Health Care systems

[Keevan_Colton]

Tharkun, reading through all your posts basically your position on those that fall through the net or end up bankrupt under the US system is this:

It's their own fault for living the way they do.

I cannot grasp the US mentality of linking someones survival to their economic worth, could someone please try and justify this in a way someone who is not completely morally bankrupt can understand?

[tharkûn]

The notion of trying to "correct" for factors which are a direct consequence of the very nature of a for-profit health-care system is pure sophistry of the highest order.

How is the American obesity rate a direct consequence of the for-profit health-care system? People on Medicaid, a completely socialized health benifit, show HIGHER rates of obesity than those off of it. How is the health care system responsible for maternal drug use, and again why does this problem appear to be worse for medicaid recipients than the general population? There ARE confounding factors - diabetes, obesity, drug use (particularly low quality), alcoholism, higher rates of hypertension ... all them are mashed into mortality statistics.

The fact of the matter is when the US Census Burea broke down the excess death rate of Americans vs Canadians you know what lead it? Circulatory disease (132.4), injuries (12.4), homicide (5., and diabetes (2.. Of those for circulatory disease is more than 6 TIMES larger than the rest combined. So first note what DIDN'T show up there - cancer, respriratory disease, or even basic infections. Of the diseases and medical conditions least confounded with obesity, none were shown to have an impact on relative mortality. The class of diseases best correlated with obesity, oh yes it accounts for the supermajorative amount of higher US mortality. Somehow I'm inclined to beleive that the minority of homicides and injuries wouldn't have ended up in a body bag if only they had been in Canada.

What makes articles like the one I cited earlier even more compelling is that if Americans are having more circulatory disease AND are more likely to survive treatment, then most likely it is not treatment causing the death differential - rather the fact that far, far more Americans are obese lard asses is most likely to cause it.

I'm pulling my numbers from the National Census Bureau (NESTV 98) who in turned used the National Center for Health Statistics and Stastics Canada. Who exactly are you pulling your numbers from when saying that a standard stastical technique employed by professional scientiests and peer reviewed journals is bunk?

t only is the American propensity for lower classes to avoid medical care a direct result of the type of system you use (hence not a factor which should be "corrected" out), but Canada has numerous serious disadvantages which are normally ignored.

Who the frik said anything about ignoring their propensity to avoid medical care? I'm talking about little things like the propensity of the mother to drink, smoke, or use hard drugs while pregnant. I'm talking about propensity of the mother to use dirtied clothes, hands of utensiles when caring for the baby and having higher rates of infection. I'm talking about the higher rates of obesity which in turn lead to higher rates of premature birth. But what the hell, let's throw the American Journal of Obsterics and Gynecology out the frikken window, the ONLY significant factor to compare in disparate infant mortality is wether or not you have socialized medicine

Yes the American system likely is a significant factor in higher infant mortality, particularly in the gap. However it does NOT account for the sum total of the disparity.

The cold weather and snow shoveling alone have been attributed as causes to countless heart attacks and injuries every year, particularly along the elderly. The great isolation of small communities due to our low population density means that many people literally need plane or helicopter rides to get to a hospital.

Okay so what are the numbers?

So as the WSJ says, you win some and you lose some. That sounds like a tossup until you remember that Canadians are not routinely bankrupted by medical care. Not to mention the steady stream of televised pleas for charity to help some poor family's kid pay for surgery that you see on American TV; a lovely American cultural fixture which is completely alien to Canada.

If it is a toss up then we need to look at the basic interplay between the two. What does the Canadian health system contribute to US health? Treating Americans across the border ... and anything else I forgot? What does the US system contribute to Canadian health? Excess capacity for certain surgeries, quicker introduction of medical devices, drugs, and procedures to the Canadian market, and gratuitious R&D funding. The current Canadian healthcare system derives significant benifit from the US health care system, far more in fact than Europe does. So if all else is equal and the US system is paying off the research, development, and scale up of new technologies that enter the Canadian market and save Canadian lives ... which is intrinsicly better?

Oh puh-lease, does it occur to you that healthy people don't ever need to go to the hospital in the first place, thus having no effect on patient outcomes?

No. A certain percentage of heart attacks, for example, have no associated risk factors - not obese, low cholesterol, doesn't smoke, drinks responsibly, etc. Further this isn't the black/white fallacy you are putting forward. If you have two patients, both with genetic predisposition to heart attacks, one is obese and the other isn't, and both have heart attacks ... the obese one is still more likely to die. Plenty of unhealthy people aren't lack further risk factors, a higher incidence of risk factors like obesity leads to stasticly lower expectations for patient outcome. Hell Mike the heart article I provided showed a very nice example of the proper use of the methodology and had hard numbers showing that it DOES matter.

Of course longer waiting periods can have adverse health effects, but wait times are prioritized based on medical need in Canada, not financial factors as in the US. More importantly, outright avoidance of medical care due to financial limitations has even worse health effects, doesn't it? Of course, this is a factor which you dishonestly try to ignore because you think it's somehow irrelevant and should be "corrected" out.

I quoted from a Canadian source about an "elective" procedure under your system. Longer waiting times for "elective" procedures correlated with adverse patient outcomes.

Avoiding medical care has its own problems. I acknowledge that there are problems in the current system, hell I call for a drastic overhaul. You seem immune to the evidence that there are problems in the Canadian healthcare system even when Canadian doctors in peer reviewed journals point them out and evidence them with hard numbers.

Ah yes, better to have excess capacity which is not used even though people are out there who are literally begging for it on TV because they don't make enough money.

Changing the goalpost. First you made the statement that " that only a grossly inefficient healthcare system would not have any wait times, because no wait times mean under-utilized facilities." When pointed out that having buffer capacity is no more inefficient than having farmers over produce food you decide to go the pathos route and appeal to ancedote. How many such people beg on television? The answer is almost none, virtually anyone who can afford to place a television ad can afford to get treatment. Most "begging" is for large foundations, i.e. march of dimes, which seek to reduce the costs, improve R&D, or otherwise amielorate the downsides of medical illness.

The truth is having some buffer capacity is a good thing. The truth is anyone who wants to can liquidate their assets and income and get on Medicaid. The gap is because there are people who can't afford insurance, are too wealthy for medicaid, and are unwilling to purposefully improvish themselves. This is a legitimate criticism, one I AGREE with. One I have already stated my perfermed method for solving. The only difference between you and I on this issue is that you advocate tossing the entire US system for monopsony of some type and I opt for restructuring existing programs.

Tharkun, reading through all your posts basically your position on those that fall through the net or end up bankrupt under the US system is this:

It's their own fault for living the way they do.

Then you need to work on reading comprehension. My position is that the gap is immoral, unethical, and needs to be fixed. People in the gap are making stupid decisions, such as delaying medical treatment until symptoms are gross and debilitating, that end up costing them in the long run. However people in the gap are the ones who are WORKING and trying to better their lives. It is a banality of US healthcare the majority of public healthcare is spent on the richest segment of the population, I would institute means testing in Medicare so the funding would be avalible to extend a scaled medicaid benifit to cover those in the gap.

In real politik terms socialized medicine is DOA in the US, a far more realistic goal would be reforming current systems as I propose or several other options floating around (like dicking with tax credits for the working poor's health insurance). Saying that socialization is the ONLY recourse is not only intellectually dishonest, it is also politicly irrelevent. For those us who would like to effect change that means finding a way to help these people that:
a. the Republican party won't kill.
b. the Democratic party can't kill.
c. isn't going to bring about voter backlash.

I don't think those who fall in the gap are necessarily their of their own fault. Nor do I think the status quo does them justice. I just think that socialized medicine comes with costs - all monopsonies do - and that in terms of seeing a real change in their situation ... socialized medicine is DOA in congress.

As far as the bankruptcies. Mike's article showed that the average medical debt is 12,000. Now you and I both know that there are individuals who have hundreds of thousands of dollars in medical bills so the median debt is far lower. Medical costs alone are not enough to cause insolvency in all the bankruptcies being filed. A good number of bankruptcies in the US are "caused" by medical bills, but are only possible because the individual is already carrying a high debt load.

Besides what is bankrupcy for? The American system is premised off the idea that some individuals will be hit by circumstances beyond their control and they should not be behind the eightball for the rest of their lives. Bankruptcy itself is a social policy designed to alleviate the burden imposed by medical difficulty; when it happens society picks up the tab for the individual. If you are not aware, American bankruptcy laws are far, far more lenient than their European counterparts, in some cases medical bankruptcy is simply working as designed. People who have some unforeseen trouble - like a farmer and hailstorm or worker and a heart attack - and cannot meet their creditors demands; so society nullifies their debts in part or in whole and they can start fresh on life. The penalties are higher premiums for debt service in the future (mortages, car loans, etc.) and the inability to declare bankruptcy again for several years.

Despite the convienent strawmen of all opponents of socialized medicine beign uncaring and callous misers, the truth is there are many people who see the costs of monopsony. I see them and know them well. Further I see the political landscape for what is and would far rather advocate a change that has a hope in hell of being implemented. Ultimately I'm a utilitarian and that means saving the most lives, which advocating for socialized medicine in the US simply isn't going to accomplish.

[Darth Wong]

How is the American obesity rate a direct consequence of the for-profit health-care system? People on Medicaid, a completely socialized health benifit, show HIGHER rates of obesity than those off of it. How is the health care system responsible for maternal drug use, and again why does this problem appear to be worse for medicaid recipients than the general population? There ARE confounding factors - diabetes, obesity, drug use (particularly low quality), alcoholism, higher rates of hypertension ... all them are mashed into mortality statistics.

So? How do you separate all social factors from a discussion of social systems? One of the great things about a safety net is that it changes the level of security that people have, which in turn tends to reduce certain kinds of self-destructive behaviour. The American health-care is a "safety net" that requires you to be impoverished before it will catch you, which is a hell of a choice.

The fact of the matter is when the US Census Burea broke down the excess death rate of Americans vs Canadians you know what lead it? Circulatory disease (132.4), injuries (12.4), homicide (5.Cool, and diabetes (2.Cool. Of those for circulatory disease is more than 6 TIMES larger than the rest combined. So first note what DIDN'T show up there - cancer, respriratory disease, or even basic infections. Of the diseases and medical conditions least confounded with obesity, none were shown to have an impact on relative mortality. The class of diseases best correlated with obesity, oh yes it accounts for the supermajorative amount of higher US mortality. Somehow I'm inclined to beleive that the minority of homicides and injuries wouldn't have ended up in a body bag if only they had been in Canada.

