August 25, 2004

Some Thoughts on Health Care

This came out quite well, I think:

FT.com / Comment & analysis / Comment - A cure for America's ailing healthcare system: By Brad Delong | Published: August 24 2004 21:49 | Last updated: August 24 2004 21:49

Whenever I contemplate America's healthcare financing crisis, I find myself sunk in the Slough of Despond and the Pit of Despair. America spends easily twice as much per capita on healthcare as the typical post-industrialised country. Yet US life expectancy lags behind. America's doctors, nurses, pharmacists and molecular biologists do amazing things. But what things they do are constrained and controlled by the bizarre, disruptive and wasteful healthcare-financing system.

I have felt this despond and despair since 1993, when I worked (part-time) on the Clinton healthcare reform effort. How to provide patients and doctors with powerful incentives to reduce the proportion of US medical spending - roughly a third - that is unnecessary and inappropriate? We wanted to find some way to bring the incentives of the market system to bear on healthcare decisions. But that proved hard to do without producing a cure worse than the original cost-overrun disease.

Only one in 250 patients claiming on private insurance files for more than $50,000 a year. But these patients account for 20 per cent of insurance payouts. US health maintenance organisations (HMOs) and insurers have incentives to keep their customers healthy and to make sure they get preventive care. But their biggest incentive is to figure out who is likely to get really sick - and then to make sure they are insured by somebody else, or not at all. Increasing bottom-line pressure on HMOs and insurers increases their desire not to cover sick people.

Another problem is that consumers who purchase health insurance are charged both for those who do not have insurance and for their own care. If you do not purchase health insurance and you do get really sick, somebody else will pick up most of the tab. If you are relatively young and healthy with few assets, buying health insurance can seem like a sucker's game. Increasing the bottom-line pressure on the system encourages consumers to drop their coverage and so magnifies the problems of the financing system. Increasing market pressure gets you the gain of reduced unnecessary and inappropriate care but also big losses: powerful incentives for HMOs and insurance companies not to cover the really sick and for individuals not to buy insurance. Trying to keep the gains while avoiding the losses is what leads to despair and despond. Today, these problems are bigger and sharper than ever, and getting bigger and sharper every year. The Clinton reform was blocked because, as Republican insider William Kristol wrote at the time, a successful Democratic party-led reform of America's healthcare-financing system would be a mortal threat to the Republican party. The Bush administration today seems to have only four goals: keeping pharmaceutical companies from having to sell drugs to anybody with any bargaining power; keeping Americans from buying drugs in Canada; making it difficult for women to obtain emergency contraception; and telling actuaries to keep their cost estimates secret.

In this context, it is heartening to see that John Kerry's healthcare advisers have been thinking hard about steps forward. They are, alas, only baby steps: even proposals that look big from a federal budget perspective are small, given that America will spend $8,000bn on healthcare over the next five years. But they are steps forward.

The most important element is that Mr Kerry's people have dusted off a clever idea from Stuart Altman of Brandeis University: the government reinsures private insurers and HMOs by constructing a “premium rebate” pool to pay annual healthcare bills over $50,000. This greatly diminishes the cost to insurers and HMOs of covering the really sick, and diminishes their incentive to make sure they do not provide insurance to anyone who needs it. Insurance rates fall and, as they fall, the incentive for the healthy to go uninsured falls. It is a serious and clever proposal for the government to do something - spread risk - for which it has, potentially at least, a powerful comparative advantage. It is a government programme that would significantly diminish the market failures that gum up the private-sector portion of the healthcare-financing system.

It is a Kerry idea. But why is it not a Bush idea, too? What reason does a Bush administration have for existing, if not to lay the foundations for the market system to work its powerful magic? And what does the Bush campaign need more right now than credible proposals to show that it is serious about improving opportunity for Americans, not just millionaires?

The writer is professor of economics at the University of California, Berkeley

Posted by DeLong at August 25, 2004 07:27 AM | TrackBack
Comments

Great stuff -- as far as it goes. To wit, the government has at its disposal the tools to push on additional structural reforms of the health care delivery system, particularly through implementing health care information technologies that can ease the apparent fragmentation of the system (i.e. electronic health records that have been demonstrated to reduce duplication of services) and shift the model of care to one that is proactive and preventive (disease management, remote monitoring particularly of the chronically ill). The government's role in this is that it pays for 40 percent or more of all US health care spending through Medicare, Medicaid, and the VA. Both Kerry and Bush talk about this -- would be interesting to know what meat they would put on the bones of this. To wit, the discussion then becomes less about health care reform than health care system modernization. There's at least a nuance of a difference.

Posted by: thegoldenmean at August 25, 2004 07:41 AM

Prof Brad Delong makes me proud of him.

THE MORE I THINK ABOUT BRAD'S PLAN, THE MORE I LIKE IT. LISTEN MY REPUBLICAN FRIENDS, THE PROBLEM OF AMERICAN HEALTHCARE IS A PROBLEM OF PAYING FOR EXPENSIVE NEW AND HIGH TECH THERAPIES.

BRAD DOESN'T POINT OUT THAT AMERICAN HEALTH CARE IS MORE EXPENSIVE BECAUSE AMERICANS HAVE MORE AND BETTER OPTIONS BECAUSE WE HAVE THE MONEY TO BOTH FINANCE RESEARCH AND GIVE OUR CITIZENS BETTER CARE.

I HOPE BUSH HIRES BRAD TO IMPLEMENT THIS PLAN AFTER W CRUSHES KERRY IN NOVEMBER.

Posted by: Adrian Spidle at August 25, 2004 08:14 AM

Four suggestions:


1) Health insurers shall be required by law to provide one and only one insurance package. That's it. Uniform terms, uniform rates, the same for everybody everywhere. Insurers may provide whatever packages they want - but those must be uniformly available - and competion shall be limited to rates and overall terms.

2) Insurers shall be obliged to accept all applicants. No cherry picking.

3) All adults shall be required to obtain and maintain an insurance policy.

4) Employers should be forbidden to provide heath benefits. Heathcare and employment have nothing to do with one another. Employment decisions should be made on other, economically rational, factors.


Posted by: Methesula at August 25, 2004 08:22 AM

Well, Methesula, I would like to add a 5th point: all health insurance shall be affordable to all persons carrying it. Hence, poor people will have lower reates than rich people, right? So long as we persist in having the idiotic free market health insurance system we have now.

Posted by: Carol at August 25, 2004 08:34 AM

the value of my health is infinite therefore it cannot be subjected to commercial transaction. This was understood in the past when physicians did not collect fees but were paid honoraria. Given the infinite value of each persons health and the fact that as we age our health becomes more brittle and it is in need of constant repair it follows that eventually the care of all of us will consume all our activity. Add to this that is our cultural vice to think that asking questions is a virtue and that one should use every available means of reducing doubt and since truth is one and doubt is infinite the multiplication of tests is a given. Together with the foregoing the "health industry" becomes a source of inmense redistribution of wealth since it can never offer a sure means of survival and the survival it offers is a simple path towards senile dementia where care becomes an enormous burden and a hopeless enterprise. Health care can never be profitable though it can be unequal with the poor supplying the means for the preservation of the powerful. The notion of profit is a mirage it can never exist except in parenthood and thought. Parents create new and fresh people while thinkers offer new ideal worlds. Commerce does not create anything it merely routes the wealth of nations towards some potentes.


Posted by: jlcg at August 25, 2004 08:41 AM

Notice how Adrian Spidle's rant are increasingly in UPPERCASE fonts as the W regime implodes on itself?

Posted by: clone12 at August 25, 2004 09:02 AM

You mean you think there is somebody in the Bush administration who is interested in public policy? In governing? What a novel thought.

Charles

Posted by: charles at August 25, 2004 09:04 AM

One thing that was not mentioned was the quality of care. I venture to say that it's much superior here than in, say, Canada, with which I have some familiarity (year-long waits for surgeries that take days to schedule in the US). I don't know if this convenience is worth ALL the money we spend in excess of the Canadian spending, but is surely is worth something. I wouldn't want to go blind until my number came up for a cataracts surgery, and I have known people there who almost did.

Posted by: walons at August 25, 2004 09:14 AM

Brad writes: And what does the Bush campaign need more right now than credible proposals to show that it is serious about improving opportunity for Americans, not just millionaires?

What reason is there to beleive Bush wants to improve opportunity for all Americans? Because he said so?

Posted by: a at August 25, 2004 09:17 AM

In his post our host makes the usual comparison:

America spends easily twice as much per capita on healthcare as the typical post-industrialised country. Yet US life expectancy lags behind.

No arguement, and I'm all for heath care finance reform. But I've always thought the politically significant comparison is between the part of the US population that has good health insurance and the rest of the world. They are in the majority, tend to be politically influential, and are averse to changing a system that produces results they personally like.

I've never seen numbers like that. Overall averages are brought down by the results experienced by the uninsured.

I don't regard that inequality as acceptable, but I seen to be in the minority.

Walons: the correct comparison is between us and what Canada's system would be like if the spent what we do. Their administrative costs are one fifth of ours (roughly 5% vs 25%). Twenty percent of 8*(10**12) is a lot of house money to play with.

Posted by: Jonathan Goldberg at August 25, 2004 09:27 AM

walons: "One thing that was not mentioned was the quality of care. I venture to say that it's much superior here than in, say, Canada, with which I have some familiarity (year-long waits for surgeries that take days to schedule in the US)."

This Newsweek "My Turn" column
http://www.msnbc.msn.com/id/5197013/site/newsweek/

makes a depressing contrast between the ease of obtaining state-of-the-art stroke care in France versus the US.

Posted by: Michael Cain at August 25, 2004 09:27 AM

I liked this dig:
The Bush administration today seems to have only four goals: keeping pharmaceutical companies from having to sell drugs to anybody with any bargaining power; keeping Americans from buying drugs in Canada; making it difficult for women to obtain emergency contraception; and telling actuaries to keep their cost estimates secret.

Heh.

Posted by: praktike at August 25, 2004 09:30 AM

Michael,

The piece you mention talks about the ease of understanding payments (and their levels) not about the ease of obtaining care.

Can't speak for France, but here is a (almost a year-old) piece from The Globe and Mail about the waits in the Great White North:

http://www.theglobeandmail.com/servlet/story/RTGAM.20031020.wwait1020/BNStory/National/

Posted by: walons at August 25, 2004 09:43 AM

Jonathan Goldberg said:

"But I've always thought the politically significant comparison is between the part of the US population that has good health insurance and the rest of the world. They are in the majority, tend to be politically influential, and are averse to changing a system that produces results they personally like."

