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Source link: http://archive.mises.org/14048/time-as-a-price/

Time as a Price

September 29, 2010 by

Healthcare in Canada is not free. Constantly full waiting rooms and long waits for procedures are not an unavoidable fact of life but a product of a “priceless” supply system, where waiting for service acts as a rationing substitute for the market price. FULL ARTICLE by Predrag Rajsic

{ 62 comments }

Douglas Chalmers September 29, 2010 at 10:24 am

This is a disappointingly weak article about an incredibly important topic. The value of TIME is not merely a function of either ‘price’ or such simplistic school-boy economics.

Time is a valuable commodity (or non-commodity), a precious opportunity in a sequence of events in which to act, and, later, to reap the rewards of one’s actions. It is also one of the fundamental dimensions in which we all live (or merely exist…) + is measurable as are the basic linear dimensions.

In case you haven’t noticed, C-H-A-N-G-E occurs within the framework of ‘time’. Thus it is our greatest opportunity to do something (anything) with our lives + our careers. Merely thinking outside of ourselves in some pathetic torpid academic detachment from reality (even in a Canadian hospital waiting room) …will not bring any real understanding of the real value of ‘time’, uhh.

Anthony September 29, 2010 at 10:45 am

Douglas,

Perhaps you interpreted the article differently from me… I thought that the article was about the economics of health care, not the nature of time. For a discussion on the nature of time as a fundamental dimension, I would recommend visiting a website dedicated to theoretical physics or philosophy, not economics.

As far as the economic arguments go, I very much enjoyed the article. Keep it up, Predrag.

Greg September 29, 2010 at 10:49 am

I don’t believe the author’s intention was to explain what time is from every conceivable perspective. I saw the article’s purpose was to explain one aspect of time, namely that it can function as a price. I thought he did a good job of this and found the article to be enlightening.

billwald September 29, 2010 at 1:00 pm

Agree 100%. This is exactly why I say that money and money inflation are no longer useful concepts. Inflation should be measured in work hours necessary to obtain consumer goods.

geoih September 29, 2010 at 9:23 pm

The work hours of who? A doctor? A garbage man?

Kavius September 30, 2010 at 6:01 am

I agree, with geoih, but will take it a step further.Take two carpenters working to build pews for a church. They are producing the same product, at the same level of quality, but one of them builds them faster; the faster person’s time is more valuable.

Jonathan M. F. Catalán September 29, 2010 at 2:19 pm

To me, the commodity isn’t time, rather the action that can take place during that time.

Jay Lakner October 3, 2010 at 7:30 pm

Agreed.

G8R HED October 4, 2010 at 8:56 am

Without the incentive – someone else pays – would there be a preference to stand in line for so long?

fundamentalist September 29, 2010 at 10:26 am

I work for a healthcare agency in the US and waiting periods in ER probably average about six hours here, too. Waiting in the ER is one of our most common complaints from members.

There are only three ways to ration scarce resources – 1) price, 2) lottery, & 3) waiting in line.

Greg September 29, 2010 at 10:51 am

Well, keep in mind that in the US, many of us don’t pay, in dollars, directly for health services. With the widespread use of health “insurance” that covers pretty much anything and everything, we end up in the same situation as our Canadian brethren. Namely, we only pay for these services with time.

Anthony September 29, 2010 at 11:04 am

Risk can also be used to ration resources… if you risk being arrested for seeking a good that will also decrease consumption (all else being equal, of course).

Seriously, though,

The argument I would expect from socialists is that of the three options waiting in line is the most fair for health care. A lottery would not allow differentiation based on need, while price excludes people who don’t make enough money to pay for services. Anyone can wait in line, so the waiting mechanism ensures that access to health care does not depend on wealth… since this is the primary goal of those who support public health care (a vast majority in Canada) they would argue that the system is doing what it is supposed to do.

Getting them to see the unseen (the productivity wasted) is a good first step, but this argument will unfortunately not convince anyone unless we can challenge the fundamental assumption that everyone, regardless of their productivity, deserves the very best health care.
It is easy to see the hospitals but harder to see where the resources would have gone if people were free to choose what to do with their money.

fundamentalist September 29, 2010 at 11:13 am

All that says about Canadians is that they don’t value their time very highly. I guess if you have a lot of time off work, then you won’t value it very much.

SB McManus September 29, 2010 at 11:16 am

Well, it says that they don’t value other people’s time very much. They might change their tune if they needed a lot of medical care and had to spend a lot of time waiting.

Craig September 29, 2010 at 7:19 pm

What choice do they have, fundamentalist?

Private fee-for-service health care has been illegal in Canada for decades.

George September 30, 2010 at 10:38 am

This is more than a little misinformed.

Whig September 29, 2010 at 11:02 am

The problem comes when individuals realise that a ‘time price’ is being paid and yet still elect to support free-at-the-point-of-delivery health systems. In doing so they make a political (not an economic choice – and of course, they impose that choice on others). I have heard economically knowledgable people advocating rationing by time (e.g. congestion, waiting) as preferable to rationing by price based on a perception of ‘fairness’ – we’re all forced to wait and no-one can buy their way ahead of the queue (although they always neglect to observe that this penalises all but the very rich who can always buy an alternative).

SB McManus September 29, 2010 at 11:14 am

Waiting isn’t necessarily fair. Higher earners are more likely to be able to take time off or use flexible work schedules to do their waiting at the most convenient time for them. Lower earners aren’t as likely to be able to do so.

J. Murray September 29, 2010 at 11:33 am

I would say it’s the other way around. Institutionalized wait times in a society that provides extensive social welfare payments gives preference to the least productive of society over the most productive. I would be unsurprised if those canvassed in Canada’s wait times mirror those in socialistic, large city hosptials in the US. Basically, skewed far poorer than the average population.

Those individuals with productive employment would be less willing to trade away time producing for time sitting in a waiting room. As such, more productive individuals will forego medical treatment for lesser problems whereas a poorer individual, whose time is less valuable and becuase of public lifestyle subsidy has less need for extra work, will be willing to take the wait time for medical ailments that could be solved without using medical system resources, such as rest time or over the counter medications.

As such, a “universal” health care system will always place preferences on the poor, especially those who are subsisting on other forms of public subsidy, because they have the spare time available to them to sit in a waiting room.

We have to remember, the ER is not where emergencies happen. People don’t drive in with an axe buried in their skulls, fill out documentation, then take a number. Real emergencies are seen immediately. The ER is typically used, in the United States anyway, as a glorified family practicioner.

When properly segregating medical expenses in the United States out to the source of payment and who uses it, those who qualify for Medicaid, the medical subsidy for the poor, spend approximately 5 times as much as the general population does in medical care. Considering the poor are not 5 times more likely to need medical care, nor are more likely to require more expensive care, it’s easily deduced that the costs are generated due to the time preference and the fact the care is percieved to be “free”.