And how about the following quote from the Heart and Stroke Foundation of Canada?

Research also shows that the number of acute heart problems increase when there’s a significant dip in the outdoor temperature or when there’s a swing to extreme atmospheric pressure. One study found that a 10-degree drop in temperature translates into a 38 percent increased risk of a recurrent heart attack.

Nice of you to simply ignore the effect of cold weather and dismiss it as insignificant without bothering to look it up at all. Yes, if we were as fat as you Americans, we would be dropping like flies. But don't pretend that Canada does not have its own health-care handicaps to overcome.

What makes articles like the one I cited earlier even more compelling is that if Americans are having more circulatory disease AND are more likely to survive treatment, then most likely it is not treatment causing the death differential - rather the fact that far, far more Americans are obese lard asses is most likely to cause it.

I'm pulling my numbers from the National Census Bureau (NESTV 9Cool who in turned used the National Center for Health Statistics and Stastics Canada. Who exactly are you pulling your numbers from when saying that a standard stastical technique employed by professional scientiests and peer reviewed journals is bunk?

Since when is this "standard statistical technique" based on ignoring handicaps for one side while trumpeting them for the other?

Yes the American system likely is a significant factor in higher infant mortality, particularly in the gap. However it does NOT account for the sum total of the disparity.

It doesn't have to be 100% of the cause for my point to be valid, so stop being an evasive fucktard. Low-income patients just don't get good care; this is not a secret. And things like expensive co-pays and deductibles only encourages people to avoid using medical care unless they have self-diagnosed it to be serious; what do you not understand about this?

If it is a toss up then we need to look at the basic interplay between the two. What does the Canadian health system contribute to US health? Treating Americans across the border ... and anything else I forgot? What does the US system contribute to Canadian health? Excess capacity for certain surgeries, quicker introduction of medical devices, drugs, and procedures to the Canadian market, and gratuitious R&D funding. The current Canadian healthcare system derives significant benifit from the US health care system, far more in fact than Europe does. So if all else is equal and the US system is paying off the research, development, and scale up of new technologies that enter the Canadian market and save Canadian lives ... which is intrinsicly better?

Given the difference in spending between 10% of GDP and 14% of GDP (4% of America's $11 trillion GDP being well over $400 billion), you could have a Canadian-style socialized system and still have over $400 billion left over to pay for all of that shit, which would be more than enough. Hell, it's bigger than your entire federal military budget. You can only carry this "we spend more money so none of your arguments count" argument so far; is the R&D and extra test facilities costing $400 billion per year? If one is going to defend the proposition (made earlier in this thread) that private systems are intrinsically more efficient, one will have to do better than that.

No. A certain percentage of heart attacks, for example, have no associated risk factors - not obese, low cholesterol, doesn't smoke, drinks responsibly, etc. Further this isn't the black/white fallacy you are putting forward. If you have two patients, both with genetic predisposition to heart attacks, one is obese and the other isn't, and both have heart attacks ... the obese one is still more likely to die. Plenty of unhealthy people aren't lack further risk factors, a higher incidence of risk factors like obesity leads to stasticly lower expectations for patient outcome. Hell Mike the heart article I provided showed a very nice example of the proper use of the methodology and had hard numbers showing that it DOES matter.

See above. You scoff at the cold weather but it's a significant factor whether you admit it or not.

I quoted from a Canadian source about an "elective" procedure under your system. Longer waiting times for "elective" procedures correlated with adverse patient outcomes.

Avoiding medical care has its own problems. I acknowledge that there are problems in the current system, hell I call for a drastic overhaul. You seem immune to the evidence that there are problems in the Canadian healthcare system even when Canadian doctors in peer reviewed journals point them out and evidence them with hard numbers.

Since when did I deny that there are any problems, fucktard? I only said that it's better than the "fuck 'em if they're in the wrong class" attitude of the American system is inferior, and it is. Despite its problems, there is no compelling evidence that American patients do better overall, despite the enormous cost of their system. You can throw up smokescreen after smokescreen to evade this fact and blame victims of your system for not being able to get $12k unsecured loans or manage their finances better, but the fact remains that the American system victimizes far more people than the Canadian system.

<snip the "what can we sell to the public" argument>

Red-herring to the question of "Which is more beneficial and which costs more in the long run?" which just so happens to be the subject of this thread.

[tharkûn]

So? How do you separate all social factors from a discussion of social systems?

Large data set and a healthy bit of statistical manipulation. The same techniques the life insurance companies use to accurately forecast average outcomes can be used to seperate out various societal factors. The problem is all the good data I've seen is under a NDA.

One of the great things about a safety net is that it changes the level of security that people have, which in turn tends to reduce certain kinds of self-destructive behaviour. The American health-care is a "safety net" that requires you to be impoverished before it will catch you, which is a hell of a choice.

And I agree. I would like to see an increase in Medicaid so that it slowly scales away to nothing. At some point Medicaid pays 100%, at 10% higher income, the benifit only covers 95% of your premium ... that should provide a better safety net and abolish the current banality of the worst off people being those who are poor and working hard to do better.

Nice of you to simply ignore the effect of cold weather and dismiss it as insignificant without bothering to look it up at all. Yes, if we were as fat as you Americans, we would be dropping like flies. But don't pretend that Canada does not have its own health-care handicaps to overcome.

Because there are downsides to hot weather as well. Johns Hopkins did a metastudy on this in 2002 and found that deviations from optimum (about 21 degrees) in either direction resulted in increased mortality risk. Heat waves, longer mosquito seasons, dehydration, sun stroke, etc. all make living in the heat unhealthy as well. By their figures, which were unfortunately confined to the metropolitan US seaboard, a 33 degree day looks roughly equivalent in mortality risk to a minus 20 degree day. To date I have not seen any conclusive data showing that the Canadian climate is more unheathful on average than the US climate. It is possible that snow shoveling is statisticly equivalent to heat waves, but to date I haven't been shown data averaging them out.

Obesity, given all the data I've looked at, seems to be the biggest disparate factor between the two countries.

Since when is this "standard statistical technique" based on ignoring handicaps for one side while trumpeting them for the other?

One doesn't. If we include snow shoveling, then we include heatwaves and to date my understanding is that it happens to be a wash. If you have data showing that the Canadian climate is more unhealthy than the American climate, I'm all ears. I have seen no data showing a compelling case that Canada has a more unhealthy climate.

Low-income patients just don't get good care; this is not a secret. And things like expensive co-pays and deductibles only encourages people to avoid using medical care unless they have self-diagnosed it to be serious; what do you not understand about this?

"Expensive copays" exist in order to affect patient choice. On drugs they are almost solely to switch a patient to cheaper generics, and are a bloody effective tool for saving money without compromising care. For doctors and specialists they exist to provide a disincentive for overuse; if the patient pays nothing then why shouldn't they be selfish and utilize all availible medical resources without a care for cost effectiveness? Yes it would be better all around if everyone understood that their cost ineffective use of the medical system had real tangible impacts, but the system is too large for the average citizen to care. So you have to take some type of control measure; be it copays, restricted referral like our Australian friend talks about, or direct rationing.

Obviously not all copays were created equal and some are not good medicine, but others most certainly are.

It doesn't have to be 100% of the cause for my point to be valid

No for your point to be valid the harm suffered by having a market orientated healthcare system must be greater than the harm suffered by having a monopsony orientated healthcare system. Delaying the development of lifesaving drugs and treatments appears to be more harmful than the inequity of a sensible market orientated system (which the US is not).

Hell, it's bigger than your entire federal military budget. You can only carry this "we spend more money so none of your arguments count" argument so far; is the R&D and extra test facilities costing $400 billion per year?

In 2003 my industry figures show around 180 billion in non drug commercial "R&D", around 20 odd billion for drugs, and around 25 billion coming out of the NIH. That of course ignores capital expenditures like building new facilities as well as basic research; likewise the capitalization costs for producing new techology (like the dedicated Silicon MEMS foundry coming online in Ohio) are ignored as basic research tends to be classified outside of medicine and capitalization costs are not collectively reported. Likewise the overhead R&D costs, like paperwork, finance, management, etc. are excluded as well - the human resources costs of R&D tend to get lumped into overall management.

The NSF, FDA, NIST, DOD, NASA, HHS, etc. funds are largely excluded from the above figures.

I would take those numbers with a hefty grain of salt as companies routinely use byzantine principles for accounting and classification, particulary if stock or another round of venture capital is trading hands, but 200 billion is not out of line for all the direct medical research. All of the upstream suppliers R&D could theoreticly be factored in for a sizeable increase but they don't break theirs down by sector. The requisite R&D infrastructure - schools, tight tolerance machining, high end magnets, etc. is well over a trillion dollars.


In any event I have to question your definition of efficiency. It is not just the spending you do on R&D that counts, it is the revenue you have in new medical technology as well. The pace of research minus a viable market drops to lethargic rates; actually buying the new products rolling out of ISSYS, Medtronics, etc. needs to be included as well. If you don't spend money on the product, even when per unit cost is terrible, as well as the research you will never get new technology introduced into society cost effectively.

See above. You scoff at the cold weather but it's a significant factor whether you admit it or not.

No I'm making the tenious assumption that dehydration related medical problems, heat stroke, sun stroke, etc. offset the problems of colder weather. Given that 90% of your population lives right on the US border, exactly how many degrees colder is the average Canadian than the average American in the winter? Conversely how much cooler is she than the average American in the summer? I cannot find the numbers to declare climate to be a complete wash, but what data I've seen looks that way.

I don't scoff at cold weather, I've been through Marquette winters which are further north than Toronto and get lake effect snow off the largest friggen lake in the world. What I doubt is that all the snow, ice, and cold weather in Canada is all that worse than the ice, snow and cold weather in Detroit, Buffalo, the twin cities, Boston, etc. or the heat waves, high humidity, and sun stroke of Phoenix, Dallas, Houston, Miami, LA, San Diego, etc.

Tell me what is the per capita difference in mortality between BC and say Alberta?

