Fiscal Conservatism?

[ActivitiesGuy]

@anon50325502

@ActivitiesGuy is that an issue in UHC’s too or just here?

If you mean the first issue I raised (providers implementing expensive, might-not-be-effective treatments), I don’t really have the expertise to comment outside the US. As we’ve been saying, it’s a sticky issue. If/when UHC becomes a thing, I would want to see a system where people do have access to treatments that have been proven effective (survival and/or quality of life benefit, specific to the field/symptom of course), but I don’t want to see that money wasted on ineffective or outright nonsensical gimmick treatments.

Of course, when something is currently accepted as effective, everyone (industry, patients, and physicians) any pushback against that will raise an uproar. If an insurance company announced that they would no longer cover (X) because there was no evidence that it was effective, how many people would actually stop to read the fine print and understand the decision? If the gubmit does that, can you just imagine the critics coming out of the woodwork with the sad story of how they couldn’t get (X) because the gubmint insurance wouldn’t pay for it?

Another good example that’s become quite controversial in recent years: placement of stents in patients with “stable” coronary artery disease (i.e. not having a heart attack, but with some mild-to-moderate chest pain and showing a blocked artery on an angiogram). Decades worth of study suggests that the stent does not have a benefit on either survival or quality of life in this population, and the highly-controversial ORBITA study this year showed minimal improvement in exercise tolerance (the last vestige that everyone was clinging onto that justified this practice was basically “well, maybe it doesn’t save lives, but patients feel better after getting stents”)

Yet, thousands of people with stable CAD get stents every year, despite no evidence that these people will benefit from the treatment. It’s become so dogmatic: interventional cardiologists will say “How do you expect me to see a blockage in the (Insert Artery Here) and do nothing?” And even after the ORBITA study was published, holy hell, did that stir up a hornet’s nest. People came out with pitchforks and torches to hammer the people that ran and published the study.

In my world? That study comes out, and the next day, stents in patients with stable CAD are no longer reimbursed by insurance (or UHC). You want it, pay for it yourself. More pipe dreams, of course, but UHC would be a hell of a lot more affordable if we didn’t pay for stuff that’s shown it doesn’t actually work.

[anon50325502]

I suppose you could extend Medicare to everyone, but only cover a set list of absolutely necessary treatments and allow private insurance to cover any additional elective treatments.

The rules on how to add a treatment to the approved list would need to be airtight, though.

[pfury]

@anon50325502

Not that I am aware of, but we aren’t the EU. We’re leading the way in obesity now. I don’t think how healthcare is paid for will change that mentality.

Are Americans just fundamentally not intelligent enough to copy the EUs lifestyles if given the opportunity?

@anon50325502

If anything, I think it places even less responsibility on personal accountability.

Not if you put my pipe dream qualities in there
Ie, UHC doesn’t cover lung cancer treatment for people who spent 20 years smoking

@anon50325502

When has a social program once implemented ever been truly been gutted for any reason, let alone the cost driver isn’t doing what they should be doing to minimize costs?

Well like I said, this is in a scenario where the GOP buys into UHC. Social programs aren’t touched currently because it’s all politics. If you write it into law that UHC has to have X amount of offset things will get slashed. GOP happy because they can slash in effective programs, Dems happy because socialism.

@anon50325502

We, generally speaking, can’t even bring up cutting social security, Medicare, Medicaid, etc…

Not to whataboutism, but we also can’t bring up cutting defense spending. I think in a world where both sides buy into UHC ala EU, all of that changes

@anon50325502

Right now, in our current system, you could save money on healthcare through preventative care, but people don’t.

Many people do

[loppar]

@pfury

Has there been a shift away from healthier lifestyles in EU since the implementation of UHC? Genuinely asking, I don’t know

Contrary to Fox News paranoia, we in Europe don’t say to ourselves “Thank God for UHC, I can do drugs, mess up my knees and balloon up to 400 pounds knowing that the state will bail me out”

Two major differences - obesity and the pill-popping. I’m still unclear with all those 400 pound plus people in the US. How one gets so big? It takes a significant amount of effort to eat all that calories just to maintain a calorie surplus.