If you remove the uninsured from the equation, then the per capita expenditure goes even higher. The "bang for the buck" that people who are actually paying for healthcare (insured premium-payers, employer premium-payers, and the taxpayers) get in this country is very poor.

If I was interested in conspiracy theories, I would hypothesize that the system was engineered to drain the resources of middle-class americans at the end of their lives, so that they had nothing to pass on to their children, thus widening the gap between rich and poor; if you can't get rich in your lifetime, then tough, your kids start from zero.

Posted by: Fred at August 25, 2004 09:55 AM

The $50,000 reinsurance plan is an interesting compromise between socialization and whatever we have now. I like that incentives to innovate are not harmed, which makes this plan almost unique in proposals from the left.

The call for equal insurance for all still leaves me cold when you look at the perfectly voluntary activities that the unhealthy engage in. It seems unjust to me that those who watch what they eat, go to the gym, and so forth should be put in the position of subsidizing unhealthy habits. I guess I'm saying that redistribution I could live with would be something like, 'rich fat people subsidize the healthcare of poor fat people.' Incentives to be healthy need to be maintained.

Posted by: Jason Ligon at August 25, 2004 10:01 AM

Not enough is talked about the warping of motivations intrinsic to the concept of insurance. The interest of the policy-holder and the insurance company is a Venn diagram with circles barely overlapping. Because policy-holders have already paid through the nose for insurance, it is only human that they would want to get all the treatments they can. Meanwhile, I'm sure there's a lot of wasteful overhead incurred by the insurance company because their raison d'etre is to maximize profits, not provide the best healthcare per dollar for their policy-holders. Free-market solutions are suspect because the situation is simply too opaque -- after all, insurance is all about being willing to pay a premium to erase uncertainty.

Posted by: Angelica at August 25, 2004 10:12 AM

Brad, could you please address some concerns about your plan expressed on my site?

http://pep.typepad.com/public_enquiry_project/2004/08/prof_brad_delon.html

Posted by: Adrian Spidle at August 25, 2004 10:23 AM

Bonus points for the Pilgrim's Progress reference.

Posted by: Dave at August 25, 2004 10:33 AM

There's also the difference between health care "cost" and health care "price". I submit that with the Byzantine complexity of pricing, we have no idea what the real "cost" is. I agree with paying a fair price if it represents the real cost and a fair profit, but at present we have no idea what that figure is.

I submit the following proposal. Instead of asking for discounts for the seniors or the uninsured or anybody else, how about no discounts for anybody.

Everybody pays the same price, large or small, insured or uninsured. No negotiating, no purchasing power, no etc.. Why should the large and rich pay less than the small and not rich?

Once we get a rational set of prices it will be a lot easier to see exactly what the costs really are and a lot easier to figure out how to pay for what we need.

Pragmatic_realist

Posted by: pragmatic_realist at August 25, 2004 10:47 AM

Ford motor company spends more on health care than on steel. Think what that does to the price of a car. This is a huge issue for employment and a competitive workforce. Japan has lower autoworker costs because health care costs are much less.

DeLong hit a home run. Kerry has some very good thinkers working for him.

Posted by: bakho at August 25, 2004 11:40 AM

My anecdotal two cents:

Last year my 75-year old father had a heart attack (free) and then, of course, he had a $100,000 triple-bypass operation.

This year he has had a diagnosis of prostate cancer (PSA of 20), and he is about to embark on another $100,000 treatment of cancer.

However, his current beta-blockers are beginning not to work, so there will be more drug costs there, and probably more operations. Then there are the non-life-threatening things that are going wrong: his disintegrating gums, nasty digestive tract issues, etc., not to mention the side effect of all his medications. And he doesn't even have diabetes or high blood pressure.

My point is that it appears that he is going to cost his health insurance some $100,000 a year, until he dies, probably within the next five years. Everyone I know has stories like this. A good friend of mine saw a favorite grand uncle spend ten months in acute care, finally dying after $600,000 worth of state-of-the art medical services.

It is dying that costs the money in our culture. As long as it costs everyone half a million or a million to die, our health insurance costs will be out of sight -- because, with the American lifestyle, you can get the same heart condition or cancer in your 30's and 40's, and so even the young have to buy insurance to cover such costs.

Posted by: Diana at August 25, 2004 11:44 AM

to complete the thought: Kerry's proposal would segregate out the kind of health care costs that my father and all his well-meaning doctors and wife are imposing on this nation, which I support because then more of the uninsured will be able to afford coverage, but by itself it will simply move the crisis into the $50,000 coverage-and-up category.

Posted by: Diana at August 25, 2004 11:51 AM

pragmatic_realist: "There's also the difference between health care 'cost' and health care 'price'."

An excellent point. This Spring my teenaged daughter went through a kidney-stone episode that involved three trips to the emergency room and two stays in the hospital. We asked for all of the detailed bills. The price to me if I had been uninsured was $41,000. The price to the insurance company (also on the bill) was $17,000. A friend who has dealt with this hospital in the past suggested that if I had been uninsured but had gone to the business office and put $14,000 in cash on the table, the hospital would have taken it and marked the bill "paid in full".

There is clearly something wrong with the way we pay for health care if the same service gets billed over a 3:1 range depending on who you are or how well you negotiate.

Posted by: Michael Cain at August 25, 2004 12:28 PM

::
But I've always thought the politically significant comparison is between the part of the US population that has good health insurance and the rest of the world. They are in the majority, tend to be politically influential, and are averse to changing a system that produces results they personally like.
::

But they're also a fluid majority, a majority that is changed by circumstance, and that's a problem in itself. That's to say, the voices of those who become excluded by the system, or simply become incapable of paying for treatment, are replaced at the lower end by people who adopt the 'I'm Alright, Jack' attitude, until they themselves become excluded or hit with bankruptcy-inducing bills, at which point they too become an 'irrelevant' minority.

That's to say, the health insurance business is a bubble market that is perpetuated because no-one can ever sell their investment and get out of the market. The problem being that policy decisions are being directed by those already insured, when real attention should be directed to those on the margins: the people who find it difficult or impossible to get insurance, and those who are pushed out of the system by rising costs, tightening exclusions, etc.

An example: my wife's grandmother has Alzheimer's, and the burden of paying for her care has now fallen onto her children -- and it's a monthly check, an out of pocket cost. (And Fred's point about how geriatric care can empty the bank accounts of the elderly middle-class -- and their children -- is also valid.)

Posted by: nick at August 25, 2004 12:37 PM

Anybody else recall seeing recent reports of a study which found it was in part the structure of US health care that leads to high costs - large institutions supplying health care against individuals and small (?) institutions demanding health care? Lost track of it. It seemed a bit counter-intuitive to me (Oxford is small? St Mary's is big?), but worth looking into.

If, as the study concluded, doctors and hospitals are engaged in something other than price taking, we may want to consider a remedy. Much as the income of US doctors relative to the rest of the public and relative to doctors in other countries seems to confirm the argument, the structural business throws me. Anybody seen the study?

Posted by: kharris at August 25, 2004 01:03 PM

http://www.nytimes.com/2004/08/15/business/yourmoney/15advi.html?ex=1093579200&en=23c4621f4393bec4&ei=5070

The Missing Rivalry in Health Care

RISING health care costs are a major concern for virtually every American company. Michael E. Porter, an expert on competitive strategy and the Bishop William Lawrence University professor at Harvard, argues that the heart of the problem is a health care system that needs less competition in some areas and more in others. Following are excerpts from a conversation with him:

Q. Is there a crisis in health care?

A. We certainly think so. Costs are going up at double-digit rates. Yet the general consumer feels that quality is suffering in the sense that there are more restrictions. People are having to pay a bigger piece of their health plan costs. And then all the data on quality and defects and errors are really quite alarming.

Q. You have argued that we have the wrong kinds of competition in health care. What does that mean?

A. The health care system is a great paradox. We in the United States have the most competition of any health care system in the world. That should be a powerful force for improving things. Yet we also have results that aren't the worst results but certainly are not desirable results.

Q. What kind of competition did you find?

A. The relevant place where you want to have competition is diagnosing and treating particular diseases or conditions. We want people to compete to do that better and better.

But as we looked at the United States health care system, we found that there's almost no competition at that level. Instead, we see a lot of competition among provider networks, whether they consist of hospitals or doctors or both, to assemble bargaining power so they can strike a better deal for themselves.

But that kind of cost-shifting or bargaining-power competition doesn't create health care value. In many ways, it destroys value, because it injects massive administrative costs and complexity into the system. So the central point is that the kind of competition that drives value creation isn't really occurring today.

Q. We have so many players, from pharmaceutical companies to hospitals to insurance companies to employers. Is there a particular villain?

A. We don't think any one entity has made the fatal decisions that have caused the system to be the way it is. Indeed, there was a set of incentives created partly by government regulation and partly by history. They have led each actor in the system to behave in ways that were rational for them but were not aligned with improving health care value.

Posted by: anne at August 25, 2004 02:56 PM

http://www.nytimes.com/2004/08/15/business/yourmoney/15advi.html?

Q. Can't employers promote the right kinds of competition when they pay for health care coverage?

A. Employers have made a lot of fundamental mistakes. They buy health care services as a commodity, by and large ignoring the issues of quality and ignoring the issues of value. They insist on signing up the health plan that gives them the best deal and then kind of holding their hands over their eyes and not paying any attention to what happens next.

Q. Does shifting costs to employees help solve the problem?

A. It used to be that employees might pay 5 percent of their health care costs. Now they're being asked, in some cases, to pay 25 to 30 percent. But that is not improving value. That is not driving improvements in efficiency or quality. That's just cost-shifting.

Q. So the system isn't delivering enough quality?

A. It's not built around quality. It also doesn't really care about costs. The system is not designed to reward the most efficient providers. All providers get the same price. The health plans don't even know what the true costs are. They don't even care.

Posted by: anne at August 25, 2004 03:20 PM

I, too, like Kerry's idea quite a bit. Bush, too, has an interesting idea, but as Kenneth Thorpe has pointed out, it doesn't do a lot to make make more people insured.

The only thing is, are we going to get to a point where people simply ship costs to the government? I haven't done as much reading on this subject as I would like, so maybe I missed something, but doesn't seem anyone is talking about this sort of thing.