Despite its problems, there is no compelling evidence that American patients do better overall, despite the enormous cost of their system. You can throw up smokescreen after smokescreen to evade this fact and blame victims of your system for not being able to get $12k unsecured loans or manage their finances better, but the fact remains that the American system victimizes far more people than the Canadian system.

Are you honestly suggesting that Canadians as as baseline unhealthy as Americans? That one of your own doctors I cited was wrong in showing roughly 15% worse overall health through hard data? In a normalized world all one would need to do is look at life-expectancy. The US has crap to show for it. In the real world one needs to include obesity - say goodbye to a whole year on average. One needs to include violence - goodbye another year. And that is the bulk of the difference. So what have you come up with on the Canadian side of the border? It is colder. I counter with heatwaves are equivalent in the US and high heat/humidity is obnoxiously worse.

Red-herring to the question of "Which is more beneficial and which costs more in the long run?" which just so happens to be the subject of this thread.

Well in that case we need to look at the perpetual savings of new R&D worldwide. Front loading your R&D makes all future R&D cheaper and brings cost savings sooner and compound longer. Conservatively on a global basis that extra 400 billion the US spends is causing a couple trillion dollars in decreased costs per annum.

The real question would be just how lousy would the R&D market be in a global monopsony? Unfortunately when the US market makes up over 50% of the global health market for novel innovations it is presently impossible to look at the real costs of a totally socialized health system - to date everyone in the world is cutting costs by using or abusing the US model.

Please note NOWHERE am I argueing that the US system doesn't have gratuitious room for efficiency improvements. Tort reform, standardized paperwork, more efficient higher education capitalization, etc.

However if the choice is between monopsony and a sensible market, the sensible market wins long term.

[Broomstick]

The notion of trying to "correct" for factors which are a direct consequence of the very nature of a for-profit health-care system is pure sophistry of the highest order.

How is the American obesity rate a direct consequence of the for-profit health-care system? People on Medicaid, a completely socialized health benifit, show HIGHER rates of obesity than those off of it. How is the health care system responsible for maternal drug use, and again why does this problem appear to be worse for medicaid recipients than the general population? There ARE confounding factors - diabetes, obesity, drug use (particularly low quality), alcoholism, higher rates of hypertension ... all them are mashed into mortality statistics.

You're putting the cart before the horse.

See, in the US (for those of you who don't know or have forgotten) health insurance is almost always tied to one's employment, and it's one's employer who decides what sort and how much health insurance you have.

Therefore, if you are unable to work, you get shitty healthcare. If your health impacts your ability to get high-wage work you are also likewise fucked.

OK... drug addicts typically are employed in lower-wage jobs. This is for a variety of reasons, among them drug use fucking you up mentally, and felony convinctions making a LOT of high-paying jobs off-limits. Therefore, drug addicts frequently do not have access to health care through their jobs, are not making enough to buy it on their own, and therefore skew the statisitcs for the lower socio-economic classes.

People who are physically disabled find it almost impossible to get work, therefore they are more likely to be on Medicaid because, not being employed, they have no alteratives.. They also find it very difficult to exercise and keep in shape, thereby contributing to overweight and obesity. And therefore, again, skewing the statistics.

Hypertension? Stress is a big factor - not having enough money to pay your basic living expenses, not to mention worry over medical care you can't afford, might just possibly be a factor here, hmmm?

I'm not quite understanding this obession you have with "maternal drug use". Are you talking about illicit drugs or drugs legally prescribed by a doctor for use while a woman is pregnant? For the former, see above diatribe on why illicit drug users are on Medicaid. For the latter - well, women with chronic health problem are both more likely to be unemployed (and thus on Medicaid) and are also more likely to required prescriptions that may need to be continued even if the woman is pregnant.

One of the big flaws in the free-market approach to health care with the use of for-profit companies is the urge to make a profit - the easiest way to do that is to insure only the healthy and boot the sick off the policies. As a result, those with private insurance tend to be healthy because that's the only way you can qualify for private insurance, and those with any sort of lingering problem, be it congenital or acquired, lose their private insurance and wind up on the public program... such as it is. And to even need a "social safety net" is an acknowledgment that the "free-market" is an unworkable "solution" to the problem of paying for health care for those who need it most.

The brutal fact is that if I get sick and I am fired because I am not there to do the job I will lose my health insurance. At which point I will be sick, unemployed, and uninsured. If I have no income I can't pay my bills. If I am sick, I am generating bills above and beyond what I normally do. It's a short step from there to bankruptcy whether you care to admit it or not. In the US, a person can be forced to drain all savings, including retirement accounts, to pay medical bills. In some states, not only the affected individual but their spouse can be required to do this, which would quickly plunge a family form the upper middle class to homeless destitution. God forbid someone has an illness or injury requiring 24 nursing care - you'll never climb out of that hole.

t only is the American propensity for lower classes to avoid medical care a direct result of the type of system you use (hence not a factor which should be "corrected" out), but Canada has numerous serious disadvantages which are normally ignored.

Who the frik said anything about ignoring their propensity to avoid medical care? I'm talking about little things like the propensity of the mother to drink, smoke, or use hard drugs while pregnant.

But - what, are high quality "soft" drugs OK, then?

I swear, listening to you I get the impression every pregnant woman in the US is knocking back whiskey, sucking on lit cigars, and injecting/snorting/otherwise consuming an entire pharmacy of mild-altering substances on a daily basis.

Hard-core addicts tend to not keep jobs. Being unemployed, they don't have private health insurance and thus are on the public system, thereby skewing the statistics. But it's a hell of a leap to then conclude EVERY poor woman is a crack addict or drunk.

You can do everything "right" and one good house fire will render you and your family homeless, at which point everyone of privilege in the US will assume you're lazy, irresponsible, and don't deserve to be treated as a full human being. You can substitute hurricaine, tornado, flood or long-term job loss for "house fire" with similar results.

I'm talking about propensity of the mother to use dirtied clothes, hands of utensiles when caring for the baby and having higher rates of infection.

Or it could just be that the mother can't afford to live in anything other than public housing which is overrun with rodents, bugs, and infested with mold... which could also raise rates of infection and about which the mother can't do jack shit, really. Sure, she can keep food in containers and spray chemicals (which may or may not be safe for the family) to get rid of the bugs, but if the neighbors don't do the same in an apartment building it will do no good - the vermin will just move in from next door.

Which is why you CAN'T separate environmental factors from raw statisitics when you're discussing public health.

Ditto for diet - healthy, fresh food is more expensive and more difficult to prepare and store than ready-made low-nutrition high-calorie crap that microwaves in under 10 minutes. This has an effect whether you care to acknowledge that or not.

Yes the American system likely is a significant factor in higher infant mortality, particularly in the gap. However it does NOT account for the sum total of the disparity.

No, just a huge portion of that disparity.

I mean, get real - other countries with better infant mortality statistics ALSO have mothers who drink, smoke, and do drugs, who eat crap, who are in less than ideal health, who are subject to various infections and accidents, too. Have you looked at the smoking rates in Europe, for example? MUCH higher than the US, including among the pregnant.

What does the Canadian health system contribute to US health? Treating Americans across the border ... and anything else I forgot? What does the US system contribute to Canadian health? Excess capacity for certain surgeries, quicker introduction of medical devices, drugs, and procedures to the Canadian market, and gratuitious R&D funding. The current Canadian healthcare system derives significant benifit from the US health care system, far more in fact than Europe does. So if all else is equal and the US system is paying off the research, development, and scale up of new technologies that enter the Canadian market and save Canadian lives ... which is intrinsicly better?

Why should the US be subsidizing everyone else's healthcare system?

I mean, maybe we're doing it out of the generosity of our American spirit... naw. I don't buy it.

It doesn't make sense from a profit-motivated, pure free-market standpoint.

And you're ignoring the benefit of R&D from other countries - and believe it or not, other countires DO contribute. There was a recent breakthrough in pancreatic/islet transplants in Canada. The first heart transplant was performed in South Africa, if I recall correctly. The first hand transplant in France. And we're buying half our flu vaccine from Britain on a regular basis.

Oh puh-lease, does it occur to you that healthy people don't ever need to go to the hospital in the first place, thus having no effect on patient outcomes?

No. A certain percentage of heart attacks, for example, have no associated risk factors - not obese, low cholesterol, doesn't smoke, drinks responsibly, etc.

Right... and once you have that surprise heart attack you are more likely to be disabled, unemployed, or underemployed, lose your health insurance, and therefore drop off the "employer insured" side of the chart and re-appear on the "Medicaid/societal losers" area.

Of course longer waiting periods can have adverse health effects, but wait times are prioritized based on medical need in Canada, not financial factors as in the US.

And, it should be noted, sometimes a waiting period may have NO adverse effect on health. A simple hernia CAN wait some months to be repaired with no long term effects. Yes, it would be better to get it fixed immediately, but it's not an emergency, wait your turn.

If we have a six month waiting list for back surgery we'd probably cut down on the amount of it done in this country - MOST back ailments will resolve in a few months, or improve significantly, but impatience (and the threat of unemployment and the consequent loss of health insurance) leads to people jumping to surgery much quicker than they should, with resulting morbidity and mortality.

Unless required for your employment, a six-month delay in getting a check-up won't hurt you either. Most screening tests can be put off for a few months without adverse effect - the exceptions being people know to be at extremely high risk.

The point here is that while health care SHOULD be prioritized on the basis of what is needed when from a medical view, in the US (and quite possibly other places) those with money get to jump ahead of the line.

I quoted from a Canadian source about an "elective" procedure under your system. Longer waiting times for "elective" procedures correlated with adverse patient outcomes.

Why are you putting "elective" in quotes? Do you doubt that some procedures are, indeed, elective?

How many such people beg on television? The answer is almost none, virtually anyone who can afford to place a television ad can afford to get treatment. Most "begging" is for large foundations, i.e. march of dimes, which seek to reduce the costs, improve R&D, or otherwise amielorate the downsides of medical illness.

No, most of the begging I see is for being needing medical care for a specific person, and usually takes the form of a jar or can at a cash register and a plea for help. Every damn restaurant I go to around here where I live has at least one and usually several. Ditto for bars, grocery stores, retail stores, gas stations and even the banks.

The truth is anyone who wants to can liquidate their assets and income and get on Medicaid. The gap is because there are people who can't afford insurance, are too wealthy for medicaid, and are unwilling to purposefully improvish themselves. This is a legitimate criticism, one I AGREE with. One I have already stated my perfermed method for solving.