SB McManus September 29, 2010 at 12:21 pm

Yes, overall the poor get (short term) benefit out of universal health care that they otherwise wouldn’t receive, whether they were willing to wait or not. What I meant to say was that, specifically as it relates to the “time” cost of waiting, most middle class and up people have an easier time adjusting their schedules to accomodate the waiting than poorer people. I suppose in the case of richer fee-for-service workers the opposite would be true because they would be sacrificing income by waiting instead of working, but for many salaried middle class people there is basically no income cost.

J. Murray September 29, 2010 at 8:23 pm

I would still disagree. Your standard salaried person (again, using US information here), obtains roughly three weeks in a given year worth of time off. Many organizations don’t even distinguish this time off as use for sicknesses or vacation time. Since time off is a precious resource, it’s unlikely the middle class salary range would be willing to waste 7% of their entire annual vacation time to sit in a hospital with a runny nose. The middle class worker doesn’t have the luxury to just take days off and consider it a wash. Time spent at Disney is preferable to time spent at Yourtown General.

There is a reason why appointment times after 1700 and on company observed holidays are very popular.

SB McManus September 30, 2010 at 11:10 am

Thanks for your further comments.

Maybe my personal experience hasn’t been representative. In both of the companies that I’ve worked for (as a salaried employee) we have been allowed to take additional time off work (above vacation time) to deal with personal issues such as health care, family emergencies, etc. My sense is that this flexibility is typical of middle class and up jobs, but would not be available to those at lower income levels. I may be mistaken and if you have any links to more detailed studies, reports, etc. I would certainly be willing to educate myself further.

billwald September 29, 2010 at 1:04 pm

Agree. The nature of poverty has changed. Poor people have most every sort of consumer good that the rich people have. The big difference is that rich people don’t stand in lines except when flying on a scheduled airline.

SB McManus September 30, 2010 at 11:12 am

This is possibly true if you think that, for example, a 1995 Honda is an equivalent consumer good to 2010 Mercedes. I think that’s a bit of a stretch.

Robert September 29, 2010 at 11:17 am

Great explanation, ER wait times in the US are significantly less than in Canada. The longest wait times are found in big city public hospitals. These hospitals (essentially socialistic) face the same problem as Canadian hospitals. The wait times in the UK got so bad that they passed a law limiting the wait time to no more than 4 hours. The hospitals responded by locking the ER doors. Unfortunately, the US seems to be headed down this same path.

Wonde September 29, 2010 at 11:26 am

But being from a developing country myself (Ethiopia), I have a storng suspicion of the role that a price could play in a society where people have nothing to spend but time. In such socities most people are too poor to afford basic food items, let alone health care expenses. As you know the majority of the population there survive on less than a dollar a day. So my point is that: introducing a price tag for basic health care services in such countries will not be a choice between efficiency and waste or between the market and an intrusive government rather it is between life (free service) and death (failing to be able to pay the price).

Nancy September 29, 2010 at 2:04 pm

But why are the citizens of Ethiopia so poor? Bad government; corrupt and arbitrary. So, let’s give them all of our health care choices? Bad idea.

Dave Albin September 29, 2010 at 2:51 pm

So, the real issues are:

1. Why have people there not developed (been permitted to develop, is more accurate).
2. Why do medical goods and services cost so much?

Both answers have similar roots.

Redmond September 29, 2010 at 1:01 pm

What seems to be lacking in the comments is the fact that if we in fact shifted to a competitave free market in Health care services, it would end up in a reduction in costs and an increase in quality.

Take Laser Eye Surgey in Toronto for example.It is not covered by Public Health Insurance, or Private health insurance – unless you have a “Gold Plated” Plan.

For the Last 10 years, the cost has gone down year over year, and there are mulitple firms now offering the service.

In addition, the technology and quality has improved.

All to the benefit of people wishing to recieve the service.

Some say Health care is too important to have to pay for – but I say that because of the inevitable lowering of price and increasing of availability through the application of the competitive forces in a laissez faire system, Health Care is too important NOT to have to pay for.

James W. McGillivray September 29, 2010 at 1:03 pm

I just read and discussed this with a colleague. Between us we have a HUNDRED YEARS EXPERIENCE with the Canadian system, both before medicare and with partial medicare and with full medicare.
We predicted that this would happen and it did. I told him about a lady that we both know. When she had medical insurance coverage her doctor told me “She comes in to see me every time she comes downtown’. The lady is still healthy. Her doctor died many years ago.
Anybody who wants to understand the importance of paying something at the time of service will understand. Those who do not wish to understand will never admit to being wrong.
Right now the system in Canada is trying out the system of capitation for family doctors that they began in Britain a century ago. They were slow to admit that it encouraged the family doctors to do less and less for each patient, sending them more and more to the hospitals.
Good luck to all. There is no free lunch.

Redmond September 29, 2010 at 2:37 pm

Within the socialized medicinal system of Canada, there are plenty of communities where people do not have access to a doctor at all.

Medical tourism exits, with people flying to foreign countries for their treatments.

Queue jumping exists as well – if I have a 2 month wait for a CAT scan, I can simply pay for it privately, or through insurance and get it the next day.

What caused that shortage? – 1 guess – Government interference in the free market for Doctors.

That is Central planning of the supply of doctors.

Canada’s doctor shortage is partly rooted in a 1991 report commissioned by the provincial deputy ministers of health. In that document, Morris Barer and Greg Stoddart, two health economists, predicted that Canada was facing a physician surplus. In response, provincial governments, scrambling to save money, cut first-year enrollment to Canadian medical schools by about ten percent. Dr. Andrew Cave, an associate professor in the Department of Family Medicine at the University of Alberta in Edmonton, says, “Despite the predictions of the gurus ten years ago, in fact, we need more doctors.”

So we have our governments reliance on central planning experts “predicting” the future of the given demand for a certain service.

You see exactly the same thing currently occuring with “green” energy – 5 year plans and centrally planned ecomnomies.

The central planners who used the 1991 report believed in the omniscience of the prediction.

From “The Fallacy of Central Planning”

The dangers of planning, which planners often ignore, because they seem academic or overcomplicated, are ethical as well as logical. The chief ethical problem involved in planning is that which Berdyaev has termed the dehumanization of man.[2]The sober truth is that, in central planning, men are pawns. As planning becomes more central and more nearly complete, there is a strong tendency to forget that the ultimate units of any society are persons and that the order exists for their sakes. Unless this is kept in the consciousness of planners, the entire situation becomes impersonal; individual decisions on the part of the people really count for nothing.A development in this direction seems to be intrinsic to an ever-growing bureaucracy. It is almost impossible, for example, to have any large-scale planning without some illustration of Parkinson’s law. Bureaucratic control always has a tendency to increase, with the consequent loss of initiative on the part of the people. The danger comes subtly and appears even in the most beneficent of enterprises.

