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Considerations On Cost Disease | Slate Star Codex
[via: https://meaningness.com/metablog/post-apocalyptic-health-care ]

"IV.

I mentioned politics briefly above, but they probably deserve more space here. Libertarian-minded people keep talking about how there’s too much red tape and the economy is being throttled. And less libertarian-minded people keep interpreting it as not caring about the poor, or not understanding that government has an important role in a civilized society, or as a “dog whistle” for racism, or whatever. I don’t know why more people don’t just come out and say “LOOK, REALLY OUR MAIN PROBLEM IS THAT ALL THE MOST IMPORTANT THINGS COST TEN TIMES AS MUCH AS THEY USED TO FOR NO REASON, PLUS THEY SEEM TO BE GOING DOWN IN QUALITY, AND NOBODY KNOWS WHY, AND WE’RE MOSTLY JUST DESPERATELY FLAILING AROUND LOOKING FOR SOLUTIONS HERE.” State that clearly, and a lot of political debates take on a different light.

For example: some people promote free universal college education, remembering a time when it was easy for middle class people to afford college if they wanted it. Other people oppose the policy, remembering a time when people didn’t depend on government handouts. Both are true! My uncle paid for his tuition at a really good college just by working a pretty easy summer job – not so hard when college cost a tenth of what it did now. The modern conflict between opponents and proponents of free college education is over how to distribute our losses. In the old days, we could combine low taxes with widely available education. Now we can’t, and we have to argue about which value to sacrifice.

Or: some people get upset about teachers’ unions, saying they must be sucking the “dynamism” out of education because of increasing costs. Others people fiercely defend them, saying teachers are underpaid and overworked. Once again, in the context of cost disease, both are obviously true. The taxpayers are just trying to protect their right to get education as cheaply as they used to. The teachers are trying to protect their right to make as much money as they used to. The conflict between the taxpayers and the teachers’ unions is about how to distribute losses; somebody is going to have to be worse off than they were a generation ago, so who should it be?

And the same is true to greater or lesser degrees in the various debates over health care, public housing, et cetera.

Imagine if tomorrow, the price of water dectupled. Suddenly people have to choose between drinking and washing dishes. Activists argue that taking a shower is a basic human right, and grumpy talk show hosts point out that in their day, parents taught their children not to waste water. A coalition promotes laws ensuring government-subsidized free water for poor families; a Fox News investigative report shows that some people receiving water on the government dime are taking long luxurious showers. Everyone gets really angry and there’s lots of talk about basic compassion and personal responsibility and whatever but all of this is secondary to why does water costs ten times what it used to?

I think this is the basic intuition behind so many people, even those who genuinely want to help the poor, are afraid of “tax and spend” policies. In the context of cost disease, these look like industries constantly doubling, tripling, or dectupling their price, and the government saying “Okay, fine,” and increasing taxes however much it costs to pay for whatever they’re demanding now.

If we give everyone free college education, that solves a big social problem. It also locks in a price which is ten times too high for no reason. This isn’t fair to the government, which has to pay ten times more than it should. It’s not fair to the poor people, who have to face the stigma of accepting handouts for something they could easily have afforded themselves if it was at its proper price. And it’s not fair to future generations if colleges take this opportunity to increase the cost by twenty times, and then our children have to subsidize that.

I’m not sure how many people currently opposed to paying for free health care, or free college, or whatever, would be happy to pay for health care that cost less, that was less wasteful and more efficient, and whose price we expected to go down rather than up with every passing year. I expect it would be a lot.

And if it isn’t, who cares? The people who want to help the poor have enough political capital to spend eg $500 billion on Medicaid; if that were to go ten times further, then everyone could get the health care they need without any more political action needed. If some government program found a way to give poor people good health insurance for a few hundred dollars a year, college tuition for about a thousand, and housing for only two-thirds what it costs now, that would be the greatest anti-poverty advance in history. That program is called “having things be as efficient as they were a few decades ago”.

V.

In 1930, economist John Maynard Keynes predicted that his grandchildrens’ generation would have a 15 hour work week. At the time, it made sense. GDP was rising so quickly that anyone who could draw a line on a graph could tell that our generation would be four or five times richer than his. And the average middle-class person in his generation felt like they were doing pretty well and had most of what they needed. Why wouldn’t they decide to take some time off and settle for a lifestyle merely twice as luxurious as Keynes’ own?

Keynes was sort of right. GDP per capita is 4-5x greater today than in his time. Yet we still work forty hour weeks, and some large-but-inconsistently-reported percent of Americans (76? 55? 47?) still live paycheck to paycheck.

And yes, part of this is because inequality is increasing and most of the gains are going to the rich. But this alone wouldn’t be a disaster; we’d get to Keynes’ utopia a little slower than we might otherwise, but eventually we’d get there. Most gains going to the rich means at least some gains are going to the poor. And at least there’s a lot of mainstream awareness of the problem.

I’m more worried about the part where the cost of basic human needs goes up faster than wages do. Even if you’re making twice as much money, if your health care and education and so on cost ten times as much, you’re going to start falling behind. Right now the standard of living isn’t just stagnant, it’s at risk of declining, and a lot of that is student loans and health insurance costs and so on.

What’s happening? I don’t know and I find it really scary."
scottalexander  economics  education  history  politics  policy  prices  inflation  highered  highereducation  colleges  universities  bureaucracy  costdisease  healthcare  spending  us  government  medicine  lifeexpectancy  salaries  teachers  teaching  schools  regulation  tylercowen  poverty  inequality  litigation  litigiousness  labor  housing  rent  homes  subways  transportation  health 
january 2018 by robertogreco
Post-apocalyptic life in American health care | Meaningness
"TL;DR:

• Much of my time for the past year has been spent navigating the medical maze on behalf of my mother, who has dementia.

• I observe that American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.

• Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies.

• Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.

• For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.

Epistemic status: impressionistic blogging during a dazed lull between an oncologist and an MRI. No attempt to validate with statistical data or knowledgeable sources."



"It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

What do you do when systematicity breaks down? You revert to what I’ve described as the “communal mode” or “choiceless mode.” That is, “pre-modern,” or “traditional” ways of being.

Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” Or, “The pathology report on this biopsy is only one sentence, and it’s unsigned. The hospital that faxed it to me doesn’t know who did it. I need details, so I called all the pathologists I know, and none of them admit to writing it, so we are going to need to do a new biopsy.”

But at the same time, each clinic does have an electronic patient records management system, which does work some of the time. And there are professional relationships with defined roles that operate effectively within the building.

I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.

A central research topic in ethnomethodology is the relationship between formal rationality (such as an insurance company’s 1600 pages of unworkable rules) and “mere reasonableness,” which is what people mostly use to get a job done. The disjunction between electronic patient records and calling around town to try to find out who wrote a biopsy report that arrived by fax seems sufficiently extreme that it may produce a qualitatively new way of being.

I would like to ask:

• How does health care continue to function at all?

• Can it continue to function at all?

• How do people within the ex-system navigate a world that mashes up high-tech infrastructure that only sometimes works with pre-modern social relationships across organizations?

• How do they understand this contrast? How do they cope personally?1

• What can we do about it?"



"Perhaps American health care is a bellwether model for the future of other aspects of life in post-systemic world? A pattern that occurs in many other sectors: as systems fail, people fall back on innate communal logic. Politics and the media are obvious current examples."
us  healthcare  systems  2017  medicine  davidchapman  medicalcostdisease  costdisease  economics  bureaucracy  communication  politics  absurdity  media 
january 2018 by robertogreco

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