Posted by: Brian at August 25, 2004 03:30 PM

KHarris

Though I do not understand the nature of competition, or balance in competition, in the health care field, I suspect there is far less competition than is desirable. Also, I do not not if the field lends itself much to competition.

Posted by: anne at August 25, 2004 03:44 PM

http://www.nytimes.com/2004/08/21/business/21buyer.html?pagewanted=all&position=

Wide U.S. Inquiry Into Purchasing for Health Care
By MARY WILLIAMS WALSH

The Justice Department has opened a broad criminal investigation of the medical-supply industry, apparently to determine whether hospitals and other medical care providers are fraudulently overcharging Medicare and other federal and state health programs for a wide array of goods - from rubber gloves to drugs to X-ray machines.

More than a dozen medical-supply companies recently received federal subpoenas in what appears to be a wide-ranging investigation into the way suppliers market products to clinics, hospitals and nursing homes that serve Medicare and Medicaid patients, and whether those institutions properly account for the purchases.

Industry executives expect many hospitals to receive similar requests in coming weeks.

The central issue, according to current and former industry executives, is whether the industry's use of rebates, discounts, barter arrangements and refunds to hospitals and other medical centers means that Medicare and Medicaid are being charged higher prices for products than the hospitals are actually spending.

The investigation appears to be centered on the medical-supply industry's dealings with Novation, a company in Irving, Tex., that is an industry leader in negotiating the contracts that thousands of hospitals, clinics, nursing homes and other facilities use to buy drugs and other supplies.

About $20 billion a year in medical products and services are sold under contracts arranged by Novation, which is owned by about 2,200 of the hospitals and care centers that use its services. They include well-known medical centers like New York-Presbyterian Hospital, Yale-New Haven Health Services and Baylor Health Care System in Dallas.

Because Novation is the link between thousands of health facilities on one side, and hundreds of medical goods and services companies on the other, the scope of the federal investigation appears to be broad.

Posted by: anne at August 25, 2004 03:44 PM

The human body was not designed for the kind of lifestyle affluent people want. When given the choice, they take the sedentary over the active, and the fat over the lean. So now in affluent America we have 2/3 overweight and 1/3 with hypertension. All this noise about how we pay for medical care distracts from the real non-medical issue: people make bad choices and these bad choices have expensive and painful consequences. Having the government pay for “preventive medical care” will help, but not much. We don’t need doctors to make the right choices. We certainly need medicine just as we need the fire department, but spending more money on the fire department when people smoke in bed isn’t the answer. We don’t need an expensive consultation with the fire chief to avoid setting our houses of fire.

The advocates of the Kerry plan refuse to answer a few basic questions. Will my taxes go up more than my medical insurance premiums? Will his plan cover immigrants, both legal and illegal? I suspect the answers are yes, yes and yes. But all I get when I bring this up is either silence or “I don’t know.”

Posted by: A. Zarkov at August 25, 2004 05:09 PM

It's a great plan, but won't the money paid to HC insurance companies by the government just come out of our pockets in the form of taxes?

Without going over all the market failures involved in healthcare insurance or the other problematic issues, it seems to me that anything short of a total overhaul is just doomed to put a new saddle on the same old nag.

You still don't get down the trail any better.

Long run = socialized medicine a la the Australian system.

Posted by: avedis at August 25, 2004 06:03 PM

There is no market-based solution for health care. Because people will pay anything to live), there is infinite room for price-gouging. Which is, of course, exactly what's going on.

No economist who touts privatization would pass Game Theory 101. John Nash didn't win a Nobel Prize in Economics for nothing. He debunked the concept of market-based solutions for life's essentials a long time ago. (I'm no socialist; regulated markets work for most things quite nicely -- but Rule #1 is that demand MUST be elastic.)

Deregulation of life's essentials has ALWAYS led to disaster. People will pay obscene prices for food, water, energy, shelter, and health care, which is exactly why Republicans want these deregulated (with the exception of food and water, which no one is too stupid to gouge). Guess what prices have skyrocketed in the last decade? Energy, shelter and health care.

Profiteering off death. . . In my otherwise rational mind (I hope), that, more than anything, makes me question whether Republicans are human beings at all.

Posted by: Dragonchild at August 25, 2004 06:12 PM

Dragonchild (and a previous poster) brings up an interesting point.

"There is no market-based solution for health care. Because people will pay anything to live), there is infinite room for price-gouging. Which is, of course, exactly what's going on."

All the economists' estimates of the value of a life are for small changes in the probability of death around a small base rate. Do we have any estimates, or are any estimates possible for large changes around a much higher base rate? Is there an economic theory, with empirical estimates to plug into the parameter values, for decision making for a person who starts with a 20 or 30 percent chance of death or severe disability, and treatment options might change that up or down by 50% -and that seems to be the case for new stroke therapies, thrombolytic therapy for heart attack, etc.

So when I read this "the value of life" is infinite" line, I sneared, trying to act like any good applied economist. But now that I think about it... they have a point.

Posted by: jml at August 25, 2004 06:29 PM

Exactly, Dragonchild.

All other forms of insurance are capped by the value of the item insured. You can purchase a $500,000 insurance policy on a $300,000 home. It would be a moral hazard.

You'd burn the house down and buy/build a new one for $500,000 that you couldn't have afforded without the insurance paying off.

Well, in helathcare people buy insurance to gain access to care they could not have otherwise afforded.

In this respect HC insurance is different than any other kind of insurance.

Add to that the fact that insurance finances the development of all types of new products. Some are cost savers. Many are not. These just enhance the existing product. However, since the consumer is divorced from the price of purchase at the point of purchase, normal valuation processes do not operate. The marginal cost of many new products is greater than the marginal benefit. Yet, these products are purchased anyhow.

Socialized medicine greatly reduces this problem by reviewing products/technologies and only covering them if the price=benefit. This goes for all products, from surgical proceedures to pharmaceuticals.

Furthermore, prevention is possible because you do not have the benefit created by prevention becoming positive externalities for other HCI co.s when people switch plans.

With one plan prevention benefits the plan that paid for the prevention.

Lot less paperwork, duplication, too......

I could go on and on touting the advantages of socialized medicine done right, but, you know, it's no good because, it's...well, socialized.

Posted by: avedis at August 25, 2004 06:35 PM

Aaaargh!

Should have said "you cannot purchase a $500,000 policy..."

Posted by: avedis at August 25, 2004 06:37 PM

The biggest obstacle to real health care reform in the U.S. is a conceptual one. Quite simply, health care is treated as a commodity, as a product to be bought and sold in a "free market". The "consumer" is meant to make economic choices based on effiency, value etc;

Of course, everyone "knows" that health care is not a commodity, it's a public good, a public necessity.

In Canada, health care is not a commodity, it's a public good. The legislation that established the national health care system in Canada is a total of 16, yes sixteen!, pages. It gives five basic principles guiding the system;


The five criteria of the Canada Health Act are:

public administration: the administration of the health care insurance plan of a province or territory must be carried out on a non-profit basis by a public authority;
comprehensiveness: all medically necessary services provided by hospitals and doctors must be insured;
universality: all insured persons in the province or territory must be entitled to public health insurance coverage on uniform terms and conditions;
portability: coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country; and
accessibility: reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers.


No one will deny that Canada has some problems, particularly with access to extraordinary medical procedures and operations. But, as Roy Romanov, in his recently published report, state, it is not and never will be reduced to treating health care as a commodity.

Removing health care from commodity thinking, from the profit motive, immediately "solves" a host of problems.

That's why the administrative cost of Canada's and the European countries such as France and Germany, ( and even the U.K.), are so much lower. They don't have to pay outrageous salaries to executives because of "competition" between different profit-oriented hospital chains or insurance companies.

The profit motive distorts health care in the U.S. to a degree that few people realize. Because catastrophic health care is so dramatic, ( and profitable), the U.S. leads in providing excellent emergency services, ( no. 1, in fact the only no. 1 that the U.S. has in the WHO survey of health care across the world). However, because preventive medicine is so "cheap", unprofitable, ( mass immunization of kids don't make a profit), and lacking in drama, ( one can hardly brag about not being sick in comparison to bragging about a cardiac), there is little interest in providing it to the general population. The irony is that preventive care saves money in the long run.

The profit motive also distorts the very salaries of the medical profession. Doctors are highly paid in the U.S. In fact, they are the highest paid, far more than Europe or Canada, ( the average income of a doctor in the U.S. is probably $200K a year in comparison to European doctors who make $80K a year- interstingly, nurses make about the same in both, about $45K a year). The excuse one hears, ( the doctors have such large student loans), is valid up to a point,
( doctors in Europe have no such burden), but it's a tiresome excuse.

Mr DeLong should really examine the fact that commodity thinking dominates the conceptual framework in which health care is debated in the U.S. It's a serious philosophical and ethical question and those values should trump the "mere" economic ones of profit and loss.

Serious ecomomists should know that, in real life, ethics and philosophy should guide people in their economic actions as much, if not more than, mere profit and loss.

Perhaps the problem in the U.S. is that people here do not have an ethical or philosophical guide to their economic actions. That's the impression I get when listening to or reading commentary on the health care crisis.

Posted by: evagrius at August 25, 2004 07:05 PM

"Perhaps the problem in the U.S. is that people here do not have an ethical or philosophical guide to their economic actions. That's the impression I get when listening to or reading commentary on the health care crisis."

Perhaps, or perhaps there is another set of values being reflected in the attempt to maintain a market based healthcare system.

Universal access is not the only measure out there, regardless of what the WHO thinks. Any lessening of innovation should be very closely examined. If a proposed system trades innovation for access, we should recognize that a trade has been made and make sure we factor in the future misery of enduring disease into our equation of utility. I know that many honestly believe that the profit motive only creates waste and not innovation, but those folks are on the hook for explaining a heck of a lot of the world's innovations since the industrial revolution. They are also on the hook for explaining why a single provider wouldn't be better in software or cars if the glories of monopoly will save us in the arena of healthcare.

With infinite demand and limited supply, some method of rationing medical care must be in place. Prices are one way to ration and government mandate is another. It is not at all clear to me why a government with the ability to prevent someone who could afford immediate care from getting treated is a positive. Are we to assume that the brother of the politician must wait in line like everyone else, or do public choice considerations again rear their heads?