And From Valclav Klaus’ Book “Blue Planet in Green Shackles”

This brings me to politics. As a politician who personally experienced communist central planning of all kinds of human activities, I feel obliged to bring back the already almost forgotten arguments used in the famous plan-versus-market debate in the 1930s in economic theory (between Mises and Hayek on the one side and Lange and Lerner on the other), the arguments we had been using for decades — till the moment of the fall of communism. Then they were quickly forgotten. The innocence with which climate alarmists and their fellow-travelers in politics and media now present and justify their ambitions to mastermind human society belongs to the same “fatal conceit.” To my great despair, this is not sufficiently challenged neither in the field of social sciences, nor in the field of climatology. Especially the social sciences are suspiciously silent.

The climate alarmists believe in their own omnipotency, in knowing better than millions of rationally behaving men and women what is right or wrong, in their own ability to assembly all relevant data into their Central Climate Change Regulatory Office (CCCRO) equipped with huge supercomputers, in the possibility to give adequate instructions to hundreds of millions of individuals and institutions and in the non-existence of an incentive problem (and the resulting compliance or non-compliance of those who are supposed to follow these instructions).

Ohhh Henry September 29, 2010 at 3:21 pm

People are so dumb. Whatever is the worst thing that a government does, people go around thinking that this is absolutely the best thing about their country. Medicare – mostly the waiting lists but also incompetent care – probably kills more people in Canada than any other cause. Even the simplest of logical exercises proves that socialist medicine is impossible, because one cannot change the price of something valuable to make it “free” and not expect negative consequences. The simplest of accounting, adding 2 plus 2, also shows that whatever its supposed medical benefits, socialist medicine cannot pay for itself because it is consuming a larger and larger portion of government budgets while it delivers less and less. Yet most Canadians – I would guess probably 80 or 90 percent – are absolutely convinced that medicare is the BEST thing about Canada.

Other people in different countries probably think that their “free” universities are the best thing ever, and people in militaristic countries no doubt think that their huge arsenal of nuclear weapons makes them “strong and free”. Perhaps this conundrum is due to the inherently contradictory nature of everything that governments do, namely, commit violence on their people in the name of peace and charity. The contradictory nature of government actions requires them to tell the Big Lie over and over again until the victims believe it.

SB McManus September 30, 2010 at 11:16 am

“Medicare – mostly the waiting lists but also incompetent care – probably kills more people in Canada than any other cause.”

I’d be interested to know why you think that Canadian health care is “incompetent” in any meaningful way. If anything, I suspect that too many tasks are mandated as being the sole territory of physicians, so they end up doing things that are overqualified for.

Jeremy September 29, 2010 at 4:03 pm

It seems like this whole article/argument rests on a very odd assumption: that people have an insatiable hunger for healthcare. I don’t know about everyone else here, but I don’t go to the doctor unless I’m sick, no matter how “free” (thanks to my health insurance) it is.

Even if I’m somehow wrong, and people do like going to the doctor for fun when it’s free, I see no reason why rules and restrictions can’t be put in place to prevent unnecessary visits. But the article completely ignores this very obvious solution.

So, I’m all for the government getting out of things it shouldn’t be in, but if the only way to show that government-run healthcare can’t succeed is to assume people want endless doctor visits … I think that’s a pretty weak claim.

J. Murray September 29, 2010 at 5:17 pm

Medical use among the elderly frequently does fall under the for fun category. Further, when arbitrarily dictating what is and isn’t worth a visit ends up with negative results. Britain is trying this and thy have the worst cancer survival rates in the Western world. This is because cancer frequently starts off with minor symptoms that are confused with non-cancerous ailments. Britain normally sends these individuals home while US doctors will order additional tests to be certain. In Britain’s. zeal to save costs of unnecessary visits, cancer identification occurs at a stage where it isn’t treatable.

Patients need to pay the bills themselves, out of pocket. This way, if a patient wants to pay for a visit just to socialize, they’re free to do so.

Jeremy September 29, 2010 at 7:58 pm

>>Patients need to pay the bills themselves, out of pocket. This way, if a patient wants to pay
>> for a visit just to socialize, they’re free to do so.
That is A solution for the bored senior problem, but I don’t see why it has to be the only one. For instance, I don’t see why a simple “you only get 10 visits to the doctor” rule wouldn’t work; it’s rationing, no doubt, but it would solve the problem of people over-using the system. And that solution would allow non-hypochondriacs to get medical care even if they have the misfortune to be poor. To me, if you have to choose between limiting a few hypochondriacs via regulation, and letting poor people die, I vote to limit the hypochondriacs :-)

>>In Britain’s. zeal to save costs of unnecessary visits, cancer identification occurs at a stage
>> where it isn’t treatable.
First off, that exact thing happens FAR more in America for people who can’t afford proper health care coverage: you can’t afford to get your cancer symptoms looked at early on, so they don’t get treated cheaply, and instead the US taxpayer picks up the (much larger than it needs to be) bill when you go to the ER (and can’t afford that bill either).

Regardless, you’re comparing apples an oranges. In a imaginary perfect free market, sure the supply and demand for tests would balance out to the perfect price point, and everyone would pay for exactly the tests they can afford. I’ll admit that. But we don’t live in fantasy land, so you can’t compare the British (or Canadian) system to it.

What you can do is compare it to the current US system, where we not only have the same exact problem (as I already mentioned), but also the exact opposite problem: the doctor makes more money if he gives you more tests. You don’t (seem to) pick up the bill, so he gives you as many tests as he can justify, even if a lot are un-needed, and then you ultimately pick up the bill by paying more in premiums than you would have to if only the necessary tests were ordered.

So, I’ll agree that any mediated system is going to have problems compared to a perfect free market system, but to compare the problems in Canada’s system to a vacuum/imaginary perfect free market system is kinda pointless. What you really have to compare are things that are possible in the real world, and by that metric the fact that this article doesn’t even consider the problems in the current American system makes it … well, also kinda pointless, in my opinion at least.

J. Murray September 29, 2010 at 8:44 pm

It’s not really apples and oranges. They’re both medical systems, not one medical system and the other a supermarket. I have to admit, I placed a subjective value judgment into the mix as have you. You’ve argued from a cost angle, I’ve argued from a sanctity of human life angle.