And pills. My God, the pills. Whenever I visit a pharmacy in the US I’m always flabbergasted by the sheer number and variety of pharmaceutical products being sold.

[anon50325502]

@pfury

Are Americans just fundamentally not intelligent enough to copy the EUs lifestyles if given the opportunity?

I don’t think it’s a matter of intelligence, but a matter of cultural differences. We’re an instant gratification society. The EU might also be like that, but it doesn’t seem like they are nearly to the degree we are.

We just, generally, don’t like preventative care. We’d rather sit and watch the rebirth of Rosanne…

@pfury

Not if you put my pipe dream qualities in there

Ie, UHC doesn’t cover lung cancer treatment for people who spent 20 years smoking

Lol, good luck with that.

@pfury

Well like I said, this is in a scenario where the GOP buys into UHC. Social programs aren’t touched currently because it’s all politics. If you write it into law that UHC has to have X amount of offset things will get slashed. GOP happy because they can slash in effective programs, Dems happy because socialism.

As you said, it’s politics, though. Dems are not going to allow other social programs to be slashed if they can help it.

@pfury

Not to whataboutism, but we also can’t bring up cutting defense spending.

Sure, generally this is true for the right side.

@pfury

Many people do

Not that many.

[pfury]

@loppar

Contrary to Fox News paranoia, we in Europe don’t say to ourselves “Thank God for UHC, I can do drugs, mess up my knees and balloon up to 400 pounds knowing that the state will bail me out

I dont think Americans do either. It’s this instant gratification shit we’re stuck in. Have a cold? Better get 3 rxs filled. Sad about your puppy? Here’s some anti depressants.

Anecdotal story. When I was 18 I got my wisdom teeth removed. 2 were impacted and ended up getting dry socket. When I left the building I was holding 6 oxys and a bottle of some generic Tylenol. Day 1 rolls through and I was mentally obliterated from the first oxy (i don’t take pain killers, my cure for headaches is to suck it up) so I wouldn’t take any more of them. Took a couple of the generics, 3 hours later I’m still feeling like 90% of the pain.

Dad says call the oral surgeon and see what he says. Give the guy a call and within 5 minutes he phones me in an RX for enough Vicodin for 4 a day for 3 weeks.

For a fucking toothache. Ended up taking a few for the first few days, day 3 I caught myself taking a pill because my timer went off instead of reacting to the pain. Immediately got the chills from the realization of how quickly I could have got addicted, and flushed the pills.

@anon50325502

I don’t think it’s a matter of intelligence, but a matter of cultural differences. We’re an instant gratification society.

I would argue the inability to consider the long term is directly tied to intelligence

@anon50325502

As you said, it’s politics, though. Dems are not going to allow other social programs to be slashed if they can help

I think Bernie Sanders would slash homeless children funding with a smile on his face if it meant realistic non sabotage bipartisan UHC

@anon50325502

Not that many.

Well I mean, tens of millions at the very least lol

[anon50325502]

@pfury

I would argue the inability to consider the long term is directly tied to intelligence

Depends on what you mean I guess. I would say not taking care of yourself means you lack foresight, which I suppose is a measure of intelligence, but, more importantly, are Europeans actually considering the long term or is living the way they do just a cultural norm.

In other words, are Europeans really living active lifestyles while eating healthier meals because they care about their long-term health or is that just how they live unconsciously?

@pfury

I think Bernie Sanders would slash homeless children funding with a smile on his face if it meant realistic non sabotage bipartisan UHC

Perhaps, but some other lefty might shit an actual brick if that happened.

@pfury

Well I mean, tens of millions at the very least lol

We seem to always end up at an impasse like this, lol.

[pfury]

@anon50325502

We seem to always end up at an impasse like this, lol.