I am very comfortable with a system that allocates new expensive treatments to those who can afford them, trickling them down to everyone else a few years later. To me, the inefficiencies we have revolve around costly FDA approval requirements and the bizarre structure of our health insurance. People who don't have to bear the costs of their treatment will choose to overconsume. Patients hate the restriction of treatments in their insurance plans, but the government would be no different if it intends to keep costs contained. You need some way to check the tendency for each person to get the most expensive care the guy down the street can afford.

Posted by: Jason Ligon at August 25, 2004 08:37 PM

Shorter Jason Ligon: "Let them eat cake".

Posted by: non economist at August 25, 2004 09:21 PM

"Universal access is not the only measure out there, regardless of what the WHO thinks."

Of course. That's why the U.S. rank 37th in the world, far behind many other countries, in the measusres that are important; life expectancy, infant mortality, low birtweight, pre-natal care, infant wellness etc;. To excuse the discrepancy by removing, say the uninsured or poor population, from consideration is an admission of failure. After all, many of those other countries have rich and poor, urban and rural, immigrants and natives. They manage to provide all or as many as possible with health care. Why can't the U.S.?

"Are we to assume that the brother of the politician must wait in line like everyone else, or do public choice considerations again rear their heads?"
Yes. Quite definitely yes. And to do otherwise, is to be unsocial and greedy. Perhaps this is where the crux of the question is; is health care, decent health care, a human right or something to purchase?

You seem to be for the latter. And you seem to have no problem with it. Perhaps you need to go back a few centuries when your thinking was quite acceptable....for the nobility.

"I am very comfortable with a system that allocates new expensive treatments to those who can afford them, trickling them down to everyone else a few years later."

Really? I guess you're quite comfortable in the trickle-down Reagan world of economics also.

Bad argument. I'll wait until you need that "special health care" only available to the chosen few but you're not of the chosen few.Or are you?

Posted by: evagrius at August 25, 2004 09:36 PM

I want to illustrate what dragonchild explained
very nicely. Competition can easily work against the consumer: it happens when comeone else is making the decisions what to buy. In healthcare, employer chooses the health plans, hospital chooses the procedures and supplies etc.

Many of us are intimately familiar with competition between various publishers of textbooks. For basic courses, there would be at least 10 different textbooks, often with no meaningful differences, and all expensive. The beauty of the system is that students do not choose the textbooks, professors do. So publishers mail around an enormous amount of free copies, send "pushers" to campuses, add dubious things like solutions to problems for the sole purview of professors (it kind of implies that professor is an idiot who cannot solve his own homeworks). Then every two-three years there is a new, non-improved edition -- so students cannot use old textbooks.

Hardly ever publishers offer lightweight inexpensive products, unless these are books that many students would buy for themselves, even without taking respective courses. In this case we are dealing with a "normal" consumer market.


Posted by: piotr at August 25, 2004 10:06 PM

>> If a proposed system trades innovation for access, we should recognize that a trade has been made and make sure we factor in the future misery of enduring disease into our equation of utility.

Ah, yes, 'if'. The problem being that you offer a hypothetical and then treat it as a given. Do we have any reason (or evidence) to believe that access stifles innovation?

There's also the argument that the current system stifles innovation at the truly productive end of the spectrum: that's to say, in providing preventative care. As others have said, a large proportion of the US healthcare budget is spent on people's final years. One hates to be cynical, but that's where the money is: emptying the bank accounts of the elderly and their middle-aged children.

>> It is not at all clear to me why a government with the ability to prevent someone who could afford immediate care from getting treated is a positive.

That's a straw man. Even single-provider systems such as the NHS allow for private insurance schemes to provide immediate access to things such as elective surgery.

>> I am very comfortable with a system that allocates new expensive treatments to those who can afford them, trickling them down to everyone else a few years later.

Such a system plainly doesn't exist in the US. Are you comfortable with that?

>> People who don't have to bear the costs of their treatment will choose to overconsume.

One could argue that people who do pay insurance premiums do just that. They're the people who want the works, because they've paid $5,000 in premiums since they last visited the doctor.

The presumption is that consumer habits will remain the same after a shift to universal coverage. That's not something I believe to be the case, given that it encourages preventative care, early screening, and the kind of medicine that keeps people out of the E.R. for acute conditions -- a common situation in the US that certainly does count as 'overconsumption'.

Posted by: nick at August 26, 2004 02:09 AM

"Ah, yes, 'if'. The problem being that you offer a hypothetical and then treat it as a given. Do we have any reason (or evidence) to believe that access stifles innovation?"

We should look closely at the removal of the profit motive, which has been the instrument of most innovation since the industrial revolution. We need to ask why people will be better off from a development standpoint when there is no reason for anyone to voluntarily direct their funds to medical research. My discomfort with nationalized systems is mostly a discomfort with the blase attitude of their supporters regarding innovation.

"One hates to be cynical, but that's where the money is: emptying the bank accounts of the elderly and their middle-aged children."

I am confused by this argument. The government should not pay to keep old people alive, and the market is wrong for doing so?

"That's a straw man. Even single-provider systems such as the NHS allow for private insurance schemes to provide immediate access to things such as elective surgery."

Who specified elective surgery? Where does one go for surgery that one doesn't have to wait in line? http://www.marginalrevolution.com/marginalrevolution/2003/10/more_on_canadia.html

"Such a system plainly doesn't exist in the US. Are you comfortable with that?"

Nope, but I disagree that a single payer system is the answer.

"One could argue that people who do pay insurance premiums do just that. They're the people who want the works, because they've paid $5,000 in premiums since they last visited the doctor."

Paying $5,000 in prmemiums doesn't incent you to contain costs on anything over $5,000. Just the opposite. You are right, they want 'the works' for paying only $5,000. Maybe even worse, you have no ability to contain your costs even if you want to on anything valued at less than $5,000.

The fundamental truth of a mandatory risk spreading measure is that it is a tax on youth and health. Brad indicated that it can 'seem like' a sucker's bet for the young. It seems that way because it IS a sucker's bet for them.

As for consumer habits under a single payer system, I don't understand why they would be different. If I never exercise, do I still get the same heart surgery paid by the system that anyone else gets? What is the emphasis on prevention in a system that treats everyone the same, young or old, athlete or couch potato?

Posted by: Jason Ligon at August 26, 2004 06:19 AM

Anne,

Thanks.

Posted by: kharris at August 26, 2004 06:48 AM

"We should look closely at the removal of the profit motive, which has been the instrument of most innovation since the industrial revolution. We need to ask why people will be better off from a development standpoint when there is no reason for anyone to voluntarily direct their funds to medical research. My discomfort with nationalized systems is mostly a discomfort with the blase attitude of their supporters regarding innovation."

I would really like you to prove your contention, that the profit motive is the main inspiration for innovation.

You haven't answered my observation on Jonas Salk and his innovation. Was it really profit that motivated him?

"One hates to be cynical, but that's where the money is: emptying the bank accounts of the elderly and their middle-aged children.

I am confused by this argument. The government should not pay to keep old people alive, and the market is wrong for doing so?"

It's a simple observation; there's more profit in keeping someone alive in intensive care than creating a preventive health care system.

( You haven't responded to the fact that the U.S. ranks low in overall health care measurements. Why not?)

Your reference to the waiting time for procedures in Canada seems horrifying....but then, you haven't looked at what the uninsured, underinsured and poor go through in this country.
I suppose that you have no experience with that.

Why don't you visit a public health clinic, an emergency room, or a school clinic to get a sense of what's really going on with a very large part of the population? Do you know that ERs are the main source of medical care for not only the uninsured but for many insured people? Something is wrong when ERs become the only provider of health care for people.


Posted by: evagrius at August 26, 2004 08:06 AM

The whole topic of universal access to health care is fiendishly complicated. And even rational approaches cannot survive the political obstacles. Gingerly building on what we have now has a chance of working. For instance lowering the medicare age and installing means testing could bring quite a few within the penumbra of medical care. Limited as medicare is.

Posted by: David Allen at August 26, 2004 08:30 AM

I really like this heathcare premium reinsurance plan of Kerry's. (It's about the ONLY thing I like about Kerry.) However, why not impose an excise tax (5%?) on heathcare benefits to finance this reinsurance pool? Why should the USG go deeper in debt to finance an obviously workable insurance proposition that has analogues in the private sector?

If reinsurance works so well for catastrophic property damage insurance, which it surely does, then it should work equally well for catastrophic medical hazard insurance. Let's just place the costs of reinsurance on the proper people: i.e., the insured for they will benefit as much as anyone from this program.

Posted by: Lawrence at August 26, 2004 08:56 AM

Imagine if in order to get the oil changed in your car, you had to submit a claim to your auto insurance company. Do you think oil changes might be a little bit more expensive? What we need is for employers to stop providing health insurance, and rather pay their employees the equivalent of what they save by not paying for health insurance benefits. Consumers would pay cash for all basic medical costs, creating a true market driven system. This would also give consumers incentive to maintain their own health, since they are receiving more directly the benefits of living a healthy lifestyle. The government or insurance companies could pay for any costs resulting from catastrophic medical situations.

Posted by: Ben at August 26, 2004 08:58 AM

Excerpts from: “Market-Driven Health Care and Social Control”
By John Spritzler
Jun 4, 2004, 15:30 (axisoflogic.com)
[Originally published without references in New Democracy Newsletter, November-December 2000.]

Four classic methods of social control: make people feel too insecure to challenge those in power, destroy people's trust in one another, make them more unequal, pit them against each other.

In the early 1970's America's corporate and government leaders re-evaluated the way they would have to govern in light of the social upheavals of the 1960's. From the time of FDR to LBJ, elite social control had been based on policies like the New Deal and the Great Society that were meant to convince working class Americans that corporate leadership would give them a better and more secure future. These policies, however, led to rising expectations and a sense of security that emboldened people to challenge authority over issues like the Vietnam War, Civil Rights, conditions of work, and welfare. In other words, the elite strategy of improving social conditions as a means of controlling people back-fired.

How profoundly the 1960's affected the thinking of elite leadership can be seen in the writing of Samuel P. Huntington, Professor of Government and Director of the Center For International Affairs at Harvard University, and co-author of The Crisis of Democracy: Report on the Governability of Democracies to the Trilateral Commission written in 1975. Huntington's Report noted that, "The essence of the democratic surge of the 1960s was a general challenge to existing systems of authority, public and private," marked by a "sharp increase in political consciousness, political participation, and commitment to egalitarian and democratic values." What especially frightened the elite was the fact that, as Huntington wrote, "In recent years, the operations of the democratic process do indeed appear to have generated a breakdown of traditional means of social control, a de-legitimation of political and other forms of authority... The late sixties have been a major turning point." The Report concluded: "Al Smith once remarked that 'the only cure for the evils of democracy is more democracy.' Our analysis suggests that applying that cure at the present time could well be adding fuel to the flames. Instead, some of the problems of governance in the United States stem from an excess of democracy... Needed, instead, is a greater degree of moderation of democracy."