The thing is, Britain isn’t doing better in the end results. Cancer is one of those things where survival rates increase along with cost decreases. The more the cheaper up-front is taken, the higher the survival rate becomes, which means that expensive and repeated treatments are not being obtained in the future. The only reason why Britain is spending less on cancer treatment isn’t because their early diagnosis is free (they don’t diagnose early at all), it’s because their quality of life calculation denies those with later stage cancers any kind of treatments. Britain’s medical system routinely denies the use of any cancer medication, including those that are proven, simply because they’re judged too expensive.

And, again, I argue from a sanctity of life angle. Am I willing to eliminate unnecessary tests and extra doctor pay for those unnecessary tests if it means having similar results of the British system? Absolutely not! The life of a human sits at the very top of the marginal value list and is trumped by nothing else. Everything in existence comes second to saving a human life. Great Britain and Canada don’t believe in this, they’re more concerned with spending as little as possible. You can’t dispute this simply because they have organizations that can deny you treatment simply because it is deemed to expensive, even if you’re willing to pay out of pocket (so you can’t argue the insurance company angle). They’ve taken the Spock quote, “The needs of the many outweigh the needs of the few” to new heights of irresponsibility.

Further, poor people in the Untied States didn’t just up and die in the streets before 1964 when all government medical care nonsense started to infect the nation. It didn’t happen. Even while the supporters of it agreed that while it wasn’t happening, there was a CHANCE it could happen, so why not be proactive and stop it ahead of time? The irony of it is that the care became more expensive and more difficult to get because of they very “insurance policy” taken out against it. How else can you explain why the uninsured and uninsurable went from 2 million in 1964 to the 48 million today? America didn’t somehow become more greedy and technology never makes things more expensive.

Socialism always disservices the poor in the name of helping them. At no point in the history of socialism spreading back to early records of ancient Babylon has socialism (it’s not new, it just got a new name) ever resulted in superior results for the least well off in a society. We’ve spent nearly $16 trillion in the name of the poor, over an accumulated 60 million people. That’s $267,000 per PERSON. Tell me a poor family of 4 wouldn’t have been better off having been cut a check for $1.08 million instead of being given Medicaid and Welfare.

The whole thing is a scam. Not only has no one ever died because of the lack of public health care, it’s that public health care that will more than assuredly make people die due to lack of care. It’s already happening today, more so in nations with more infected systems than the Untied States. The only reason universal systems can be so arrogant about their superiority is because they make sure they deny the care before it ends up on a statistic sheet.

Andy September 30, 2010 at 3:33 am

“Further, poor people in the Untied States didn’t just up and die in the streets before 1964 when all government medical care nonsense started to infect the nation. It didn’t happen.”

J Murray, are your opinions based on experience or literature alone?

My wife is an in-home caregiver for retarded and mentally ill clients. I can give you details about two cases where her clients were discharged with life threatening conditions. Her insistance that they be treated saved their lives.

“The irony of it is that the care became more expensive and more difficult to get because of they very “insurance policy” taken out against it.”

Do you agree that private insurance has had the exact same economic effect? Do you further agree that the people who benefit from public insurance have about the same disregard for the time rationing effect that many others have for the price rationing effect of private insurance?

Ohhh Henry September 29, 2010 at 5:38 pm

Even if I’m somehow wrong, and people do like going to the doctor for fun when it’s free, I see no reason why rules and restrictions can’t be put in place to prevent unnecessary visits. But the article completely ignores this very obvious solution.

Obviously people will tend to overuse medical care when it costs them nothing but time to make use of it. Especially people who for lack of a better word I will call “gomers” – hypochondriacs, people with chronic afflictions that are often self-inflicted or exacerbated by their lifestyle, and old people who are often over-medicated and determined to get their money’s worth out “the system”. Studies have been done of the people who are taking up the most time and money in emergency rooms in Canada, and it’s a fairly small number of people with chronic conditions like asthma and addictions for whom an ER is an extremely ineffective and wasteful form of treatment.

Creating “rules to prevent overuse” means rationing, which is exactly what happens in every socialist redistribution scheme that tries to reprice something lower than it would be in the free market.

Dave Albin September 29, 2010 at 6:27 pm

In a free market, you would have “doctors” who would cater to these very people – those who see medicine as a leisure-time activity. I don’t understand why these people are the way they are, but they will find someone to give them what they want no matter what kind of system we have – so, all the more reason to free up the marketplace for medicine.

J. Murray September 29, 2010 at 7:55 pm

Exactly. The hypochondriac market is the one best serviced by those derided as spiritual healers, new age healers, or snake oil salesmen. Hypochondriacs are only looking to have their conscious temporarily calmed. People peddling ginko balboa are the best way to service this market. It frees up crucial medical resources and skilled personnel to provide care to legitimate ailments.

Jeremy September 29, 2010 at 8:07 pm

>>Studies have been done of the people who are taking up the most time and money in
>> emergency rooms in Canada, and it’s a fairly small number of people with chronic conditions
>> like asthma and addictions for whom an ER is an extremely ineffective and wasteful form of
>> treatment.

So, as I mentioned to J. Murray, the issue of people not getting treatment early on when it’s cheap, and then getting much more expensive treatment in the emergency room later, is far from a Canadian, or even socialized medicine issue. We have the exact same problem, only worse; to steal form my reply to J:
People who can’t afford proper health care coverage can’t afford to get cancer symptoms looked at early on, so they don’t get treated cheaply, and instead the US taxpayer picks up the (much larger than it needs to be) bill when they go to the ER (and can’t afford that bill either).

So I really don’t see how our system is any better in that regard; if anything socialized systems deal with that particular problem better than we do.

>>Creating “rules to prevent overuse” means rationing, which is exactly what happens in
>>every socialist redistribution scheme that tries to reprice something lower than it would be
>>in the free market.

Ok, I know this is heretical here on Mises, but some socialist systems work very well. When was the last time you complained about your police protection (unless you live in a really poor area)? Fire protection? Food safety? Public roads? If my house catches on fire, the firemen come, the police look for the arsonist after, both were able to get to my house because of public roads, and I can be reasonably confident that I won’t die of salmonella while eating a consolatory hot pocket as I watch my house burn down. All of that is possible thanks to the socialist/rationed police/fire/food inspection/road services.

Now, I’m not saying private solutions couldn’t possibly do better (there was a very interesting article on here about what a private police solution might look like a few months back, for instance). But to pretend like any rationing/socialist system is going to inherently be a failure is to ignore the mountain of evidence to the contrary.

Some things are better for the government to do. Some things (it’s pretty safe to say, “anything the government can’t specifically do better) are better for the private sector to do. We as a society should have an intelligent debate about which is which, and why, and that’s perfectly healthy and good. But when you resort to socialist=evil you stop thinking, and you miss out on many good real world solutions to problems.