And what was that solution again? I might have missed that. Please, re-state it so we are all aware of this.

Also, as someone who existed for 10 years in the "too wealthy for Medicaid" range I am not certain the term "wealthy" fits - I made damn little money. I suppose I could have quit my job, gone on welfare, and thereby qualified for Medicaid... but you know, I wanted something better in life than vermin-filled public housing where any nice possessions (or even crappy possessions) I owned were free game for thieves.

Under our current system, if one child in a family with, say, four children suffered catastrophic illness/accident the whole family would require destitution before getting help for the ill/injured. This may require them to move to a less-safe living situation (thereby putting other family members at risk), reduce educational opportunities for the other children, and otherwise have significant impact on the lives of several individuals... which may put all of them at greater risk of needing medical services in the future.

On a moral and social level, this seems far from ideal.

Tharkun, reading through all your posts basically your position on those that fall through the net or end up bankrupt under the US system is this:

It's their own fault for living the way they do.

Then you need to work on reading comprehension.

Nope, I'm getting that, too. Perhaps you should reconsider how you are expressing your thoughts because that really is how you're coming across. If what people are hearing are not what you are trying to communicate it's time to reconsider how you're saying what you're saying.

[tharkûn]

You're putting the cart before the horse.

No I'm not implying any causal relationship at all. People may be more likely to do drugs because they are poor, or people who do drugs are more likely to become poor - for a confoundation analysis either situation is equivalent.

What I'm saying is that if you are going to compare stastics from one healthcare system to another you need to make sure that all other factors have been stasticly normalized out. America has more obese individuals than Canada - therefore any comparison of mortality rates MUST renormalize to account for baseline differences in obesity. Canada has colder weather and I think more snowfall - therefore any comparison of mortality rates MUST renormalize to account for baseline differences in snow and low temeparute exposure. America has more hot weather and heatwaves - therefore any comparison of mortality rates MUST renormalize to account for baseline differences in heat wave and hot weather exposure. Same thing for comparing economic groupings - the poor are more likely to be obese than the wealthy - if you randomly selected 1000 poor and 1000 wealthy you would end up with obese poor persons than obese wealthy persons. I am NOT making any claims about why this is, I am merely stating that discrepancies EXIST and that they have an impact which CANNOT be ignored.

When you are looking at the effectiveness of a process or procedure on two different populations you must normalize or control all other variables. It doesn't friggen matter if the populations are Canadians vs Americans, Rich vs Poor, Male vs Female, or Young vs Old ... you need to get rid of all the other confounding factors to get the most accurate data.

But - what, are high quality "soft" drugs OK, then?

Less likely to burn out the kidneys and cause massive complications. Note I didn't say won't burn out the kidneys I said LESS LIKELY to burn out the kidneys. There will obviously be ancedotal cases where a hard low quality drug doesn't burn out the kidneys while a soft high quality one does - I am speaking of STASTICAL RELATIONSHIPS.

I swear, listening to you I get the impression every pregnant woman in the US is knocking back whiskey, sucking on lit cigars, and injecting/snorting/otherwise consuming an entire pharmacy of mild-altering substances on a daily basis.

Because you have prejudged me and my arguements. Take 10,000 Canadian pregnant women; take 10,000 pregnant American women (both randomly selected) - which population is going to have healthier habits and lifestyles? I absolutely garuntee that it will be the Canadians in a random sample. It might be that 100 Canadian women lead particularly unhealthy lives, but the American women might tally in at 115 - obviously these women are going to have a larger and more significant impact on infant mortality than the 1,785 women who are healthier. Thus because the average American women (you know the fictious composite with 2.1 kids) is more unhealthy there will be an impact on infant mortality.

The people who most influence comparative health indicators are the marginal cases - it doesn't matter if the disparity is 10% of Canadians vs 15% of Americans, 1% vs 2% or even .0015% vs .0020% the margin is where the disparity arises and it simply cannot be ignored. When I say that the average person is unhealthier I mean (in most cases) that 50%+ of either population are equivalently healthy - and therefore don't impact relative indicies. It is the difference in the frequence distribution that matters.

Or it could just be that the mother can't afford to live in anything other than public housing which is overrun with rodents, bugs, and infested with mold... which could also raise rates of infection and about which the mother can't do jack shit, really. Sure, she can keep food in containers and spray chemicals (which may or may not be safe for the family) to get rid of the bugs, but if the neighbors don't do the same in an apartment building it will do no good - the vermin will just move in from next door.

The point is the living conditions here are not wholly dependent on health care. Hence this is a CONFOUNDING factor. Take a population of women who live in the above conditions and an otherwise equivalent population that doesn't - virtually all procedures you subject both populations to will result in worse outcomes for the disadvantaged population. That should be obvious. Now take two populations where one population has 1% of women living in the above conditions and the other has 2% living in the above conditions, ceteris parabis - the second population will still show worse outcomes irregardless of the procedure or process you put them through. Now take a population with 1% disadvantaged vs a population with 2% disadvantaged women and subject the first population to one process and the second to another - you MUST correct for the fact that there are TWO variables in play (the process and living conditions).

Now think about all the confounding factors that exist when comparing nations - smoking rates, drinking rates, religious mores (utterly huge in HIV statistics), obesity rates, single parenthood, climate, genetics, etc. When you compare two nations' healthcare systems you need to statisticly adjust the outcomes to account for the fact that populations are not equivalent. If country A has lower rate of AIDS mortality than country B it does NOT mean that country B has better AIDS infrastructure (sex ed, condom availibility, blood screening, etc.) it could just be that you are comparing a strict Islamic state (where adultery, sodomy, etc. are punishable by death) to a sexually liberated country. Asking which healthcare system produces better outcomes REQUIRES these types of corrections to answer honestly.

These types of corrections are ROUTINE and NECESSARY and the only way to do them is via statistics. In order to not spend paragraphs speaking about the population demagraphics I talk about the fictious average person. She will be the average weight and height of all her fellow citizens. She will have had the average number of sexual partners - say 5.5 and the average number of children - 2.1. When the average American is more likely to be obese than the average Canadian she might only mass a few kilos more - but that implies a large disparity in overall obesity rates. Likewise when I talk about prevelence to do drugs, etc. I am talking about a fictious composite where you average out the collective habits of MILLIONS of persons.

Ditto for diet - healthy, fresh food is more expensive and more difficult to prepare and store than ready-made low-nutrition high-calorie crap that microwaves in under 10 minutes. This has an effect whether you care to acknowledge that or not.

You know when I say you have to correct a stastic for it, that directly implies that I beleive it has an impact. If more people in the US have a poor diet than people in Canada; then all the health outcomes that effects must be corrected because that effect is real and is not normalized between the two countries.

No, just a huge portion of that disparity.

Data?

I mean, get real - other countries with better infant mortality statistics ALSO have mothers who drink, smoke, and do drugs, who eat crap, who are in less than ideal health, who are subject to various infections and accidents, too. Have you looked at the smoking rates in Europe, for example? MUCH higher than the US, including among the pregnant.

Yes they have them as well, however HOW FREQUENTLY do they crop up in the population? Europeans smoke more; Americans do dirtier drugs, exercise less, are more obese, work longer hours, test worse on stress tests, etc. These types of comparisons are not something you can trivially do by looking at only the factors that pop into your head during an internet debate. Getting good data requires extensive number crunching with difficult actuarial methods and the results tend only to be published in dry technical journals; hell getting even lousy numbers requires a visit to a peer reviewed journal. Having read through studies done for marketing purposes - where the company spent buckets of money for good data and processing - I doubt any claim you make that Americans and Canadians or Europeans have equivalent health baselines.

Why should the US be subsidizing everyone else's healthcare system?

I mean, maybe we're doing it out of the generosity of our American spirit... naw. I don't buy it.

It doesn't make sense from a profit-motivated, pure free-market standpoint.

The life cycle of a new medical drug/device:
1. Proof of concept. Somebody somewhere does some science proving that the new pill/device does something better than whatever else is on the market (cheaper, faster, or better). Sometimes this is covered by academic budgets, sometimes by private money. Some patents are filed here.
2. 1st round scale up. Somebody takes the above concept and egineers it to be produced in limited volume - say 1,000 - 10,000 units depending. A production facility is set up and you crank out some devices. Most often the money here is private. Patents are protected here.
3. Clinicals. After you have a ready supply of pills/devices you take and use them in controlled tests to better evaluate the proofs in step one as well as to weed out harmful side effects, contra-indications, etc. Many products flop at this stage. Most often the money here is private.
4. Limited production. At this point you migh re-engineer production for further scale-up or you might just start selling to the public.
5. Profit potential. Once you start making a per device profit normally an obscene amount of money changes hands and you do another round of egineering/scale up. At this point the bottom falls out of many per unit prices.
6. Mass production. At this point you are done with R&D costs and most capital costs. Your sole goal at this point is to sell your product as often for as much as you can before your IP expires and it all goes public domain. At this point, typicly international sales start in earnest.

Each step along the way all the previous costs are SUNK, so when a company goes to Europe and says hey I want to sell this and the bean counter says we will only pay X it is only the costs associated with step 6 that factor into the decision to sell or not. The American market/government pays for steps 1-5 which is where the bulk of the R&D costs lie, remember winning ideas pay for the massively more common losing ideas. If you can't pay for steps 1-5 in the US market, typicly you can't pay for them ANYWHERE and your product goes tits up.

Monopolies sell into monopsonistic markets only because the more competitive buyers market in the US will pay off the earlier costs. All told most companies make 10% profit - with a 5-20% spread typical (all numbers exlcude companies that go under). The only reason to sell to a monopsony at reduced prices is if somewhere else you have recouped all the costs associated with getting it to market. If no one pays for steps 1-5 then the product simply dies.

And you're ignoring the benefit of R&D from other countries - and believe it or not, other countires DO contribute. There was a recent breakthrough in pancreatic/islet transplants in Canada. The first heart transplant was performed in South Africa, if I recall correctly. The first hand transplant in France. And we're buying half our flu vaccine from Britain on a regular basis.

Stastics please. The first polio vaccine was made in America, as was the first open heart surgery, as was the first retroviral drug, as was the first GM production line ... an anecdotal pissing contest is meaningless.