Corporate leaders abandoned the old method of social control embodied in the New Deal and the Great Society and began relying instead on a fundamentally different, "get tough," strategy designed to strengthen corporate power over people by making them less secure. This new strategy motivates corporate leaders' new enthusiasm for the "discipline" of the free market, which they use to justify not only market-driven health care but downsizing and attacks on the social safety net.
Market-driven health care is part of a pattern of government and corporate policy initiatives over the last several decades which have one thing in common: they strengthen corporate power over people by lowering people's expectations in life, and by reducing their economic, social, and emotional security. These policies include corporate downsizing and the "temping" of jobs; the elimination of the "family wage," so that now both parents have to work full-time and have less time with their children; drastic cuts in the social safety net of welfare and related assistance; the introduction of pension plans based on individualized investments that leave each older person to his or her own fate; and the use of high stakes tests in public elementary and secondary schools to subject children to the same stress and insecurity that their parents face on the job. In the workplace, employers have adopted anti-worker tactics that had not been used since the early 1930s, most notably firing striking workers and hiring permanent replacements, as President Reagan did during the air traffic controllers' strike. All these policies put people on the defensive and pressure them to worry more about personal survival than working together for social change.
Elites have been able, in the area of health care and elsewhere in society, to misrepresent as "efforts to control excessive costs" or "to remain competitive" or "to gain efficiency" what have in fact been measures aimed at destroying popular power and undermining democracy. They have largely been able to keep debate over vital issues such as health care out of the public arena and restrict discussion to policy elites and to health professionals who by themselves are not strong enough to challenge elite power.
Most Americans are struggling to make our society one where relations between people are based on a commitment to each other, on equality, trust, and solidarity. [The] conflict [is] between most Americans and a small elite, over the core values that should shape our society. Ordinary Americans are an implicitly revolutionary force because the values by which they try to shape the world contradict the elite's capitalist values. [If they] connect with each other on the basis of a true understanding of the problem of corporate domination of our society and a true understanding of the solution, the corporate elite's fear of losing control is well founded.


Posted by: Robert Beal at August 26, 2004 10:34 AM

Regarding social control. The single provider of all medical services controls society to a much greater extent than the corporation that buys health insurance. A market driven approach is a devolving of social control. Why is government control so acceptable?

evagrius:

I don't believe you have read any comments of mine to the effect that the US system is in good condition. The WHO measures in their comparisons are blatantly anti market. Colombia ranks higher than the US consistently according to the WHO.(http://www.cato.org/dailys/07-05-00.html)

What I am questioning is the idea that a nationalized system is the answer. I would note that the only reason single payer systems are as inexpensive as they are is because profits earned in the expensive US market subsidize the medicines used in those systems.

Jonas Salk is an exception and not a rule, and his overhead was nothing remotely like the $400 million it takes to bring a drug to market, where it gets to compete and maybe lose. Look to your left and right, in your medicine cabinet, you refrigerator, in your garage. Very little you have is a result of altruism. Incentives matter.

Posted by: Jason Ligon at August 26, 2004 11:22 AM

"I would note that the only reason single payer systems are as inexpensive as they are is because profits earned in the expensive US market subsidize the medicines used in those systems."

Noting does not make it so.

Posted by: anne at August 26, 2004 12:17 PM

anne:

Irrespective of the nation of origin of the pharma company, the US market represents the bulk of its profitability. This is fairly obvious when you consider what we pay compared to what others are paying. Investor relations at any of the companies will verify this, if you like. The low prices that nationalized systems get are somewhat due to bulk purchasing power, but mostly due to sunk costs being recovered by elevated prices in the US. All the bulk buying power in the world wouldn't allow Canada to negotiate prices just above marginal production costs if they couldn't recover sunk costs elsewhere.

Part of me wants reimportation just to see what our friends to the north say when they have to pick up their own tab. The realist in me says that they won't pay, they will go to Brazil and violate copyrights, thereby destroying voluntary incentive to invest in pharmaceuticals.

Posted by: Jason Ligon at August 26, 2004 12:50 PM


I understand this argument, but find it hard to believe that there is no significant profitability to drug sales in France or Sweden or Canada or Japan. Though the argument is often made, I am not close to convinced. Drugs developed in France or Japan, are sold at a profit in France or Japan. Such drugs are not sold at a loss until approved in America. There is much to consider here.

Posted by: anne at August 26, 2004 01:55 PM

Why isn't anybody mentioning the role of BETTER EATING HABITS AND NUTRITION in the fight against health care costs? With the vast majority of chronic diseases in this country either preventable, reversible, or both, why isn't a NUTRITIONIST brought onboard as a primary caregiver along with a physician?

Let's face it--produce is cheaper than prescriptions. We need more fresh produce and less pills in our lives.

If we spent more time and money in farmer's markets, we'd spend less at Walgreens or other local drug stores!

Don't believe me? Google it for yourself. I've already spent hours on the web looking at research papers on various health topics.

The government isn't going to bail us out of this one (or any other)--it isn't politically expedient. We need ot take the reins when it comes to aspects of our own lives. Health care workers, politicians, and drug company emloyees get paid the same whether you live or die.

Posted by: An angry wench at August 26, 2004 05:03 PM

Jason,"What I am questioning is the idea that a nationalized system is the answer. I would note that the only reason single payer systems are as inexpensive as they are is because profits earned in the expensive US market subsidize the medicines used in those systems. "

You can argue it all you want and you'd be wrong.

It seems to me that "free-market" is a religion to yoy and therefore you will argue in the face of facts to the contrary of free market solutions.

Free market mechanisms with skewed incentives are what is causing the problems (for the most part).

You want to un-skew the problems? Then we no longer are talking about free markets, but so what?

Jason, before I continue with you I need to know, are you a libertarian?

Posted by: avedis at August 26, 2004 05:50 PM

"Regarding social control. The single provider of all medical services controls society to a much greater extent than the corporation that buys health insurance. A market driven approach is a devolving of social control. Why is government control so acceptable?"


Do you know how health care is administered in Canada, Germany, France etc; ? You'll find a variety of approaches. Canada's health care is administered by the provinces, each having its own variety of coverage and benefits, all following the five basic principles but allowing for local need. Germany administers its health care through a number of non-profit health insurance companies, the same for France. That is, one can have a choice of the type of coverage you want. You're guaranteed a basic coverage no matter what and you can pick any physician etc; you want. The decisions on health care are made by both physician and patient. No, it's not a "free market" but it works well enough. I don't think any of these countries, nor the U.K. or Australia and New Zealand have the situation you describe.

What would a "free market" be for health care? When I decide to purchase an automobile or any other material product, I can decide on my choice based on numerous options, ( gas consumption vs. comfort, safety vs. speed, color, even cup holders). But the choice is made, in theory, through comparison. Can you really make the same decisions about health care? Suppose your doctor states you need a certain procedure. A second opinion back your doctor. First, do you know the "purchase price"? Second, can you then "shop around" for the cheapest surgeon and hospital?
Of course not. One can, in cases of prescription drugs, choose a cheaper version, but I doubt anyone can do that for most health care.
A while ago, the Wall Street Journal had an article on the results of a survey of American's knowledge of the cost of health care. Most could not state the price of prescription drugs, medical procedures, ambulance service, hospital stays and the like. How can they? There's certainlyno advertising and...would you really want that?

Now, if you really are for the free market, I would urge you to become knowledgeable about those costs.

Another point. If the "free market" is so wonderful, why does the U.S. spend more per capita and per GDP than any other country and still has fifty million uninsured ?

"What I am questioning is the idea that a nationalized system is the answer. I would note that the only reason single payer systems are as inexpensive as they are is because profits earned in the expensive US market subsidize the medicines used in those systems."


Considering that most of these other countries focus health care as preventive care and on children and youth more than other groups, your argument is frail.

( A peculiar fact; the average British male is now nearly 3 inches taller than the average American male, ( excluding recent immigrants from "short" countries). The Dutch are the tallest in Europe, nearly 6 ft 4" .They attribute their growth to good pre-natal care, good childhood nutrition and good pediatrics.)


"I don't believe you have read any comments of mine to the effect that the US system is in good condition. The WHO measures in their comparisons are blatantly anti market. Colombia ranks higher than the US consistently according to the WHO.(http://www.cato.org/dailys/07-05-00.html)"

I've always though the Cato Institute was an ironic name for an organization so unlike Cato.

At any rate, I read the article and it was quite poor.

Even discounting those countries with poor record keeping, one can't help but notice how poorly the U.S. does in comparison to Japan, Canada, and Europe. Those countries are quite adept at record keeping.

Look more closely at the stats.


"Jonas Salk is an exception and not a rule, and his overhead was nothing remotely like the $400 million it takes to bring a drug to market, where it gets to compete and maybe lose. Look to your left and right, in your medicine cabinet, you refrigerator, in your garage. Very little you have is a result of altruism. Incentives matter."

A recent study was released, ( sorry, I only heard the author on radio while commuting), arguing that drug companies are actually doing very little innovative research. The innovations that are touted usually turn out to be a dedicated to developing variations of known drugs, not new drugs for previously untreated conditions. The new drug is usually no more effective than the old and quite often more expensive, that is, more profitable. So much for innovation.

One can also point to the HIV drugs controversy.
Profits or lives, right?


Posted by: evagrius at August 26, 2004 07:21 PM

There is one aspect of the health care business that has never made sense to me. We talk about market based health care which is supposed to keep costs down. Those who have their health insurance chosen for them through employment don't usually have a choice. But the choice were talking about is how to finance health care not how to obtain quality health care. For the patient, they should be able to choose the provider who gives them the best care. Yet, obtaining good medical care comes when the doctor knows more about you. Unless one has a trusted family doctor, one is in no position to obtain through market forces the best care provider when you have had an accident or are sick etc. Health care just doesn't lend itself to market forces like buying a car does.
If we build roads, like we do medical care, our roads would be a hodgepodge of dirt, cement, asphalt, cobblestone and brick. We have a user tax collected by the government and distributed to private enterprise road buiders. Basically, that is what single payer is all about. We have a tax or premium collected by one agency and than paid out to the health care providers. Everyone is covered. No exceptions.