I didn’t say it to be argumentative, but to demonstrate that clearly many people understand the value of preventative care. How many people understand the value yet just can’t afford it?

Furthermore, how much more incentivized would be people be if other social programs funding were tied to UHC.

Ie, UHC law says X % of the difference in spending has to come from other social programs. With legit buyin from both parties, I don’t think it would be that difficult

[ActivitiesGuy]

@anon50325502

I suppose you could extend Medicare to everyone, but only cover a set list of absolutely necessary treatments and allow private insurance to cover any additional elective treatments.

The rules on how to add a treatment to the approved list would need to be airtight, though.

That’s my way-too-simple, pie-in-the-sky version of how UHC could be implemented in the US.

Specific and limited number of treatments are covered. Option to pay for additional care. Etc.

Of course, opponents of UHC will (rightfully) point out the amount of administrative overhead that will necessarily come with this. How many cases will have to be audited to catch waste or inappropriate treatments? What happens to the provider(s) that perform a treatment off the list and try to sneak it through? How many people will just fudge documentation to justify doing something (i.e. that patient with “stable CAD” is now listed with “crushing chest pain and shortness of breath” to justify putting in a stent)?

So on and so on.

[Basement_Gainz]

@ActivitiesGuy

sufficient evidence to conclude they are NOT effective, and they remain in use anyway because they’ve just become ingrained in practice as a thing you’re supposed to do

You mean like Statin drugs showing no decrease in all-cause mortality?

Also @pfury @anon50325502 @loppar @ActivitiesGuy enjoying this thread.

@loppar

I’m still unclear with all those 400 pound plus people in the US. How one gets so big?

I got to 235 without even trying. Eating “clean” 80% of the time. Sitdown jobs combined with the ubiquitous presence of bagels, doughnuts, pizza and garbage for free really pack the weight on.

In a normal office setting at a mid to large company there’s not one day that goes by without free food.

[anon50325502]

@pfury

I didn’t say it to be argumentative, but to demonstrate that clearly many people understand the value of preventative care. How many people understand the value yet just can’t afford it?

I know you weren’t trying to be argumentative. “tens of millions” would represent slightly more than 3% of the population to 30% of the population, but something like 75% of the population is overweight. My guess is only a small percentage of the remaining 25% (80M) do anything preventative. I’m not sure what other measures to use.

So, like I said, we’re just at an impasse as to what “many” means.

@pfury

How many people understand the value yet just can’t afford it?

Not sure.

@pfury

Furthermore, how much more incentivized would be people be if other social programs funding were tied to UHC.

What programs could be tied to UHC that would directly effect thus incentivize those folks? Food stamps? Unemployment? Government housing?

@pfury

Ie, UHC law says X % of the difference in spending has to come from other social programs. With legit buyin from both parties, I don’t think it would be that difficult

We can’t balance a budget…

[pfury]

@anon50325502

What programs could be tied to UHC that would directly effect thus incentivize those folks? Food stamps? Unemployment? Government housing?

All of the above, imo. If people don’t abuse UHC nothing gets touched. Simple as that.

@anon50325502

We can’t balance a budget…

With bipartisan support, I’d bet anything we could.

And keep in mind this all isn’t even my preferred method of UHC, I just think it’s the most realistic future

[anon50325502]

@pfury

All of the above, imo. If people don’t abuse UHC nothing gets touched. Simple as that.

Yaaa, I just don’t see that getting more than like 1 vote, lol.

@pfury

With bipartisan support, I’d bet anything we could.

Sure, but bipartisan support for something related to healthcare let alone creating a massive entitlement program that might cut other entitlement programs is not going to get bipartisan support.

I generally like what you’re saying it’s just like 3 universes away from our reality.

@pfury

And keep in mind this all isn’t even my preferred method of UHC

What’s your preferred method?

[pfury]

@anon50325502

Sure, but bipartisan support for something related to healthcare let alone creating a massive entitlement program that might cut other entitlement programs is not going to get bipartisan support.