The truth is the US market drives medical research. Take that market out of the equation and the pace of research implodes. When over 50% of the market is in the US, despite its smaller population, GDP, etc. something is causing that imbalance.

And, it should be noted, sometimes a waiting period may have NO adverse effect on health. A simple hernia CAN wait some months to be repaired with no long term effects. Yes, it would be better to get it fixed immediately, but it's not an emergency, wait your turn.

Broomstick vs British Journal of Surgery and The Lancet, hmm let's see who to beleive? The annual strangulation risk was ~1.7% (this figure is derived from a lifetime incidence and is frontloaded) oh and when you are that unlucky sod who undergoes strangulation because of waiting longer? Well the studies conflict, but 2.6-12% (12% has better stastics behind it, but is significantly older) of of those people die. Now what is a .04 - 0.2% risk of mortality worth? Well when you are doing hundreds of thousands of these operations a year you end up with hundreds of more corpses at the end of the year. Even if you manage to catch a whopping 50% of those strangulating hernias before they complete the process and upgrade the status you still are going to have hundreds of dead people for delaying the surgery.


But remember kids hernias can wait with no long term effects and no I'm not dicking over "simple" I'm using the data for inguinal hernia which affect about 40 people per 10,000 per annum; the repair thereof being one of the most common surgical procedures in the world.

This is exactly the type of BS that leads to bad medicine. Nobody gives a rat's ass about 1.7% or 2.6% - those types of risks are thought to be small and thus wiating extra months is no big deal. Of course the number of dead in the end outweighs your average airliner fatalities in year ... what does it matter - it's usually an elective surgery?

If we have a six month waiting list for back surgery we'd probably cut down on the amount of it done in this country - MOST back ailments will resolve in a few months, or improve significantly, but impatience (and the threat of unemployment and the consequent loss of health insurance) leads to people jumping to surgery much quicker than they should, with resulting morbidity and mortality.

In other words doctors aren't doing their jobs and convincing their patients that back surgery without sufficient wait is a losing bet. There is a reason we have doctors, we should have people wait in such instances not because they have no other choice, but because it is a good medical practice.

Unless required for your employment, a six-month delay in getting a check-up won't hurt you either. Most screening tests can be put off for a few months without adverse effect - the exceptions being people know to be at extremely high risk.

No most check-ups can be put off for a few months without significant adverse effect. In many cases the rate of complications may increase by 1 in 100,000 or something but there is some risk in delaying screening. Wether or not that risk is worth the cost of avoiding I leave to the ethicists and economists - it does exist.

The point here is that while health care SHOULD be prioritized on the basis of what is needed when from a medical view, in the US (and quite possibly other places) those with money get to jump ahead of the line.

Of course you do realize that the premium paid for line jumping results in greater infrastructure investments and thus shorter lines for EVERYONE, right? Theoreticly you could just increase the taxes and build more hospitals, subsidize more doctors/RNs/PAs, and increase capacity that way ... but it doesn't seem to be all that common in world medicine. Most socialized medical programs have longer waits even in the face of statisticly significant increases in patient mortality.

Why are you putting "elective" in quotes? Do you doubt that some procedures are, indeed, elective?

The specific procedure, the one the article quotes, has a significant impact on long term patient outcomes. To whit do the operation and fewer people die. I leave it to the discerning reader to wonder why I might not view that specific operation as all that "elective".

Obviously there are some procedures which are really elective, for obvious example a good many boob jobs and please quit with the ancedotal counterpoint - I acknowledge that masectomy patients can benifit from a good breast augmentation and that chronic back pain can be relieved by some breast reductions ... just that most such procedures are elective in that they don't have a significant benificial impact on patient outcome.

No, most of the begging I see is for being needing medical care for a specific person, and usually takes the form of a jar or can at a cash register and a plea for help. Every damn restaurant I go to around here where I live has at least one and usually several. Ditto for bars, grocery stores, retail stores, gas stations and even the banks.

Cite some specifics and numbers. Around here said cans are currently going towards holding a bone marrow registry which in many socialized countries simply doesn't friggen happen.

And what was that solution again? I might have missed that. Please, re-state it so we are all aware of this.

Currently Medicaid has a hard cap. Earn more than this amount, have more than this level of wealth ... no benifits for you.

My plan is to ask some very smart qualified professionals - which I am not - how much income is needed for basic subsistence. So they come back and say that it costs Q dollars to eat, drink, and sleep with a roof over your head in this town (and don't tell me about transportation, clothing, etc. all of that would be factored in as relevent). Now everyone who earns Q dollars or less - you would have full subidization of healthcare premiums (for profit, non-profit I don't give a damn). Now let's say you earn Q + 100 dollars, then your healthcare benifit would scale down - you'd have all your premiums subsidized except 50 dollars. Earn Q + 200 dollars - then watch your subsidy be cut by 100 dollars. Thus the benifit would taper to zero so that people don't face a disincentive to be productive workers and so that by the time their benifit reaches zero they can afford their own premiums AND be earning more discretionary spending money above and beyond basic subsistence levels.

How to pay for this? Well my prefered choice would be to kick the truly wealthy seniors out of Medicare and Medicaid. If they truly possess the reasonable means to pay their own medical benifits, then they should not be given a free ride while others who can't are caught in the gap. A certain amount of welfare payouts will be reduced when the working poor get better healthcare, this would be rolled in as well. Lastly I'd tap an IP tax on any monopsonistic healthcare provider outside the US who uses processes developed with US government money and doesn't pull an equivalent share of R&D costs.

There are many byzantine ways of implementing the above, such as graduating the scaledown of the benifit, tax credits, different funding sources, etc. But that is what I think a sensible gap plug would be.

Also, as someone who existed for 10 years in the "too wealthy for Medicaid" range I am not certain the term "wealthy" fits - I made damn little money. I suppose I could have quit my job, gone on welfare, and thereby qualified for Medicaid... but you know, I wanted something better in life than vermin-filled public housing where any nice possessions (or even crappy possessions) I owned were free game for thieves.

Wealth is used as economic term to differentiate from income. Wealth is your accrued net worth, income is what you take in. One can have a positive net wealth and a negative income or vice-versa. "Too wealthy" merely means that one has an accrued net worth in excess of the cutoff for Medicaid.

Under our current system, if one child in a family with, say, four children suffered catastrophic illness/accident the whole family would require destitution before getting help for the ill/injured. This may require them to move to a less-safe living situation (thereby putting other family members at risk), reduce educational opportunities for the other children, and otherwise have significant impact on the lives of several individuals... which may put all of them at greater risk of needing medical services in the future.

On a moral and social level, this seems far from ideal.

Which is why I call for drastic change.

Nope, I'm getting that, too. Perhaps you should reconsider how you are expressing your thoughts because that really is how you're coming across. If what people are hearing are not what you are trying to communicate it's time to reconsider how you're saying what you're saying.

I'm sorry I've said it multiple times in different ways and using different manners of textual emphasis. I can only assume that either you didn't read what I wrote before, did not understand what I wrote and failed to ask for clarification, or simply want to strawman my motives. My very first post states:
The current US system needs DRASTIC[emphasis in original] reform. For a start medical school and nursing school need to be ramped up to produce more human talent. For another congress needs to blackmail the insurance industry into standardizing the paperwork - one set of paperwork irregardless of who pays the bill. For a third something has to be done about the insurance gap [emphasis added], some type of subsidized insurance might be possible. Lastly I'll just say that laws and regulation need a complete and total rewrite to irradicate defensive medicine, bogus treatments/'science', and byzantine barriers to bringing new products to market.

[Darth Wong]

<snip lots of "rich vs poor" health-care arguments>

You do realize that half the point here is the fact that the American health-care system has a propensity for making you poor, right?

Broomstick vs British Journal of Surgery and The Lancet, hmm let's see who to beleive? The annual strangulation risk was ~1.7% (this figure is derived from a lifetime incidence and is frontloaded) oh and when you are that unlucky sod who undergoes strangulation because of waiting longer?

As someone who has actually had hernia surgery in Canada, you're full of shit. Not only does the Shouldice Clinic take a large number of American patients, but patients are prioritized based on medical factors such as the likelihood of strangulation, and in cases deemed serious, the waiting time can be less than 24 hours. My roommate at the Shouldice Clinic was given an appointment the day after he came in for his initial consultation because he was a serious case. I waited several months because I was in good shape, not because the system forces everyone to wait several months.

For a start medical school and nursing school need to be ramped up to produce more human talent. For another congress needs to blackmail the insurance industry into standardizing the paperwork - one set of paperwork irregardless of who pays the bill. For a third something has to be done about the insurance gap, some type of subsidized insurance might be possible. Lastly I'll just say that laws and regulation need a complete and total rewrite to irradicate defensive medicine, bogus treatments/'science', and byzantine barriers to bringing new products to market.

How would this scheme solve the problem of your health being left to insurance companies? Anyone who has experience dealing with car insurance or homeowners' insurance knows how insurance companies behave, how they punish you for actually trying to use your insurance, how they gouge you and try to fuck you with the fine print, etc. The mere fact that the health-care system works on a similar basis virtually guarantees the kind of problems we're talking about, when people who develop serious health problems get fucked over by their insurance companies and driven into bankruptcy etc.

[tharkûn]

You do realize that half the point here is the fact that the American health-care system has a propensity for making you poor, right?

Maybe that would be why I propose drastic changes to the system to alleiviate that ?

There are problems in the American healthcare system, I simply don't buy that the best or only solution is socialized healthcare.

Not only does the Shouldice Clinic take a large number of American patients, but patients are prioritized based on medical factors such as the likelihood of strangulation, and in cases deemed serious, the waiting time can be less than 24 hours. My roommate at the Shouldice Clinic was given an appointment the day after he came in for his initial consultation because he was a serious case. I waited several months because I was in good shape, not because the system forces everyone to wait several months.

The plural of anecdote is not data. I cannot find Canadian statistics but in the UK a retrospective study of stangulation patients found that 39% of patients didn't report it to their doctor, 41% had reported it to their doctor but hadn't been referred for surgery initially, and 20% were referred for surgery as an "elective" procedure. A study with worse stastics showed that a full 72% of strangulated hernia patients had waited a year or more before getting emergency surgery.

