rounds with my Dad until age 22. I’ve seen two dozen surgical procedures in the OR, from open hearts to cancer surgery to subdural hematomas. I’ve watched patients present and die. I’ve had two surgeries myself where hot shot neuros were required. There is nothing like being wheeled into that cold, bright light OR basically bare naked and knowing some guy is going to burrow through your neck and fiddle around near your spinal cord to focus the mind. I think I’m quite grounded.
“On routine care…………..On the big ticket items, the emotional component is a driving factor. They are usually diagnosed by their family doctor, whom they know and trust. He/she recommends the specialist. They recommend the procedure. Most people do not question the need for the procedure. Most people are not willing to go shop around……………..What you want would take a huge cultural shift.”
No! What I want is for people to quit confusing emotional medical decisions with insurance decisions. I simply don’t believe a health insurance/provision system should be based upon decisions made in the context of dire/emotional circumstances. People don’t make auto insurance decisions when they are in a totaled car 2 minutes after a crash! They decise what coverage they need well before that, and without knowing exactly what will happen in the future.
It is a complate malformation of policy that has lead us to a position where people in an ER need to make economic/insurance based decisions. My philosophy would fix that. Most current proposals do nothing.
“Then, you aways forget the provider side. Hospitals and providers have learned how to work insurance for maximum returns. Without insurance, people are at the mercy of whatever they are charged.”
Dude! Say what???? I haven’t forgotten jack!! I’m a businessman. I’m in the tug of war between supplier and provider every single day of my life. You think your profession is special??!! Of course the providers attempt to work the insurers. And vice versa. Welcome to America. I must again state Econ 101. The consumer is divorced from the decision. They are at the mercy only because of that. A game is played in the current situation.
“Throwaway, since most people dont work in medicine. Most cities with two or three heart programs should have just one. Volume makes a difference. However, heart programs pay well so many hospitals want one. In the ideal world, that drives down costs, but in insurance world and referral world, it does not. Now, suppose we manage to instill price competition. In theory, the program with the best ROI, outcome for dollar spent, should win out. Then you are left with one program, and no ore price competition. Entry costs are high to start a new program, so the remaining program can charge much higher prices than a competitive market would allow for until they reach the trade off on entry costs. Even then, the newer competition will likely have worse outcomes until they build adequate volumes.”
I know, steve. But who should decide? The consumer, or you, or government or…………
Look, steve, I think you by now know my MO. I’m falsely provocative in an attempt to spice things up here and to rile people up to fully think through their positions. And of course I put myself out there on a limb at times for people to fire their arrows at me by the dozen so I can think through my positions. Else, why are we here? To pat each other on the back, or just spit venom at each other? No. Its to vet issues we find interesting and to see and challenge other’s point of view. In my opinion you are a shining light here. I’m currently very dissappointed in MR, who seems to think any attack on Obama policy is racist. I find that disgusting and intellectually lightweight. And small s sam seems to be licking wounds and sniffing his anus. Oh, well . If you have associates that might be interested in the site please do invite them.