Dave Albin September 29, 2010 at 10:27 pm

I think you are missing a few key points in your final 3 paragraphs. First, where you live, police and fire departments (to mention two local city or county departments you mentioned) may do a good job. Now, go to any inner city, and (at least the police) may not do a good job there. They may be understaffed, poorly funded, or simply afraid to fight crime there. What can the people in the inner city do about it? Very little – they are forced to pay taxes to support this failing department. This removes resources from individuals and families that could be used to come up with better solutions. If several private security agencies were available to clean up a crime-ridden inner city, residents could choose the best one (or different ones) to meet their needs. If the private security firm became ineffective, they could be fired, and a new one put in their place. So, you are correct that something run by a government may not be a all-out failure, but it usually cannot be made better, cheaper, etc., no matter what the circumstances. Apply this concept to the other examples you mentioned (roads, food safety agencies, etc.).

You make me cringe when you say things like “We as a society should have an intelligent debate about which is which, and why, and that’s perfectly healthy and good.” – this sounds great until you consider that:

1. What is good for you may be horrible for me – your value system and wants and needs may be opposite of mine.
2. What’s an intelligent debate? Congress has “intelligent debates” and then forces large % of the population to do things they don’t want.
3. This groupthink mentality has led to some of the greatest tradegies in human history.

Jeremy September 30, 2010 at 10:50 am

So, to respond to your first paragraph … you argued with fantasy land. In a fantasy perfectly free market world where there are lots of competing private security companies that all offer coverage of your area, that might be true. It’d be awesome … but it’s not reality. The reality is that if you could somehow manage to privatize police protection in inner cities (good luck with that one) you would undoubtedly see one or maybe two large companies take over that city. Neither one would do a good job, but people would have to choose between them and nothing at all. It won’t be magic utopia time, it will be shitty corporate protection is even shittier than public protection time.

We “socialize” our police force for a reason, and that reason isn’t that they provide perfect coverage for every citizen (that would require changing the messed up income distribution of our society, which is an entirely different issue). It’s that public police forces come closer to that perfect coverage than anything else we’ve found (so far; again I’m not ruling out the possibility of technology or some clever person someday coming up with something private that’s better, I’m just saying based on all the evidence in the real world now).

As for the intelligent debate thing …
1. I disagree. The vast majority of people can agree to common values; that assumption underlies everything our founding fathers did when creating this nation. Those guys bickered like you wouldn’t imagine from their respectful portraits on money; they’d make today’s Democrats and Republicans look like best buddies. But despite that, they knew that everyone, on every side, could agree to things like “all men are created equal” and that they are endowed with certain basic rights (life, liberty, and all that jazz). Furthermore, everyone agreed that it was a good thing(tm) to protect and preserve those rights. And it doesn’t just stop with rights: I’m willing to bet that you and I both want a society where everyone is as healthy as possible, and where (when there is scarcity of health care services) services are distributed as fairly as possible.

So, might we disagree on how to best get that? Absolutely! But that doesn’t mean we can’t discuss our differences, identify why we disagree and what info we might have that the other doesn’t have. Intelligent debate is the cornerstone of our democracy.

2. Feh, nothing Congress does is intelligent ;-) But that’s a failure of our political system, which I think most Americans would agree has some serious issues … not their debates.

3. Wait, intelligent debate = group think? You just completely lost me there.

Steve September 29, 2010 at 8:01 pm

I can’t tell if you’re joking or not, so I’ll write as if you aren’t. It’s so obvious that more restrictions and regulations will fix the problem! The article didn’t ignore this obvious “solution,” those running socialized medicine in Canada did. Or maybe the system is already restricted to the max. There’s only so many people you can tell to bug off with their “unnecessary visits” without incurring public outcry or a sack full of lawsuits.

Restrict further a restricted system that doesn’t work because of the restrictions. Now that’s a weak argument!

Andy September 30, 2010 at 2:25 am

Someone FINALLY said it!!!! Another odd assumption would be that poor people without money for healthcare should be more concerned with time rationing than the people advocating for price rationing in healthcare. LOL.

Andy September 30, 2010 at 2:27 am

Someone FINALLY said it!!!! Another odd assumption would be that poor people without money for healthcare should be more concerned with time rationing than the people advocating for price rationing in healthcare. LOL.

Kitty Antonik Wakfer September 29, 2010 at 6:24 pm

I found Predrag Raisic’s article presentation good and hope that he goes beyond having it published here at Mises.org where most readers already agree with his arguments. Getting it published as an OpEd piece in one or more of Ontario’s newspapers (paper and/or electronic) would be more beneficial towards reaching the many Canadians (and USers too) who think that not having to pay at the point of service is equivalent to *free* and/or healthcare is a proper function of government. Perhaps a good start would be a Letter to the Editor in response to a recent opinion piece written originally in the Charlottetown Guardian about the CMA president’s suggestions regarding changes (more like tweaks) to Canada’s healthcare system. There was a reprint of of this editorial September 27 in the Kitchener-Waterloo area The Record. http://news.therecord.com/Opinions/Editorials/article/781689

Commenter Redmond is quite correct about the proliferation of lasik eye surgery options (and prices) available in the Toronto area over the last several years – I hear the radio ads often during the 6 months per year I spend as a legal visitor at my Canadian husband’s legal residence. (Paul legally visits me the other 6 months at my legal residence in Arizona.) Additionally, the sales for hearing tests and upgrades of hearing aids, as well as various dental procedures, are numerous. These health related services are obviously not covered by Ontario’s Health Insurance Plan (OHIP) – they are not deemed “necessary”.

As an interesting contrast – and confirming Redmond’s comment “there are plenty of communities where people do not have access to a doctor at all”, there is the roadside sign visible to southbound traffic on very rural County 507 (Buckhorn Rd) between Gooderham and Buckhorn that I and Paul have seen on every trip we take to Peterborough. “Country Doctors Wanted” – and briefly promotes, to those who are taking this route “back to the city” from “cottage country”, the advantages of the area and lifestyle for physicians (and supposedly those in-training or simply friends/family of the same). This year was the 3rd season we’ve seen this sign – though it may have been there since before we started making this ~every 6 week trip to the nearest “big city” from even further north. I wonder what response the group (or individual) has had that erected it (and is this independent search even permissible per Ontario law?), since it has been there for at least 3 summer seasons, and also where the nearest physician is located in that area. Most of the general physicians in the Bancroft area are not taking new patients and the wait time to be seen by the others is several months. (If you have something urgent you are directed to “go to emergency”.) Additionally, I saw notice in a local Bancroft area ad-paid newspaper that Dr Robert McDonald at 156 Lakeshore Drive in Barry’s Bay (~50 km northeast of Bancroft, as the crow flies) is closing his office “after 47 years of medical practice”. Note that he isn’t selling/turning over his practice to another (younger) physician, but rather closing it effective October 30th 2010. I can’t remember reading an equivalent type ad in the US, but I expect that they will soon be coming as the various aspects of “Obamacare” become effective. Dr Joseph M Scherzer of Scottsdale AZ is likely just an early announcer – http://dailycaller.com/2010/04/14/arizona-doctor-says-obamacare-will-force-him-to-close-shop/

There are numerous examples for demonstrating to people the logical consequences of their non-liberty promoting ideas/actions. Taking the appropriate opportunities in the venues most likely to reach those people is essential to hopefully having effects towards positive changes in societies. Either that or survive the implosion…..