Yes you can triage patients to give the most urgently needed care first. However it is a far better outcome to have no delay. Diagnostic techniques are not perfect and the risk of strangulation is cumulative. Waiting has a very real risk even if you have compotent doctors able to perform effective triage. Despite efforts to triage patients based on risk there still are strangulations that slip through the cracks and even in unstrangulation patients there is a .05% risk of mortality, there is a small amount of evidence showing that wait time is factor even here.

The fact is Broomstick said no risks for waiting on a simple hernia. The truth is taking the most simplistic hernia (inguinal) I provided data showing that risk of complication and hence mortality goes up by waiting to repair a simple hernia. A good triage system with low enough baseline waits and good patient screening during the wait can minize the risk to acceptable levels; but there is always a risk, be it small or miniscule, that things will go tits up if you wait. Given the obscene abundence of hernias - where millions of patients have them every year - small risks kill people.

How would this scheme solve the problem of your health being left to insurance companies?

Why is that a problem? This entire debate everyone on your side of the aisle has been talking about the uninsured or the under insured because that is where the bulk of problems with the American healthcare system lies - in the gap. Do you have any data showing worse outcomes for insured Americans compared to Canadians under socialized medicine? Insured individuals have access to medical care, and American medical care, once you get access, is the best in the world.

You also do realize that non-profit healthcare exists, right? That there are insurance companies that have no profit motive in the US.

Yes I beleive there are some problems with the insurance companies, but the answer is not to abolish them, but rather to use oversight and full disclosure.

Really Mike do you have anything to offer in the way of actual numbers showing that socialized healthcare has better outcomes? Your entire debate has been to hammer on the flaws in the American system, yet you have said nothing about why socialization is inherently superior to a decent market orientated system with a sensible safety net.

[SirNitram]

Watching this debate is quite hilarious. Where is 'abolition' of insurance companies proposed? There's such things in Canada and other nations with single payer systems.

Furthermore, how are 'treating all citizens' and 'Not inducing bankruptcies' not objective advantages? Oh wait, they are...

[Darth Wong]

Maybe that would be why I propose drastic changes to the system to alleiviate that ?

Changes that won't really help because individuals will still be at the mercy of insurance companies.

There are problems in the American healthcare system, I simply don't buy that the best or only solution is socialized healthcare.

Your solution won't do shit.

The plural of anecdote is not data.

I don't need reams to data to disprove your blanket generalization, fucktard.

How would this scheme solve the problem of your health being left to insurance companies?

Why is that a problem? This entire debate everyone on your side of the aisle has been talking about the uninsured or the under insured because that is where the bulk of problems with the American healthcare system lies - in the gap.

Are you honestly this fucking stupid? Insurance companies do not want to cover everyone. Leaving this to the insurance companies will ensure that there will always be uninsured and under-insured; why the fuck do I have to spell this out?

You also do realize that non-profit healthcare exists, right? That there are insurance companies that have no profit motive in the US.

So your solution is to hope that all insurance companies will go this route? How many of these altruistic non-profit insurance companies are there?

Yes I beleive there are some problems with the insurance companies, but the answer is not to abolish them, but rather to use oversight and full disclosure.

How would that remove their incentive to get rid of expensive customers?

Really Mike do you have anything to offer in the way of actual numbers showing that socialized healthcare has better outcomes?

I don't have to, moron. I only have to show that it is not worse, hence it does not compensate for the massive social and health problems associated with your "fuck 'em if they can't pay the bills" system.

[tharkûn]

Changes that won't really help because individuals will still be at the mercy of insurance companies.

Oh yes because you proven so much hard data that being "at the mercy" of health insurance companies, particularly not-for-profit ones is bad. Bad oh I know it is private therefore it must be evil

I don't need reams to data to disprove your blanket generalization

Quit with the strawmaning. The point was that delaying hernia operations carries a risk. This backed up by scientific data and were published in peer reviewed journals. The truth is there is a risk when delaying hernia surgery, wether or not that risk is sufficiently small to be acceptable - I leave that to wiser heads.

insurance companies do not want to cover everyone.

Wrong. Not-for-profit insurance companies exist to cover everyone they can. Even in the for profit realm you cover riskier patients by upping the premium.

So your solution is to hope that all insurance companies will go this route? How many of these altruistic non-profit insurance companies are there?

All of them don't only some need to. How many are there? I'd have to go dredge up 990's, but there are easily dozens if not hundreds or thousands currently (insurance tends to be rolled into other things with many smaller non-profits).

How would that remove their incentive to get rid of expensive customers?

The fact that they could raise the premiums of expensive customers without having customers being unable to pay; right now you raise the rates to high and people fall into the gap and drop coverage. Under my plan you raise rates and the subsidization kicks in. Another fun point is that I remove a good bit of the assymetrical relationship, now if your insurance dicks you over and you are marginal - you have few alternative choices; with a scaling benifit you can switch insurance with fewer impacts.

I don't have to, moron. I only have to show that it is not worse,

And I don't have to show mine to be better, I only have to show that it isn't worse because it does not retard R&D and leave millions of individuals dead waiting for a life saving drugs or treatments to come through

Your system gives everyone the same level of care more or less; however in so doing you introduce pressures on the system that retard R&D. In the long global view, R&D saves more lives.

[Darth Wong]

Oh yes because you proven so much hard data that being "at the mercy" of health insurance companies, particularly not-for-profit ones is bad. Bad oh I know it is private therefore it must be evil

The profitability of insurance companies is a matter of public record, fucktard.

http://www.consumerwatchdog.org/healthc ... 04617.php3

Quit with the strawmaning. The point was that delaying hernia operations carries a risk.

Classifying any non-zero risk as automatically significant is idiotic and you know it. If we go by the logic that any non-zero risk requires mitigation, we are looking at gigantic increases in health-care costs everywhere, and you know it. The fact is that a normal hernia surgery is not an emergency, and doctors rather than financiers should decide whether it should be treated as one.

insurance companies do not want to cover everyone.

Wrong. Not-for-profit insurance companies exist to cover everyone they can. Even in the for profit realm you cover riskier patients by upping the premium.

Of course you cover riskier patients by "upping the premium", ie- gouging them on price so that a serious health problem not only disrupts their lives, it also destroys their finances! Yippee! And what about patients who simply can't afford to pay these increased premiums, to say nothing of people who can't afford high co-pays, deductibles, etc? "Subsidized payments" is your solution, and it is an utterly absurd one because you use it only to rhetorically avoid the eeeeeevils of "socialized medicine". Tell me, what's the difference between the government paying the hospital and the government paying the insurance company to pay the hospital? Oh yeah, a price-gouging middleman. Great idea.

Your system gives everyone the same level of care more or less; however in so doing you introduce pressures on the system that retard R&D. In the long global view, R&D saves more lives.

Can you explain precisely how the presence of a government insurer discourages R&D among private drug companies?

[Keevan_Colton]

Your system gives everyone the same level of care more or less; however in so doing you introduce pressures on the system that retard R&D. In the long global view, R&D saves more lives.

If they get treatment.



You are completely without a clue or a conscience arent you?

R&D can theoretically save more lives, if:
a) the research in question pans out and actually provides something
b) that something is actually more effective, rather than incrementally different...
and most fucking importantly c) people actually get access to the fruits of the fucking R&D you shit head.

Guess where your nice little thing falls apart...and the other two, are not true in every instance of R&D...they can potentially save people further down the line, but hanging people that can definetly be helped today out to dry for the sake of a potential future is morally bankrupt.

[tharkûn]

http://www.consumerwatchdog.org/healthc ... 04617.php3

Woop de doo. The industry made 10.2 billion dollars in 2003; total revenue in the same year was in excess of 600 billion dollars. Let's see that would be, oh yes, 1.7% profit, oh the horror Of course the fact that most of that profit is generated by "short term" investment means nothing.

Is ludicriously easy to generate flashy numbers when you do percent increases from previous years, particularly if you use atypical years like 2002-2003.

Classifying any non-zero risk as automatically significant is idiotic and you know it. If we go by the logic that any non-zero risk requires mitigation, we are looking at gigantic increases in health-care costs everywhere, and you know it. The fact is that a normal hernia surgery is not an emergency, and doctors rather than financiers should decide whether it should be treated as one.

I quoted the actual figures as reported. The truth is that delaying hernia surgery kills people; not that many per capita, but some. Even a small amount of risk adds up to dead people. It may not be cost effective to mitigate the risk to a greater level, saying it doesn't exist is a banality. I have no idea how Canada stacks up here, but certainly the UK figures showed room for cost effective change. I would note that many automobile safety mandates, let alone airline or nuclear power safety regulations, are less cost effective than reducing hernia waiting periods.

Of course you cover riskier patients by "upping the premium", ie- gouging them on price so that a serious health problem not only disrupts their lives, it also destroys their finances!

Please. Some disincentive must exist to prevent people from gaming the system. You notice that everywhere in the world there is some method of rationing healthcare, the market approach has the upshot of moving more cash into the system and driving R&D. There is no way of alleviating all suffering in the world that comes without other costs. I prefer the method which doesn't set back progress.

pee! And what about patients who simply can't afford to pay these increased premiums, to say nothing of people who can't afford high co-pays, deductibles, etc? "Subsidized payments" is your solution, and it is an utterly absurd one because you use it only to rhetorically avoid the eeeeeevils of "socialized medicine". Tell me, what's the difference between the government paying the hospital and the government paying the insurance company to pay the hospital? Oh yeah, a price-gouging middleman. Great idea.

The difference is between a monopoly and a market competition. I don't trust monopolies to control the phone market, the computer software market, or clothing market ... I sure as hell don't trust a monopoly to run the healthcare market. Competition is a good thing.

Can you explain precisely how the presence of a government insurer discourages R&D among private drug companies?

Well first I will appeal to the fact that this is observed today. Why does Canada have such low R&D investment?

Second you need to look at scale up. With a monopsony where everyone is garunteed the same benifits you either have to be cost effective enough to sell to everyone or you don't sell. When most drugs, devices, and procedures start out they aren't cost effective for the masses; but in a competitive market place niche markets exist which generate positive cash flow and provide real world vetting. When you have a single payer there tends to be pressure to "pay for it for everyone" or "pay for it for no one". Eventually most of these treatments will see sufficient cost reductions to make it to market - the question is one of how many years are willing to wait on a pitiful stream of funding to see it happen.