Why not? UHC is a Dem pipe dream and being able to write into law the ability to reign in social programs is a GOP pipe dream.

It reminds me of that mantra where in a good negotiation both sides feel like they got screwed.

@anon50325502

What’s your preferred method?

UHC that offers basic (maybe even intermediate) services, but absolutely nothing advanced except in the case of emergency (what I mean by this is we’ll cover you after a car accident, but if you smoke yourself into lung cancer or drink yourself into liver failure you need 3rd party). Anything advanced (cancer treatments, etc) has to be supplemented with aftermarket insurance.

Also a system that doesn’t support any procedure with “sub X%” success rate (tbd by Eggheads, idk the real stats well enough to toss out numbers).

I think what we currently allow in Medicaid is patently absurd. I say this having been on Medicaid ending about 5 years ago.

[Aragorn]

@anon50325502

Honestly, and it’s pretty hilarious considering all of the back and forth I’ve had with our resident brain dead alt lefty, I would be fine, possibly even support, UHC IF the federal government didn’t already have its claws in so many things and IF we didn’t run a deficit for decades at a time and IF we weren’t so far in debt as a nation and IF people took steps to prevent disease/obesity/etc…

We simply cannot continue to just add huge social programs and hope the next generation finds a way to pay for their inevitable bloat.

This is the big stumbling block for me. We maxed out the last 55 credit cards and we smoke and drink a pack a day, but ya know that 56th one will solve all our problems when we play the lottery with it

[anon50325502]

@pfury

Why not? UHC is a Dem pipe dream and being able to write into law the ability to reign in social programs is a GOP pipe dream.

With both pipe dreams being almost universally opposed by the other party.

Can you imagine a Dem voting for a bill that would essentially penalize a _______(insert minority or poor person here) because they didn’t take preventative steps to curb their healthcare costs? I can’t.

[Aragorn]

@ActivitiesGuy

substantial cost savings in healthcare could be achieved if we took a harder stance against reimbursement for practices that are lacking sufficient evidence of efficacy. Don’t reimburse hospitals and/or physicians for things that are not proven to work. Don’t give FDA approval to things that are not proven to work. The only way that stuff gets paid for is if the patient enrolls in a research study to test whether it works.

This is a gem of a post. I agree that is the only way the necessary cost savings would be feasible. I go both ways on this however. I am a big believer in clinical judgement. How many times have we gone through the the “there’s no evidence it works…oh wait” shift in research? Elimination of–or disincentivizing–the research and innovation pathways are not ways to succeed in my opinion, and some of that is necessarily tied to “clinical instinct” that runs counter to currently accepted evidence. I do agree it is critical to have evidence based care and best practices, and can readily relate to your IABP illustration.

I can think of a number of instances the research has backtracked, and/or is just insufficiently precise, just as I can think of a number of times “clinical wisdom” was mistaken and needed correcting. I would personally rather pay more with more incentive for innovation than a more reactive scenario required to control the costs of UHC

[Aragorn]

@ActivitiesGuy

But there are absolutely a fair number of devices and/or procedures currently in use that have sufficient evidence to conclude they are NOT effective, and they remain in use anyway because they’ve just become ingrained in practice as a thing you’re supposed to do. This is why, while I defend the FDA in threads with our resident idiot as serving an important function, if anything I wish they were a lot HARDER on approving things. We’ve lowered the bar a little too much and allowed things to get traction or approval that work in theory, not practice, and it’s upsetting that money gets wasted on expensive-but-not-that-effective-devices when putting that money to work elsewhere in public health could have a greater impact for more people.

Just to be clear, I totally agree with this

[Aragorn]

You and me both

[Aragorn]

@pfury

Ie, UHC law says X % of the difference in spending has to come from other social programs. With legit buyin from both parties, I don’t think it would be that difficult

Initially maybe not, but the emotionally driven class warfare voter strategy is just too attractive to put away for long. It would have to be a constitutional amendment or it would be railroaded out within a senator’s term.