Robert September 29, 2010 at 6:28 pm

Fantastic article. Very well written and extremely informative.

Robert T September 29, 2010 at 7:03 pm

THIS is why I read Mises.org…
FANTASTIC.

Ohhh Henry September 29, 2010 at 10:36 pm

Ok, I know this is heretical here on Mises, but some socialist systems work very well. When was the last time you complained about your police protection (unless you live in a really poor area)? Fire protection? Food safety? Public roads?

All of these government services are fairly lousy and vastly overpriced where I come from, for the simple reason that they are monopolies upheld by threat of force. The managers and employees of public monopolies, acting out of ordinary and natural human desire to advance their self-interest, strive to make their organizations as expensive and ineffective as they possibly can without being actually lynched. Monopolies bring the greatest rewards to those who control them by being inefficient, which raises their costs, which results in higher revenues and personal profits in the form of salaries, benefits, power and perks. Whereas competitive organizations in a free market have the exact opposite motivation, because for them inefficiency leads to loss of customers and revenue.

There is no reason why any of the services listed above must be government monopolies. There are many examples throughout history and around the world of private police forces, firefighters and roads. They are not common any more because starting in the 19th century they were gradually hobbled by regulation, or given patents turning them into monopolies, and finally expropriated and turned into unionized sinecures. The dire financial straits of virtually every single “modern” country with socialist monopolies such as you list above – crippling debt, inflation and taxes – show that none of these socialist systems “work well”. They barely work at all, and they are near the point of consuming the last dregs of wealth in the societies in which they flourish.

Dave September 29, 2010 at 11:27 pm

My wife is a nurse, my daughter is a nurse and my brother a Doctor. We live in western Canada. One of the scams that is routinely run in the emergency dept. is pulled off by the ambulance service. If it is a holiday weekend, to increase their business the ambulance drivers cruise along skid row and pick up as many drunks and junkies as they can coerce into their ambulances. Then they are taken to the “emerg”. It doesn’t stop there. The ambulance drivers cannot leave until their “patients” are admitted by the hospital staff.

Of course the nurses are not going to take drunks and junkies who, other than their inebriation, are relatively healthy until they deal with actual critical people. This means the ambulances are tied up for hours on end. Of course this causes a backlog and temporary shortage of ambulances. Once it gets to a critical point when there are only a few ambulances available there is what they call a “Code Red” for EMT service. Of course the news media is tipped off to the “emergency” by the ambulance drivers union.

It works quite well of course. The municipal and provincial governments hold meetings to solve the problem and….you guessed it, they hire more ambulance drivers and buy more ambulances! I could go on for hours about the deliberate abuse in our health care service.

Predrag September 30, 2010 at 6:34 am

Thank you all for reading the article. Some of you have raised other issues like fairness of different supply systems and the issue of affordability. I think these are important questions that require careful analysis, which is beyond the scope of this article. There is, however, literature that deals with similar issues in different contexts.

On the other hand, this article was contained to explaining a specific phenomenon using economic theory. With respect to the comment about assuming insatiable desire for healthcare – no, the only thing that the article is assuming is that the demand curve is downward sloping (this is actually not assumption but a conclusion deduced from the law of diminishing marginal utility). The only empirical issue that affects the details (but not the principle) of the result is the numerical increase in quantity demanded for a given change in price (i.e., the “slope” of the demand curve) which, given the experience, generally increases (but not to infinity) as the price goes down.

Andy October 2, 2010 at 1:32 am

I constantly hear that competition between health insurers will bring the cost of healthcare down. How?

I’m thinking that economy of scale would eventually create a relatively limited number of insurers , much like the state sanctioned monopolies we have now. Big insurance has a profit margin of approximately 5%, suggesting there isn’t much wiggle room for reducing premiums anyway.

How much price influence does the insurance industry have over the healthcare industry? It seems that insurers would prefer high healthcare cost. (at least greater than the lowest premium that could be offered) Healthcare providers probably desire price negotiation with multi-billion dollar corporate payers over haggling with average wage consumers. Would consumers have the will to change demand enough to reduce cost?

What happens when you under insure and are unable to afford co-pays and deductibles?

Doug McGuff, MD October 3, 2010 at 7:23 pm

Predrag,

As an emergency physician I can attest your article is even more correct than you realize. In the US things are no different than they are in Canada because we are under a Federal mandate called “EMTALA” which forces us to see everyone regardless of ability (or intention) to pay.

The game-theory of adjusting to fluctuating wait times is even more sophistocated than you describe. Our “poor patients” who are non-paying or on public assistance will troll the waiting room and when the queue falls below the double digits they will get on their i-phones (I’m not kidding) and send out a mass text-message to all in their network. We began to figure this out when we noticed that as soon as the waiting room would thin out to 9 patients, it would suddenly jump to 20…without fail.

Your description of what happens when you bring on more coverage is spot-on as well. We have brought on new partners and expanded coverage 2 times in the recent past and both times the result has been a rapid rise in wait times and the numbers stacking up in the waiting room. Your analogy showed a decrease in wait from 4-6 hours and an increase from 30-40 patients sitting in the waiting room. What your example fails to take into account is what is attached to the other end of the ER…the hospital itself. The hospital has a finite number of inpatient beds. In the US (as is certainly true in Canada) there is a shortage of inpatient beds due to government-instituted price controls on the inpatient side of medicine. With more rapid turnover and volume on the front-end (the ER) you more quickly consume beds on the back-end (the hospital). Once all the hospital beds are full, any further patients that are sick enough to be admitted have to be housed in the ER. Within a matter of 2 hours, the ER’s bed capacity can be cut in half. So, at the instant the hospital beds become full, the 4 hour wait that you described in your example of expanded coverage suddenly jumps to 12 hours. Even worse, the time of the extra doctor you hired is now totally wasted as he is now standing around helpless as he has nowhere to see the patients stacking up outside. This is where we are now…all 20 beds full, 12 beds lining the hallway, seeing the simple cases in the chair at triage and 25 in the waiting room.