Posted by: Joyce Guard at August 26, 2004 09:20 PM

Let me be clear. If we can have a system that covers everyone for anything they need, maintains at least current levels of innovation, allows for the choice of paying for the ability to get a procedure without waiting in line, and doesn't cost any more as a percent of GDP than what the US mish mash system currently costs, I'm right there with you no matter how socialist the system looks.

Unfortunately, I strongly suspect this is the healthcare system that only works on Big Rock Candy Mountain.

There are tradeoffs. Many of you believe that the government is in the best position to manage these tradeoffs and that the doesn't face perverse incentives. I don't happen to agree. Monopolies don't work well. When you put government in control of them, they still don't work well, because a government monopolist is still a monopolist. He faces no competition, and his incentives are to maximize his pay and minimize his work.

Innovation will be the first thing to go in the tradeoffs under a government system in a western democracy. There are too many old people, and the demand will be 'give me free stuff that I can see now.' Innovation is not seen until later, and even if some stupid government policy directed money away from a cure for diabetes, the crafter of that policy will never be held accountable for the thousands of people he has killed.

Look at the Canadian system, look at NIH, and look at Australian and Kiwi systems. Look at the drugs and devices they use, deduct the contribution made as a result of profitability in the US drug market alone, and see if there is an impact. These systems aren't spending very much AT ALL on direct innovation because we are doing it for them.

We are at an impasse. Some believe that 100% of the difference in cost between the US and other systems is 'wasted' on profits and buys us nothing. I think that is a naive view. Certainly, everyone who feels that way should invest 100% of their 401(k) into pharma companies, which clearly shouldn't volatile issues at all, and they should have guaranteed returns. Any financial advisor in the world would tell you that pharma should only be considered as an investment with money you are willing to lose. They play a game of enormous investment losses hopefully offset by enormous gains. If they aren't playing that game, someone else will be, or we will have no new drugs. No free lunch.

Posted by: Jason Ligon at August 27, 2004 06:36 AM

re: Market based healthcare:

On cars, "But the choice is made, in theory, through comparison. Can you really make the same decisions about health care? "

Yes. It is a complete fabrication that healthcare demand is perfectly inelastic. Medicines used 10 years ago worked to some degree, so they will still work to some degree in most cases. Many treatments are for annoyances like alergies that have a wide range of options available. If you don't have to pay for your own care, of course you want the most expensive thing out there. That is why divorcing costs from the beneficiary across the board is a bad idea.

Posted by: Jason Ligon at August 27, 2004 06:45 AM

"If you don't have to pay for your own care, of course you want the most expensive thing out there. That is why divorcing costs from the beneficiary across the board is a bad idea."

Again, I ask you the sinple question; do you, you yourself, know the cost of your health care, the true cost?

Of course not. There's plenty of evidence showing hospitals having differing prices for treatments for different patients, depending on their insurance coverage. Recent stories have shown that the price difference can be as much as three times higher for uninsured patients than for insured patients. Who is to know?

Can you, yourself, make decisions regarding medications or treatments? Are you a person with a medical education? Even so, could you really be objective about your treatment?

Your position is theoretically interesting but factually, realistically, it isn't tenable.

The only way your argument could hold water would be for all recipients of health care to have an excellent medical education.

As for your argument against government monopoly, you forget, ( as anti-government critics so often do) that the government is composed of public servants. They are ultimately responsible to the public. It may take time and effort but they have to respond to public pressure. Private corporations have no such pressure. They have no obligation to the public, only the shareholders.
Unlike government, their hierarchy is not subject to transparency, that is, it's often difficult to identify the responsible parties in charge.

So, please, answer the simple question; do you yourself, right now, know the true cost of your health care?

Posted by: evagrius at August 27, 2004 07:37 AM

Canada tossed the health insurance companies out of basic care. But Blue Cross and the private insurance companies are still very much around selling supplemental and travel insurance. In comparison the Democrats seem a pretty timid lot. It is only the Republicans who paint the Democrats as wild-eyed radicals. You could argue that both U.S. parties are in the pockets of the insurance companies and the health care status quo and nobody is willing to rock the boat to any major degree.The key word seems to be "affordable" rather than universal. Maybe Ralph Nader should forget about running for president and think about starting a third party to the left of the Democrats. In Canada, the New Democratic Party often serves to keep the Liberal Party from straying too far to the right into Republican Lite mode.

Posted by: Roy Atkinson at August 27, 2004 11:01 AM

The idea that we should make health care practitioners compete amuses me. Look at it from a potential doctor's point of view. You have to go through a minimum of 7 years of training after college, working very hard, and then you have a career filled with amounts of work and stress that most people can't even imagine. Sixty hour weeks are common. One malpractice claim and you're out of the ballgame. The only way to induce people to do this is to guarantee them a very good living. If you make them fight it out in the marketplace like Walmarts, people will not go into medicine. Sure, the doctors who are already in the system have nowhere else to go, but prospective medical students will get the message. We already have a shortage of nurses and primary care doctors. A shortage a specialists is coming.

Posted by: JRossi at August 27, 2004 11:13 AM

"So, please, answer the simple question; do you yourself, right now, know the true cost of your health care?"

I don't even understand the question. I don't know the 'true cost' of a car, either, except by virtue of information compiled from private resources like edmunds.com. All I know is what price they offer me and what price I am willing to pay. I don't know the true cost of legal services. I don't know the true cost of plumbing. I don't know the true cost of financial advice.

I could ask a doctor to provide me a list of treatments with associated costs and I could take this same list and shop it around.

Public employees are just employees of a giant monopolistic company that can throw you in jail for disagreement with them. The public servant is accountable to some portion of the public that will keep them in office, not to The Public Good, whatever that is. Is a position of the Right to Choose looking out for the public interest, or is the Ban Prenatal Homocide position the one that serves the pulic interest? It depends on which part of the public you represent. While democracy may be necessary for determining that particular issue, don't confuse that necessity with the idea that the policy serves the public 'at large'. It serves some and hoses others. Material allocation that ignores the significance of who earned the wealth in the first place is especially prone to hanky panky. Benefits paid by some and enjoyed by others arise because everybody wants free stuff and few have the gumption to produce significant wealth on their own. The job of the public servant is to give to those who will support him and take from those who won't. It is a fallacy to act as though those in government suddenly act altruistically when they get in office. The government will not be run by philosopher kings (you might have noticed we don't have one in office now). Imagine someone you can't stand running all healthcare in the land. Much better to limit the damage that can be done.

Private agencies are accountable to their customers. The only way they can represent the interests of shareholders is to convince an expanding body of customers that they are providing a service of value. If there is a terrible company, no one will choose to go there, and another will pop up or take their market share.

Posted by: Jason Ligon at August 27, 2004 12:59 PM

How about this idea. Let's force insurance companies pay the patient for delivered care. Perhaps if it worked like collision insurance it would give the customer an incentive to shop. If I had to get three 'estimates' for a procedure and submitted them to my insurance, which then gave me a check for 50,000 dollars, maybe I would have a cousin do the operation and split the money with him. The provider would have to lower his price to compete with other providers, including my cousin in order to attract my business. Voila, now there is once again price competition in the health care industry, where there is none now.

Posted by: Dan at August 27, 2004 03:59 PM

"So, please, answer the simple question; do you yourself, right now, know the true cost of your health care?"

"I don't even understand the question. I don't know the 'true cost' of a car, either, except by virtue of information compiled from private resources like edmunds.com. All I know is what price they offer me and what price I am willing to pay. I don't know the true cost of legal services. I don't know the true cost of plumbing. I don't know the true cost of financial advice."

here's a good starting point;

http://www.harrisinteractive.com/news/newsletters/wsjhealthnews/WSJOnline_HI_Health-CarePoll2004vol3_iss13.pdf

As for your comments on government and corporations, perfect Ayn Rand. Useless for discussion.

Posted by: evagrius at August 27, 2004 07:57 PM

The gross medical costs minus that portion which goes to lawyers, insurance companies and administrators could be greatly diminished. Mdical care could available to all American citizens. These tertiary groups absorb a vast amount of the money that goes into the huge pool of medical care, raising the costs to incredible levels.

All patients could sign a release from legal liability for the medical care providers. This would be an indemnity form. This practice would release everyone from paying insurance companies and lawyers who provide absolutely nothing to medical care. I would be most happy to sign such an agreement; it would assure fair compensation for the medical provider and care for the patients. People would solicit only the medical providers with whom they feel confident.

Posted by: Dr. Carl F. Selnes (MSgt Ret.) at August 27, 2004 11:18 PM

"here's a good starting point;

http://www.harrisinteractive.com/news/newsletters/wsjhealthnews/WSJOnline_HI_Health-CarePoll2004vol3_iss13.pdf"

In other news, people who have never had a deck built and have never priced one have no idea how much a deck costs. People who have never priced lawyers don't know how much legal services cost. People who have never had a financial plan don't know how much those costs. How can people ever make decisions about these matters!?

"As for your comments on government and corporations, perfect Ayn Rand. Useless for discussion."

More James Buchannan and Gordon Tullock. Since it is clear that public servants work for the common good and not their own agendas, it must be equally clear that the Bush administration is working for the public good, right?


Posted by: Jason Ligon at August 28, 2004 09:50 AM

"In other news, people who have never had a deck built and have never priced one have no idea how much a deck costs. People who have never priced lawyers don't know how much legal services cost. People who have never had a financial plan don't know how much those costs. How can people ever make decisions about these matters!?"

The prices are available are they not for those services? I mean that one can inquire and demand a price. One can also make inquiries from a Better Business Bureau or Legal Aid etc; and obtain pricing information.

One can't really do that at present with medical care, prescription drugs being the exception. We've seen the results of that flurry of excitement over re-importation.Otherwise, the prices of other services are not easily available.

Of course, one can argue that the present situaton is not a "free market" and one would be correct.

Ironically, the types of health care coverage available in other countries do allow for a type of free market. One can pick any provider and the success of that provider depends on providing excellent medical care.

One possible solution would be for all Americans to have the per capita amount, ( about 5K a year), every year and be given the freedom to purchase any health care or save in a medical account. That would be a foundation for a "free market"

"Since it is clear that public servants work for the common good and not their own agendas, it must be equally clear that the Bush administration is working for the public good, right?"