Another fun mechanism is monopsony leverage. If you are a monopsony you can dictate prices to some degree and leverage lower prices. Sounds good, except that when you do so you cut firms out of the market and they either withdraw, go under, or consolidate. In the long term (decades) you end up with fewer firms and the balance of power shifts, likewise prices rise due to reduced competition.

Other fun issues include disincentive for the government to protect and promote intellectual property - it costs orders of magnitude more money to get and defend intellectual property in Europe than the US. Also there is brain drain where technologists who have a bright idea go abroad to develop, market, and reap profits in the society which is most generous to their selfish motives - I know of a venture capital fund that does nothing but bring European and Asian brains to the US.

Keevan:
a. On average it does. The flops outnumber the successes, but the successes can sometimes add months to life expectancy.
b. Oh please medicine is evolutionary, not revolutionary. If a new pill came out every year that was 1% more effective at treating high cholesterol than last years it would save thousands of lives. Over a single decade millions of lives would be saved.
c. Eventually prices come down. They come down faster if somebody is buying the product commericially. Take open heart surgery, what was once limited to a handful of the most expensive hospitals in the world and only for the more privileged masses is slowly penetrating the global market. Likewise antibiotics took YEARS to make it into the backwaters of the world ... when they did MILLIONS of lives were saved. Medicine today is a dynamic field, if you have a successful treatment that only the wealthy can afford you can bet cold hard cash that somebody is doing serious research to bring down the cost barriers.

Faster R&D saves lives. More money means you can hire more brains for the research, use more extensive facilities, and sport higher risk with consumately higher reward. All of that means that the time from being rolled out at Johns Hopkins to being availible in Timbuktu goes down. That means fewer people die in the interim.

[Darth Wong]

Woop de doo. The industry made 10.2 billion dollars in 2003; total revenue in the same year was in excess of 600 billion dollars. Let's see that would be, oh yes, 1.7% profit, oh the horror Of course the fact that most of that profit is generated by "short term" investment means nothing.

How do you reconcile your rosy interpretation with the double-digit premium increases, hmm? And don't give me this song and dance about how standardized forms would eliminate excessive administrative overhead. You know perfectly well why companies eliminate huge chunks of their administrative staff after a merger.

Is ludicriously easy to generate flashy numbers when you do percent increases from previous years, particularly if you use atypical years like 2002-2003.

Oh, I see. Just label them as "atypical". The fact that no real checks and balances exist on this "atypical" behaviour isn't a problem, right?

I quoted the actual figures as reported. The truth is that delaying hernia surgery kills people; not that many per capita, but some. Even a small amount of risk adds up to dead people. It may not be cost effective to mitigate the risk to a greater level, saying it doesn't exist is a banality. I have no idea how Canada stacks up here, but certainly the UK figures showed room for cost effective change. I would note that many automobile safety mandates, let alone airline or nuclear power safety regulations, are less cost effective than reducing hernia waiting periods.

What part of "waiting periods can be as low as 24 hours if the doctor feels it's urgent" did you not understand, exactly?

Of course you cover riskier patients by "upping the premium", ie- gouging them on price so that a serious health problem not only disrupts their lives, it also destroys their finances!

Please. Some disincentive must exist to prevent people from gaming the system. You notice that everywhere in the world there is some method of rationing healthcare, the market approach has the upshot of moving more cash into the system and driving R&D. There is no way of alleviating all suffering in the world that comes without other costs. I prefer the method which doesn't set back progress.

You have yet to show that it sets back progress. You just keep stating it as a fact when it is no such thing. And this "disincentive" thing is bullshit; people do not choose get sick.

pee! And what about patients who simply can't afford to pay these increased premiums, to say nothing of people who can't afford high co-pays, deductibles, etc? "Subsidized payments" is your solution, and it is an utterly absurd one because you use it only to rhetorically avoid the eeeeeevils of "socialized medicine". Tell me, what's the difference between the government paying the hospital and the government paying the insurance company to pay the hospital? Oh yeah, a price-gouging middleman. Great idea.

The difference is between a monopoly and a market competition. I don't trust monopolies to control the phone market, the computer software market, or clothing market ... I sure as hell don't trust a monopoly to run the healthcare market. Competition is a good thing.

Did you even read what I wrote? You say that an extra middleman is a good thing because the middlemen can compete with each other. Do you not see the absurdity of that argument?

Can you explain precisely how the presence of a government insurer discourages R&D among private drug companies?

Well first I will appeal to the fact that this is observed today. Why does Canada have such low R&D investment?

Nice "post hoc" false cause fallacy. You said it yourself; we don't need to, because the Americans do plenty of R&D with their much more expensive health-care system. If we ramped up our health-care spending from 10% of GDP to 14% of GDP like the US, we could afford more R&D too, but there's no reason to do that right now.

Second you need to look at scale up. With a monopsony where everyone is garunteed the same benifits you either have to be cost effective enough to sell to everyone or you don't sell.

Bullshit. Private drug companies in Canada are not required to distribute every product they make to anyone who wants it. We buy drugs in drugstores, just like everyone else. The only difference is price controls, and if lagging R&D were a big problem, we could easily solve that with government-subsidized R&D. You already talk subsidies in your "plan", but those are subsidies to a completely unnecessary middleman. These would make much more sense.

When most drugs, devices, and procedures start out they aren't cost effective for the masses; but in a competitive market place niche markets exist which generate positive cash flow and provide real world vetting. When you have a single payer there tends to be pressure to "pay for it for everyone" or "pay for it for no one". Eventually most of these treatments will see sufficient cost reductions to make it to market - the question is one of how many years are willing to wait on a pitiful stream of funding to see it happen.

See above.

Another fun mechanism is monopsony leverage. If you are a monopsony you can dictate prices to some degree and leverage lower prices. Sounds good, except that when you do so you cut firms out of the market and they either withdraw, go under, or consolidate. In the long term (decades) you end up with fewer firms and the balance of power shifts, likewise prices rise due to reduced competition.

You think the balance of power right now is perfect? What's wrong with the balance of power shifting more toward the users of health-care and away from the providers?

Other fun issues include disincentive for the government to protect and promote intellectual property - it costs orders of magnitude more money to get and defend intellectual property in Europe than the US. Also there is brain drain where technologists who have a bright idea go abroad to develop, market, and reap profits in the society which is most generous to their selfish motives - I know of a venture capital fund that does nothing but bring European and Asian brains to the US.

So? Then they can do their research there and you reap the benefits anyway, by simply buying the drugs when they become available. The question is what benefits you are most interested in: a health-care system that is beneficial for your people or a health-care system that is beneficial for corporate shareholders.

[tharkûn]

How do you reconcile your rosy interpretation with the double-digit premium increases, hmm?

Double digit increases in healthcare consumption. For the year in question the most conservative estimate I've found was a 9.6% increase in consumption. Of course the demographic, investment, and regulatory dynamics are going to add to that. Further looking back at 2000 and 2001 we see that increases in premiums were lower than increases in cost; hence most industry analysts said 2002 was a year of "catch-up pricing". But remember kids all you need to do is show a single year in a vacuum and show large percentage increases for a single data point.

And don't give me this song and dance about how standardized forms would eliminate excessive administrative overhead. You know perfectly well why companies eliminate huge chunks of their administrative staff after a merger.

Funny when you break down the cost of overhead the obscene majority of it is paperwork; not in management. But what the hell let's not use numbers to make our points, but relay on gross generalizations.

Oh, I see. Just label them as "atypical". The fact that no real checks and balances exist on this "atypical" behaviour isn't a problem, right?

When several states change their regulation what would you call it? Likewise in both of the two preceeding years premiums rose at a rate less than costs and the year cited was widely viewed as one of catch-up pricing.

What part of "waiting periods can be as low as 24 hours if the doctor feels it's urgent" did you not understand, exactly?

The part where the doctor became omnscient and could forecast risk without error. Every country in the world pumps urgent people up to the front, even in the market orientated US an urgent patient can and does pump other patients off the operating table on short notice. The stastics I cited INCLUDE the fact that doctors were triaging patients, the only data I have where doctors don't triage patients is from Columbia and is decade old (included as a point of historical reference) and the risk goes up by an order of magnitude.

The only way the numbers I cited are hideously wrong is if Canada's system is grossly better than the British. Seeing as I couldn't find stastics for Canada in any of my usual methods I don't know what your actual risk is.

You have yet to show that it sets back progress. You just keep stating it as a fact when it is no such thing.

Oh right the fact that US spends more on R&D, produces more patents, and more treatments originate in the US than could ever be explained by population or GDP differentials means nothing. The fact that Europe has much less friendly IP laws means nothing. The fact that medical firms write off the European market until the very end of the cycle means nothing.

As far as disincentive, please. People don't chose to get sick, well excluding some hypochondriacs, but they do chose how to treat the illness. Major insurance companies found that if people pay the same price for a generic or brand name drug, the masses will take the brand name. The brand name has zero health benifit over the generic, excluding psychological reactions, as the active ingredients are chemically IDENTICAL. So what do the health insurance companies do, they charge a higher copay for the brand name. For insurance company the higher copay in no way offsets the price differential, but the patient now has an incentive to economize and take the cheaper generic.

Likewise if you go in to the doctor complaing of a headache, good medicine is to maybe do a quick examination and take two Tylenol. One could opt for an MRI or CAT just to be safe, but that is extremely cost prohibitive. So you need some type of disincentive to encourage patients from milking cost ineffective tests. In socialized medicine rather than use pricing or premiums; this disincentive tends to be outright regulation and rationing.

Every medical system in the world has some type of disincentive, regulation, or rationing to stop a few patients from breaking the system through cost ineffective treatment.

Did you even read what I wrote? You say that an extra middleman is a good thing because the middlemen can compete with each other. Do you not see the absurdity of that argument?

So tell me again why GM spun off Delphi? All it did was add a middle man between GM and the next tier of suppliers.

Of course the entire funding market is not going to come out of government coffers, the majority will still be coming from the middle class and upper class Americans who can afford to pay their own premiums - like they do now.

Besides I think it is a good thing to have an impartial government above the economic fray for regulatory purposes. When the government is the healthcare system the only recourse the public has when somebody dicks up is to sue the government or to elect a new government.

Nice "post hoc" false cause fallacy. You said it yourself; we don't need to, because the Americans do plenty of R&D with their much more expensive health-care system. If we ramped up our health-care spending from 10% of GDP to 14% of GDP like the US, we could afford more R&D too, but there's no reason to do that right now.