So, to all your readers, I can assure you this article is very accurate. The only inaccuracy…it is even worse than what is described.

Andy October 4, 2010 at 3:11 am

Isn’t the AMA’s lobbying for the BCBS monopoly that began health insurance in it’s present state in 1929 a rent-seeking behvior? Licensure for physicians: rent seeking. The subsequent lobbying for mandated coverage largely has come from the insurance industry. So now we are going to criticize those that are less fortunate for engaging in their own rent seeking?

The difference between this debate and the prisoner’s dilemna is that all players are very aware of what other players are going to do. I’ll give-up medicare and you’ll keep paying for private insurance that helps inflate medical cost for you and I both. Get real. You all might have a point if you would boycott your own healthcare coverage as well, but you won’t. Maybe we’ll learn to cooperate before we become bankrupt.

Doug McGuff, MD October 4, 2010 at 8:10 am

Andy,I am not sure if your comment was a general one, or directed at me. Realize that the AMA does not represent US physicians. A tiny percent of physicians are members of the AMA. Yes, the AMA was an originator of this problem as you describe…as well as its support of the gradual march toward “universal care”. Those physicians who support the AMA are generally socialist-leaning, or power mongers seeking to rub elbows with the political elite.My description of the game-theory carried out by those in the ER waiting area (about 74% non-paying) was not meant to criticize them. They are behaving in a perfectly rational manor with regard to the “system” as it currently exists. Their response is completely logical and efficient. What is faulty is a collectivised system of healthcare, whether it be a government redistribution or a third-party payor system of commercial insurance.You are correct, the solution is to pay at the delivery of the service. An example: there is a veterinary ER not far from where I practice. In the human ER we see 40,000 patients per year, have single coverage at night, and cannot get ultrasound studies at night. In the animal ER they see 16,000 patients per year, have nighttime double coverage and CT/ultrasound on a 24/7 basis….and the services are infinitely cheaper. The difference…there are no third party payors and payment is due at the time of service.

Andy October 5, 2010 at 1:39 am

I believe that it is unrealistic to expect that “pay at delivery” will happen anytime soon. Big insurance is “too big to fail”. I appreciate your answer, but it always seems the criticism is aimed at the “poor”, as if Medicare and Medicaid are the sole cause of our healthcare problems.

I don’t neccessarily agree with your characterization of the AMA. I was merely reminding everyone where the problem originated, deflecting some of the scapegoating from the poor that I read elsewhere on a daily basis. I’m sure that many members of the AMA genuinely care about medicine and the people they care for. I don’t think that I would change licensing for qualifying physicians just to save a few dollars either. Insurance has done well for those that can afford it and medicine in general, despite it’s exclusions.

I feel that, unfortunately, EMTALA is necessary. I have been to the E.R. three times in my life, twice for myself and once for my daughter. The first time that I went, I had no insurance and was billed $2500 for services rendered. It took me two years to pay for the $2500 visit, and I have no outstanding debt with any healthcare providers at present because I have paid my bills in full.

My wife finally convinced me to enroll in my State’s subsidized health insurance program, three months before my emergency appendectomy. The $5500 paid by the state for a $25,000 surgery was better than the $1,000 or so that I would have paid per year for the next 25 years. I pay taxes, and I pay a premium based on income for my insurance.

If I would have paid for the cheapest individual private insurance that I could find, there would have been a 10 year lag in payment just to cover the $10,000 deductible for that surgery. Point being, everyone going to the same hospital or insured by the same company is going to make up the difference one way or another. If I were denied treatment, you would have to pay to house my wife in one of Indiana’s correctional facilities. :) (probably more expensive) Throw me in debtors prison, you get to pay for my foreclosed home. Take your pick.

What criteria do you use to determine who actually can or who intends to pay? I understand that there are a lot of people, Drs. included, that milk the system. The problem is that when you enact some arbitrary system of determining who will or won’t pay their bill ahead of treatment, you are necessarily going to throw someone like myself under the bus as well.

I know from my wife’s experiences that the mentally retarded are not always treated well in emergencies, without a saint like her to advocate for them. She can’t do it all, few of her co-workers share her dedication, and I think we need more advocacy than most of us would believe.

Doug McGuff, MD October 7, 2010 at 10:03 am

Andy,

The points you make are a little disconnected, but I will address them one at a time.

1. Saying that it is “unrealistic” to expect pay at delivery to occur anytime soon (basically that it is politically inexpedient) doesn’t change the fact of what is the solution to this problem. Let me be clear, I am NOT aiming criticism at the poor, rather I am aiming my criticism at those who grab power in the guise of helping the poor. Finally, Medicare and Medicaid IS the cause of our healthcare problems. When the cost to the recipient is zero, demand is infinite. Government then steps in with price controls and either shortages or cost-shifting have to occur. What you have experienced (your $2,500 ER visit, or $25K surgery is cost-shifting). What will happen when Obamacare prevents cost-shifting will be the occurence of shortages.

2. The fact that there are people in the AMA that “genuinely care about medicine and the people they care for” does not change the fact that they greased the skids for medicine to become socialized and that their leadership desires to rub elbows with the politically powerful and to become politically powerful themselves.

3. It is funny that you use your own fiscal irresposibility as a justification of my enslavement under EMTALA. Once again the $2,500 bill would have much less if it were not for the cost-shifting that occurs as a result of Medicare/Medicaid, the collectivisation that occurs with third party payors under the current laws, and the unfunded mandates of EMTALA. In my own practice, 76% of the patients we say are “self-pay” EMTALA-mandated visits. About 1% of those patients make ANY attempt at payment (which puts you in a rare category—Thank You). Of the remaining 24%, about 85% of that total is Medicare/Medicaid. Without cost-shifting the ER would close. A final comment about this paragraph: When you elected to go uninsured, that decision backfired on you and it took you two years to pay a $2,500 bill I find myself thinking…what does this guy do when his transmission goes out? And then, after this experience, your wife had to convince you to purchase health insurance. It makes me think you should be spending more time on Dave Ramey’s or Suze Orman’s blog.

4. The fact that the cheapest individual policy would require a $10,000 deductible is related to the collectivised insurance laws that give large groups tax advantages and bargaining power that is denied to individual purchasers. The fact that if you elected such a policy you would then feel justified in doling out the money over ten years just reveals the fact that you hold some sort of contempt for those who provide your care. This development of contempt between the recipient and provider is the sine qua non of a price-controlled system. Tell me, when real rationing comes who will your wife become violent towards? If a $10,000 dollar deductible threatens you with debtor’s prison or home forclosure, I would again refer you to Dave Ramsey or Suze Orman and remind you that your fiscal irresponsibility does not justify my enslavement under EMTALA.