If that's what the public wants. Most public servants are not political appointees. They must follow regulations and administrative dictates.
Their activities are overseen by elected officials and if they fail in their duties, one can replace the elected directors.

Is there the same level of accountability in corporations? No.

Posted by: evagrius at August 28, 2004 08:07 PM

I have a great idea. Lets expand Medicare to include ALL Americans. And lets pay for all Medicare costs with a new 1 percent tax on ALL corporate revenues. Yes, revenues - not profits which can be easily manipulated. Only "For profit businesses pay this tax."

This has the following wonderful effects:
1. All Americans have good health care coverage.
2. All Americans making less than $90,000 a year get a tax break - no more Medicare tax. Even the working poor who pay NO income tax get a tax break.
3. State and Local governments will get a huge infusion of cash as they no longer have to pay health care benefits.
4. Small businesses will be greatly stimulated by having health insurance premiums lowered.
5. Large businesses will no longer have incentives to outsource labor, cut staffs, and reduce hours in order to avoid health care costs for employees. Their cost is fixed regardless of the number of employees because it is based on REVENUE and not employees.
6. The national cost of health care will be greatly reduced by elimination of costly profit taking and administrative costs of private insurance. Businesses with a lot of employees may actually see their cost go down as many are now paying more than 1 percent in premiums.
7. Unions will be able to bargain effectively.

And then we can move to add a Canadian style prescription drug program to the new system.

How about it?

Posted by: Alyce J. Bowers at August 30, 2004 12:40 PM

Any system that preserves for profit insurance companies will not solve the financial problems in medical care because their overhead(about 25%) is a key problem. The same factors that support Bush-republicanism also are a key factor in preventing our moving to single payer national coverage for all: racial and religious bigotry. If we had a real sense of community as most countries do, meedical care for all would not be a contentious isssue.

Posted by: marvin kristein at August 30, 2004 10:16 PM

They that approve a private opinion, call it opinion; but they that mislike it, heresy: and yet heresy signifies no more than private opinion.

Posted by: free poker online at August 31, 2004 06:26 PM

Errare humanum est - To err is human. / It is human to err (Seneca)

Posted by: free amateur galleries at September 12, 2004 02:45 PM

Hi, I noticed you were talking about Prostate Cancer at this site
Please feel free to submit your site to shdir.com (if im mistaken, im very sorry, it's a semi-auto program to find relevant sites ;-)

Posted by: Prostate Cancer at September 15, 2004 10:51 AM

> And “punishment” means prison or liquidation,
> not mere dismissal.

No, it's whatever works best at the time that you can get away with. Despite the recent fashion for claiming to be at war with it terror is a tactic, not an ideology.

Comparably, Heisenberg was (eventually) able to work relatively freely during the Deutsche Physik period because Stark and Lenard couldn't get away with disposing of him.

Posted by: Jon Hanna at September 19, 2004 12:54 PM

Strange, comment ended up on the wrong article.

Posted by: Jon Hanna at September 19, 2004 12:57 PM

Acta est fabula, plaudite! - The play is over, applaud! (Said to have been emperor Augustus' last words.)

Posted by: lesbian orgy at September 23, 2004 07:21 AM

best casino online
best online casino
blackjack online casino
buy online casino
casino betting online
casino careers online
casino gambling online
casino game online
casino games online
casino games online free
casino online
casino online free
casino online free online casino
casino online gambling
casino online gambling games com
casino online games
casino play for fun online
casinos online
free casino games online
free casino online
free casino online games
free money online casino
free online casino
free online casino bonus
free online casino game
free online casino games
free online casino money
free online casino slots
grand casino online
grand online casino
how to start an online casino
hoyle casino online
internet casino online
largest online casino
las vegas casino online
las vegas online casino
lasseters online casino
lasvegas online casino
lucky jacks online casino guide
lucky nugget online casino
mac online casino
mgm grand online casino
mgm mirage online casino
mgm online casino
new online casino
no download online casino
online casino
online casino affiliate program
online casino american express
online casino betting
online casino black jack
online casino blackjack
online casino bonus
online casino bonuses
online casino business
online casino com
online casino complaints
online casino connection
online casino craps
online casino deals
online casino directory
online casino for sale
online casino fraud
online casino free
online casino free bonus
online casino free cash
online casino free money
online casino gambling
online casino game
online casino games
online casino games free
online casino gaming
online casino guide
online casino law
online casino laws
online casino let it ride
online casino mac
online casino macintosh
online casino marketing
online casino news
online casino no deposit
online casino no download
online casino odds
online casino payouts
online casino paypal
online casino poker
online casino portals
online casino promotion
online casino promotions
online casino rankings
online casino rating
online casino ratings
online casino review
online casino reviews
online casino roulette
online casino scams
online casino slots
online casino software
online casino sport
online casino sport book
online casino sports betting
online casino sportsbook
online casino tips
online casinos
online free casino
online free casino games
online gambling casino
online internet casino
online sportsbook and online casino games
own an online casino
own online casino
own your own online casino
play casino games online
play casino online
river belle online casino
riverbelle online casino
sands online casino
sportsbook online casino
the online casino
top online casino
vegas casino online
vegas online casino
vegas towers online casino internet gambling virtual
www casino online gambling games com

Posted by: online casino at September 27, 2004 09:54 PM

5 card stud
7 card stud
7 card stud hi lo
card game
free texas holdem
free texas holdem poker
holdem poker
internet poker
live poker
multi player poker
omaha hi
omaha hi lo
one on one
online
online poker
Online Poker Games
poker games
texas holdem
texas holdem poker
texasholdem
world poker tour

Posted by: texas holdem at September 27, 2004 09:54 PM

If you come looking to learn the rules or the basics of texas
holdem, check out our Poker
Basics, or our Texas
Holdem strategy section. You be able to find out both how the game is played,
and how to play the game better.

Posted by: texas holdem at September 28, 2004 02:30 PM

Amoxicillin is a penicillin-like antibiotic used to treat certain infections caused by bacteria, such as pneumonia; bronchitis; venereal disease (VD); and ear, lung, nose, urinary tract, and skin infections. Amoxicillin also is used before some surgery or dental work to prevent infection.

Posted by: Amoxicillin at September 28, 2004 03:46 PM

Zithromax is in a class of drugs called macrolide antibiotics. Zithromax (azithromycin) fights bacteria in your body. Zithromax is used to treat many different types of bacterial infections, such as bronchitis, pneumonia, tonsillitis, skin infections, ear infections, and certain sexually transmitted diseases.

Posted by: Zithromax at September 28, 2004 03:46 PM

mortgage leads

Posted by: mortgage leads at October 4, 2004 09:17 PM

I am not one of those who think that the people are never in the wrong. They have been so, frequently and outrageously, both in other countries and in this. But I do say, that in all disputes between them and their rulers, the presumption is at least upon a par in favour of the people.

Posted by: vimax extender at October 7, 2004 11:23 AM

2618 How can this all be as nice? Check out my site http://www.pai-gow-keno.com

Posted by: keno at October 8, 2004 12:33 AM

I am not one of those who think that the people are never in the wrong. They have been so, frequently and outrageously, both in other countries and in this. But I do say, that in all disputes between them and their rulers, the presumption is at least upon a par in favour of the people.

Posted by: vimax extender at October 8, 2004 04:21 AM

Sup Homies! - Just need to Refill My Inkjet Cartridges - for my Epson Inkjet Cartridge But I cannot Find Discount Inkjet Cartridges and the HP inkjet cartridges cost to much for my budget. But I might take a look at Cheap Inkjet Cartridges or Canon Inkjet Cartridge maybe even just a inkjet cartridge refill!

Posted by: Inkjet Cartridges at October 10, 2004 02:01 PM

764 http://www.texas-hold-em-i.com play texas hold em online here.

Posted by: texas hold em at October 11, 2004 11:24 PM

Your safe Online Pharmacy

Posted by: Your safe Online Pharmacy at October 12, 2004 08:10 PM

Nice site yo got here! I really like it!

Posted by: penis extender at October 13, 2004 07:47 AM

Buy cheap fioricet online

Posted by: Buy cheap fioricet online at October 13, 2004 07:49 PM

3 http://www.e-texas-hold-em.com

texas hold em

Posted by: texas hold em at October 14, 2004 05:01 PM

home mortgage loan

Posted by: home mortgage loan at October 14, 2004 10:37 PM

Online Masters Degree Programs

Posted by: Online Masters Degree Programs at October 15, 2004 10:10 PM


latex sex videos
http://www.latex-fetish.us

pregnant sex
http://www.pregnant-sex.name

scat shit pics
http://www.scat-movies.info

south beach diet
http://www.south-beach-diet.name

Posted by: latina sex girls action videos at October 16, 2004 05:02 AM

7742 http://www.rapid-debt-consolidation.com

consolidate debt

Posted by: debt consolidation at October 16, 2004 05:24 PM

Great blog you got here!

Posted by: penis extender at October 18, 2004 08:25 AM

online casino

Posted by: online casino at October 18, 2004 11:08 AM


latex sex videos
http://www.latex-fetish.us

pregnant sex
http://www.pregnant-sex.name

scat shit pics
http://www.scat-movies.info

south beach diet
http://www.south-beach-diet.name

Posted by: latina sex girls action videos at October 18, 2004 05:52 PM


latex sex videos
http://www.latex-fetish.us

pregnant sex
http://www.pregnant-sex.name

scat shit pics
http://www.scat-movies.info

south beach diet
http://www.south-beach-diet.name

Posted by: latina sex girls action videos at October 19, 2004 08:32 PM

5230 You only get one set of teeth. Take care of them with a good
dental plan. Dental
insurance is
money well spent. I sleep better since I signed up for my new dental insurance
plan.
Get yours at: http://dental-insurance-plan.freeservers.com/
http://www.online-sports-betting-source.com

online sports betting
Sports Betting Odds
Sports Betting Line
Football Sports Betting
NCAA Sports Betting
NFL Football Betting Line
American Football Betting
Online American Football Betting
Online Football Betting Lines
Online Sports Book
NFL Football Odds
NCAA Football Odds
Las Vegas Football Odds
2004 Super Bowl Odds
Sports Book Betting
Las Vegas Sports Book
Sports Book Odds
Internet Sports Gambling
Sports Betting Information
College Football Betting Odds
College Betting Line
NFL Point Spread
NCAA Point Spread
Super Bowl Point Spread
Vegas Point Spread
Legal Sports Betting
Online Betting Odds
Online Sports Book Betting
Online Sports Betting Site
home based business
home based business
opportunity

Posted by: dental insurance at October 20, 2004 06:55 AM

The real question is not whether machines think but whether men do.