5. Currently, we have no criteria to determine who intends to pay. By law, we can only find out after the fact that 3/4 of those we treat are not going to pay. Only if medicine were practiced in a free market could we make such determinations. By the way, in the ER, our decision to treat any apparent emergency condition is based on the presence of an emergency, not on payor status. If you have a real emergency, urgency, or really…even a bona-fide medical condition you will not get “thrown under the bus”. What many ER’s are currently doing is performing the exam and workup. If the workup reveals that an urgent condition exists then prescriptions, work excuse etc are provided with no discussion of payment. If the workup shows a non-urgent condition, then a small co-payment (usually $25) is requested as a requirement of receiving prescriptions and work statements.

6. This final paragraph is just insulting. I am an advocate for my patients. I do what I feel is best for their welfare regardless of their ability to pay (or cooperate, or speak, or refrain from spitting, cursing, biting etc). I appreciate the work of professional patient advocates, because frankly we often don’t have the resources to reassure a mentally handicapped patient who ends up in a bed next to a cursing drunk. However, to suggest that she is an “angel” somehow implies that ER workers are ogres. Also, I have noticed that the various angels tend to visit most frequently between 9am and 4pm and that when funding dries up, they disappear altogether. As one of the ER ogres I have personally written off hundreds of thousands of dollars in charity care to residents of our area group home for the mentally disabled, as well care to the poor who I felt had legitimate medical need. The real angels IMO are my partners and other emergency physicians who each provide about $300,000/year in uncompensated care (using Medicare rates in the calculation) and are there at 3am on Christmas morning when my child is sick.

Andy October 12, 2010 at 6:11 am

Unpaid co-pays and deductibles will have THE EXACT SAME COST-SHIFTING EFFECT. Just because you buy a $5/ month policy (or whatever you can afford or are willing to pay, or insurers are economically able to offer) doesn’t mean that you are adequately covered.

Miscalculate and buy a cheap, rather than comprehensive policy, your insurance group and healthcare providers pay the cost that you are unable to pay.

Why is it politically inexpedient? First, rationing that surely will occur is already being experienced by many Americans. I wouldn’t expect much political support from those that don’t have much of a choice other than “free healthcare”.

Insurance companies only have to sell insurance policies that offer affordable premiums, not affordable healthcare. Affordable healthcare would make health insurance obsolete. I wouldn’t expect much political expediency from them or their customers in moving toward a more economically sound, “pay at delivery” healthcare system, until they find themselves in the same position as other Americans that have been priced out of the private insurance market.

Rationing has to occur one way or another. Considering the nature of healthcare, contrasted against any other market, I would expect a zealous resistance from anyone affected by the slightest changes. Convincing consumers that healthcare should be rationed the same, as say, the automobile market, WILL be an uphill battle.

I used my own experience to illustrate the cost-shifting effect that could have been, comparing privatized and public insurance. It’s not much different. I simply do not have $10 k to pay for anything at this point.

The choice to be uninsured was a good economic decision, at the time. It is a choice that millions of healthy 20 and 30 somethings make with little forethought given to future medical needs, and even less thought for those that need medical care before them.

I could afford my own medical expenses, because I had few. Not everyone is as fortunate as I am. The total cost of my decision not to insure was not realized by anyone, including but not limited to myself, until I was 39 and had an unexpected emergency surgery. That is the private market. You can choose to participate or not.

“The fact that if you elected such a policy you would then feel justified in doling out the money over ten years just reveals the fact that you hold some sort of contempt for those who provide your care”.

I don’t hold contempt for healthcare providers. I don’t feel “justified”, but I simply do not have $10K to spend on a medical bill. How do you justify paying (if you can) a $4500 premium with a $10,000 deductible? Who wouldn’t rather gamble?

I was able to send $1000/yr. For 2.5K bill. Same process would take 10 years to repay $10k, assuming the transmission didn’t fall out of my car. :) I don’t have a problem with paying, just illustrating that our actions affect many around us. The 25 year old boy that I was didn’t understand his obligation to society, the forty year old man that I am does.

The last time that I had a major car repair (since you asked), my mortgage was paid half a month late. Took 2 months to get back on track, waiting for the next financial event. I paid $100 for a starter that I installed myself. I don’t go to mechanics, my costs are time and parts whenever my car breaks down.

“In the US things are no different than they are in Canada because we are under a Federal mandate called “EMTALA” which forces us to see everyone regardless of ability (or intention) to pay”.

“…based on the presence of an emergency, not on payor status”.

“What many ER’s are currently doing is performing the exam and workup. If the workup reveals that an urgent condition exists then prescriptions, work excuse etc are provided with no discussion of payment. If the workup shows a non-urgent condition, then a small co-payment (usually $25) is requested as a requirement of receiving prescriptions and work statements”.

I’m not sure that I understand your dislike for EMTALA. What would be done differently without?

Your first response was in regard to intention or ability to pay, then all of your subsequent responses have been about defending yourself against an allegation that I have never made. If you can quote anywhere that I have said any of Latesha’s clients were denied treatment because of payment status, please let me know.

Like I have said before, excluding all of the positive experiences that I have had and most of Latesha’s clients have had, more advocacy is needed than we would like to believe. I support EMTALA for that reason alone.

You wouldn’t like it if I refused to deliver a pizza to your house because you don’t tip, or because you are black or gay or fat. I don’t have that option because I am beholden to an employer that would fire me long before any lawsuit. Why are you different from me? I’m still not clear on who you think should be refused access to E.R. services.

Andy October 12, 2010 at 6:38 am

“What many ER’s are currently doing is performing the exam and workup. If the workup reveals that an urgent condition exists then prescriptions, work excuse etc are provided with no discussion of payment. If the workup shows a non-urgent condition, then a small co-payment (usually $25) is requested as a requirement of receiving prescriptions and work statements”.

If this practice of “exam and workup” continues as you describe, how will you reduce cost without doing one of the following: Refuse treatment BEFORE payment, aggressive and costly collection practices after treatment, legally require health coverage for everyone (voluntary doesn’t seem to be working), refuse treatment to uninsured (assuming free market absent EMTALA), rely on people to start paying all of their obligations without fail as they should.

You have mentioned medicare and medicaid as the culprits: “Finally, Medicare and Medicaid IS the cause of our healthcare problems”. I think that they both contribute more to the system financially than the uninsured and the underinsured that have emergencies and are unable to pay their portion of the bill. They are PART of the problem, not THE problem.

Colorado springs Foreclosures April 20, 2011 at 6:54 am

Someone FINALLY said it!!!! Another odd assumption would be that poor people without money for healthcare should be more concerned with time rationing than the people advocating for price rationing in healthcare. LOL.

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