Posted by: fleshlight at October 20, 2004 10:54 AM

prescriptions for women

Posted by: prescriptions for women at October 21, 2004 01:49 PM

8042 online casino games

Posted by: casino games online at October 22, 2004 06:21 AM

Universal doubt cancels itself.

Posted by: penis pills at October 23, 2004 04:14 AM

Online Casino Games

Posted by: Online Casino Games at October 23, 2004 11:23 PM

a href="http://play-black-jack-with-me.com/blackjack/id.htm">Play Blackjack

Posted by: Play Blackjack at October 24, 2004 11:00 AM

Play Blackjack

Posted by: Play Blackjack at October 24, 2004 11:00 AM

mortgage leads

Posted by: mortgage leads at October 25, 2004 10:43 PM

mortgage leads

Posted by: mortgage leads at October 25, 2004 11:36 PM

The fundamental sense of freedom is freedom from chains, from imprisonment, from enslavement by others. The rest is extension of this sense, or else metaphor.

Posted by: penis enlargement pills at October 26, 2004 06:32 AM

The fundamental sense of freedom is freedom from chains, from imprisonment, from enslavement by others. The rest is extension of this sense, or else metaphor.

Posted by: penis enlargement pills at October 26, 2004 07:14 AM

Happy to read this, that is great guys!

Posted by: gazduire at October 26, 2004 02:48 PM

7865 http://www.i--cialis.net
Offering Cialis with overnight delivery. Also, If your looking for generic cialis this is a good site to visit.

Posted by: Generic cialis at October 27, 2004 02:15 AM

travel
online gambling
finances
homes
internet
health
shopping
insurance
education
careers
entertainment
business
internet marketing
autos
romance
You guys may find interesting these links.

Posted by: gifts at October 27, 2004 04:42 AM

refinance mortgage

Posted by: refinance mortgage at October 28, 2004 10:43 PM

6240 http://www.e-slots.info slots click here to play
online slots

Posted by: slots at October 30, 2004 10:12 AM

4139 Kona Coffee Starbucks Coffee Jamaica Blue Mountain
Coffee
coffee maker gourmet coffee green mountain coffee kenya coffee organic coffee specialty coffee folgers coffee coffee brewers costa rica coffee Tullys Coffee Millstone Coffee coffee grinder http://www.coffee-delivered.com

Posted by: coffee at November 3, 2004 10:54 PM

Money does not pay for anything, never has, never will. It is an economic axiom as old as the hills that goods and services can be paid for only with goods and services.

Posted by: vimax at November 4, 2004 12:23 PM

http://canadian-pharmacy.canada-pharm.biz/ Canadian pharmacy http://discount-pharmacy.discount-pharm.com/ Discount pharmacy http://canada-pharmacy.canada-pharm.biz/ Canada pharmacy http://canada-drugs.canada-pharm.biz/ Canada drugs http://discount-drugs.discount-pharm.com/ Discount drugs http://discount-prescription-drugs.discount-pharm.com/ Discount prescription drugs

Posted by: Canada pharmacy at November 6, 2004 09:27 AM

Now I lay me down to sleep
I pray the double lock will keep;
May no brick through the window break,
And, no one rob me till I awake.
Online Dating http://www.online-dating-com.com

Posted by: Online Dating at November 6, 2004 08:42 PM

Love is the triumph of imagination over intelligence.

Posted by: sex toys at November 9, 2004 01:47 PM

8608
directv
direct tv directv satellite direct tv satellite directv dvr direct tv dvr direct tv tivo directv tivo directway
direcway
directway internet directway satellite direcway internet direcway internet free hbo free cinemax free dvd player satellite radio http://www.satellitetvboutique.com

directv
direct tv
directv satellite direct tv satellite directv dvr direct tv dvr direct tv tivo directv tivo directway
direcway
directway internet directway satellite direcway internet direcway internet free hbo free cinemax free dvd player satellite radio http://satellite-tv.cjb.net

Posted by: direcway at November 9, 2004 03:22 PM

information on oklahoma

Posted by: information on oklahoma at November 10, 2004 06:17 PM

I agree with what you say - makes sense to me. Looking for some propecia?

Posted by: propecia at November 11, 2004 06:43 PM

I agree with what you say - makes sense to me. Looking for some propecia?

Posted by: propecia at November 11, 2004 06:43 PM

floricet, buy floricet, order floricet, floricet online

Posted by: floricet, buy floricet, order floricet, floricet online at November 12, 2004 05:50 PM

Great site !
Really enjoyed the posts!

Posted by: Loanny at November 15, 2004 06:39 AM

This is a underconstrained linear system with eight equations and nine unknowns — no good. However, a homogeneous 3x3 transform can be arbitrarily scaled, so setting I=1 drops the ninth unknown:
Search Google http://www.google.com/

Posted by: Google at November 17, 2004 10:57 AM

lesbian incest mother son incest pics incest story incest taboo rape photo incest chat free insest stories mother fuckimg son mother seduces son brother sister incest family incest pictures incestgrrl incest sex pics incest chat incest erotic stories incest porn gay family incest incest pictures young incest Hello from London!

Posted by: incest stories at November 19, 2004 01:38 PM

Fantastic website you have here.
It was exactly what I was looking for!!

Posted by: Aggy at November 22, 2004 05:59 AM

4878 http://www.top-texas-hold-em.com

texas hold em

Posted by: texas hold em at November 22, 2004 02:37 PM

stop sign meens stop but not say so when you see the sign not stay forever just stop and keep on going

Posted by: Totally Teens at November 24, 2004 06:06 AM

Some day soon I will be back.

Posted by: Totally Teen at November 24, 2004 06:09 AM

Vivid Page

Posted by: Tranny Hunt at November 24, 2004 06:11 AM

2268 Kona Coffee Starbucks Coffee Jamaica Blue Mountain
Coffee
coffee maker gourmet coffee green mountain coffee kenya coffee organic coffee specialty coffee folgers coffee coffee brewers costa rica coffee Tullys Coffee Millstone Coffee coffee grinder
http://www.coffee-delivered.com

You only get one set of teeth. Take care of them with a good
dental plan.
Dental
insurance is
money well spent. I sleep better since I signed up for my new dental insurance
plan.
Get yours at: http://dental-insurance-plan.freeservers.com/

individual
dental
plans
You only get one set of teeth. Take care of them with a good
dental plan.
Dental
insurance is
money well spent. I sleep better since I signed up for my new
dental insurance
plan.
Get yours at:
http://www.dental-plan-source.com
individual dental
plans
You only get one set of teeth. Take care of them with a good
dental plan.
Dental
insurance is
money well spent. I sleep better since I signed up for my new
dental insurance
plan. Get yours at:
http://www.e-dental-insurance-plans.com/
individual dental
plans

Posted by: individual dental plans at November 24, 2004 11:01 PM

http://dallas-escorts.usa-escorts-123.com/Lincoln-Escorts.html Lincoln Escorts http://atlanta-escorts.usa-escorts-123.com/Independant-escorts-escort-plano-texas.html Independant escorts escort plano texas http://alabama-escorts.usa-escorts-123.com/North-Carolina-dunn-escorts.html North Carolina dunn escorts http://gay-male-escorts.usa-escorts-123.com/asian-troy-mi-escorts.html asian troy mi escorts http://st-louis-escorts.usa-escorts-123.com/escorts-in-cape-coral-florida.html escorts in cape coral florida http://alabama-escorts.usa-escorts-123.com/escorts-bogota.html escorts bogota http://ohio-escorts.usa-escorts-123.com/miami-escorts-service.html miami escorts service http://dallas-escorts.usa-escorts-123.com/cincinnati-incall-escorts.html cincinnati incall escorts http://milwaukee-escorts.usa-escorts-123.com/GRAND-RAPIDS-MICHIGAN-ESCORTS-AND-MASSAGE-PARLORS.html GRAND RAPIDS MICHIGAN ESCORTS AND MASSAGE PARLORS http://gay-male-escorts.usa-escorts-123.com/detroit-independent-escorts-cheap.html detroit independent escorts cheap http://memphis-escorts.usa-escorts-123.com/escorts-in-tulsa.html escorts in tulsa http://mature-escorts.usa-escorts-123.com/Pleasures-Playhouse-atlanta-escorts.html Pleasures Playhouse atlanta escorts http://mature-escorts.usa-escorts-123.com/escorts-Maxine's-Girls-Sacramento.html escorts Maxine's Girls Sacramento http://tennessee-escorts.usa-escorts-123.com/portland-OR-independent-escorts-and-tantra-massage.html portland OR independent escorts and tantra massage http://nashville-escorts.usa-escorts-123.com/tampa-independent-escorts.html tampa independent escorts http://milwaukee-escorts.usa-escorts-123.com/Escorts-Available-green-bay-escort.html Escorts Available green bay escort http://memphis-escorts.usa-escorts-123.com/Escorts-maryland-sensual-massage.html Escorts maryland sensual massage http://gay-male-escorts.usa-escorts-123.com/Escorts-Personal-Central-FL.html Escorts Personal Central FL http://ohio-escorts.usa-escorts-123.com/escorts-nh-incall.html escorts nh incall http://michigan-escorts.usa-escorts-123.com/escorts-pics-denver.html escorts pics denver http://mature-escorts.usa-escorts-123.com/Greenville-NC-Escorts.html Greenville NC Escorts

Posted by: black female escorts in richmond va for free at November 25, 2004 01:44 AM

rape sites incest taboo rape photo japanese school girl rape video rape porn photo of rape of nanking date rape free rape videos rape bondage teen free rape videos incest rape rape victims the rape of the lock fantasy rape stories rapes teen rape pictures teen rape pictures rape videos erotic rape stories date rape bondage rape erotic rape stories free rape stories male rape forced sex gay rape Hello from Poland!

Posted by: gay rape at November 25, 2004 03:52 PM

Just super

Posted by: Upskirts Mania at November 26, 2004 06:08 PM

Cmon guys i love the way you do your job

Posted by: Upskirt Sniper at November 27, 2004 05:09 AM

I guess there is nothing i can say but ask you to keep everything as it is

Posted by: XXX Raimi at November 27, 2004 11:03 PM
Post a comment









Remember personal info?