If you spent more on R&D it would result in faster breakthroughs and more new health products entering the market. And don't give me crap about Canada's smaller GDP, the impact MICHIGAN has on global R&D is measurable and large.

Of course even you are right you saying that it is a good thing to leech off some one else rather than pull your own weight, and say let more money be devoted to access rather than R&D you consome. But what the hell, if they aren't Canadian who gives a damn?

Private drug companies in Canada are not required to distribute every product they make to anyone who wants it. We buy drugs in drugstores, just like everyone else.

You know Canada is not the be all, end all of socialized medicine. You are NOT a monopsony, just an oligopsony. Likewise the socialized integration of healthcare in Canada is not all that great compared to Europe ... which is why I think Canada has better healthcare than Europe on average.

The only difference is price controls, and if lagging R&D were a big problem, we could easily solve that with government-subsidized R&D.

Right The French tried that, got nowhere. The British allegedly tried that, got nowhere. The Soviets tried it for decades, got nowhere.

You already talk subsidies in your "plan", but those are subsidies to a completely unnecessary middleman. These would make much more sense.

Yes because a centralized controller of R&D funding exhibits better ability to vet and screen promising lines of R&D than the market Likewise a centralized planner can better forecast the R&D so as to avoid shortages than the market

I don't trust a centralized plan for food production, I sure as hell am not going to do so for medical R&D. I have no problem if the government funds R&D as one player among many, but centralized R&D funding tends to suck it hard on cost effectiveness when it is tried in the real world.

You think the balance of power right now is perfect? What's wrong with the balance of power shifting more toward the users of health-care and away from the providers?

No I don't think the balance of power is good right now, a major part of the problem is job-lock and the assymetry implied by the insurance gap. What is wrong with power shifting toward the user? Depends on how far it shifts. With monopsony you end up having many of the same problems of monopoly. In the long run monopsony tends to breed monopoly and having such a monolithic market on both sides tends to be hideously inefficient.

So? Then they can do their research there and you reap the benefits anyway, by simply buying the drugs when they become available. The question is what benefits you are most interested in: a health-care system that is beneficial for your people or a health-care system that is beneficial for corporate shareholders.

It takes years for medical devices and treatments to penetrate the European markets after they have penetrated the American markets, for instance mammography is still nowhere near as common in Europe as the US - and that duly shows up in the cancer survival rates. During the those years many Europeans dying who would not have otherwise.

This is about us vs them, it is about do you want to have medical progress or do you want to have equalized access. If the corporations can't make healthy profits in medicine - then they won't invest in medicine. Instead they will say put out more Brittney Spears albums, spill proof cloths, or knife blades that cut through marble ... by having a healthy profit you get a crapload of corporate resources - capital, brainpower, manhours, etc. to flow into health that you would otherwise go to whatever else can make them money.

[aten_vs_ra]

I'm probably putting my foot in my mouth here, but it seems that marketing directly to the government doesn't doesn't work, how would you explain the defense market being profitable. I assume most of their income would come from government contracts.

[aten_vs_ra]

edit.
I'm probably putting my foot in my mouth here, but it seems that if marketing directly to the government doesn't work, how would you explain the defense market being profitable. I assume most of their income would come from government contracts

[tharkûn]

The defense market is quite different from the healthcare market.

Many big ticket DoD items have extremely limited production runs and argueably aren't even "mass produced" at all. If the government wants a new fighter jet they pay for a few hundred over several years and are done with it; if they want a new medical treatment they want thousands to millions of units. In the former case there never will be ramp up to bring about economies of scale nor will there be all that many customers in a later expanded market.

Another fun thing is that the defense department doesn't kill contracts for being cost ineffective. Even if you go over budget there is a very good shot you will still get paid, even if what you sell is a peice of crap - see Stryker. In medicine if you double your per unit costs, as routinely happens with defense projects, you simply don't get paid.

Not suprisingly the defense industry is much more highly consolidated than the health industry. In that manner it is a textbook example of monopsony encouraging monopoly. All told DoD pays a hefty premium because there are few realistic competitors and they are forced front load payment.

On the flip side if government monopsony is so wonderful, why not have single payer home insurance, car insurance, life insurance, etc. ? Why not reduce management costs by merging all the car companies into one national company and run it that way?

[SirNitram]

Tharkun, what is your obsession with the strawman of a single payer system being one where all other insurance sources are destroyed? Do you think it makes you appear clever?

[Broomstick]

Quit with the strawmaning. The point was that delaying hernia operations carries a risk. This backed up by scientific data and were published in peer reviewed journals. The truth is there is a risk when delaying hernia surgery, wether or not that risk is sufficiently small to be acceptable - I leave that to wiser heads.

You know, performing hernia operations carries a risk, too.

Get over it - the risk of delaying a hernia operation IS small, especially when proper triage is practiced. I question whether US triage is really that good, since there are so many disincentives for people to come in.

By the way - at the moment the Canadians are THE experts in hernia operations, from triage to surgery to recovery. If you're going strictly by outcomes their model would be the one to follow.

OK, fine, you didn't like the hernia example - what about cataract surgery? When is that ever an emergency? Regular eye exams should catch these long before they seriously impact vision, allowing for ample time to schedule.

How about cochlear implants - now THERE's an expensive technology which is, arguably, entirely elective. Sure, they can improve quality of life and, in the early deafened, promote much better verbal skills but what the hell, hearing aids and sign language work, too - except those aren't covered by insurance. So there are health insurance companies that will pay for extensive surgery and all the risks connected to that, expensive technology, and the follow up rehab required... but they won't pay for a simple hearing aid. Ah, yes, that a really rational approach to medical care, isn't it?

(Not that I'm arguing against cochlear implants - they most certainly have valid uses)

I once knew someone who's "maternity coverage" would pay not one penny for a normal pregnancy and delivery, but would cover up to 90% of a "complicated" pregnancy or a Ceasarian. Wow, you should have seen the "complication rate" for the pregnant women under that policy. There was enormous incentive to find problems and intervene because few people can cough up the money on the spot to pay the retail price of pregnancy and delivery in this country. Wow, the free market strikes again!

And on and on and on....

insurance companies do not want to cover everyone.

Wrong. Not-for-profit insurance companies exist to cover everyone they can. Even in the for profit realm you cover riskier patients by upping the premium.

How the FUCK are sick, disabled, unemployed people supposed to pay those higher premiums?

THAT is where the free market system and the US system breaks down - those most in need are least able to pay. So unable, in fact, that the government instituted a socialized, government-run safety net of last resort to minimize the number of people lying in the gutter and expiring of treatable conditions.

How would that remove their incentive to get rid of expensive customers?

The fact that they could raise the premiums of expensive customers without having customers being unable to pay; right now you raise the rates to high and people fall into the gap and drop coverage. Under my plan you raise rates and the subsidization kicks in.

The mere fact they need subsidizing shows that the sickest can't afford insurance, not on their own.

I don't have to, moron. I only have to show that it is not worse,

And I don't have to show mine to be better, I only have to show that it isn't worse because it does not retard R&D and leave millions of individuals dead waiting for a life saving drugs or treatments to come through

Not all R&D is created equal. It's useful only if the studies are well designed, well done, and you get intelligible results.

A LOT of "R&D" done in the US is funded by drug companies and compares one drug to another over a very short term. Even when published in a peer-reviewed journal it's not always useful in the sense of actually helping patients.

Your system gives everyone the same level of care more or less; however in so doing you introduce pressures on the system that retard R&D. In the long global view, R&D saves more lives.

When my husband was hospitalized last year with a condition that carries a 30% mortality rate under the best of conditions I wasn't interested in the "long, global view". I was interested in whether or not I'd be taking him home on his own two feet or in a box within a fortnight.

And it wasn't high tech anything that saved him - what he needed was IV fluids and close watching to treat any emerging complication. IV fluids and some competant nurses. We were lucky - we only had to pay 10% of the total bill because I have good insurance. Those nine days he spent in the hospital were MORE than my total yearly income (and just for the record - my income is twice the overall US average). That 10% of the bill was greater than the amount we spend on housing in an entire year. How many families can afford to have their rent or mortgage double overnight? In one week we wiped out our savings - the equivalent of six months of living expenses. After our tax refund for this year is thrown into the pot we will still have another 1,000 to pay off from those nine days - and we only had to pay 10%. It hurt - and we were FAR better off than most Americans, having savings and good insurance.

It's quite simple - if we had not had insurance we WOULD be bankrupt by now.

Despite our savings and lack of debt.

If you don't see what's wrong with a system where a family that earns more than the average, that has no debt other than a single car loan, and six months of living expenses in the bank can be beggered by a week long stay in the hospital that didn't require elaborate interventions, surgery, or cutting edge drugs then ... well, I really don't know what to say, other than I sincerely hope you don't have a rude awakening in your future.

[Patrick Degan]

Linky

ABSTRACT:

In 2001, 1.458 million American families filed for bankruptcy. To investigate medical contributors to bankruptcy, we surveyed 1,771 personal bankruptcy filers in five federal courts and subsequently completed in-depth interviews with 931 of them. About half cited medical causes, which indicates that 1.9–2.2 million Americans (filers plus dependents) experienced medical bankruptcy. Among those whose illnesses led to bankruptcy, out-of-pocket costs averaged $11,854 since the start of illness; 75.7 percent had insurance at the onset of illness. Medical debtors were 42 percent more likely than other debtors to experience lapses in coverage. Even middle-class insured families often fall prey to financial catastrophe when sick.

But then, these inconvenient realities somehow just don't exist in Tharkun-World.

[tharkûn]

You know, performing hernia operations carries a risk, too.

Yes it does, however the cumulative mortality risk goes UP if one waits.

Get over it - the risk of delaying a hernia operation IS small, especially when proper triage is practiced. I question whether US triage is really that good, since there are so many disincentives for people to come in.

Small is a relative term, I posted the actual frikking risks as reported in peer reviewed journals. Given the massive number of hernias even an extremely slight increase in risk means a planeload full of people die. Compared to the level of acceptable risk elsewhere in the world, such as airline safety, it is not negligable.

By the way - at the moment the Canadians are THE experts in hernia operations, from triage to surgery to recovery. If you're going strictly by outcomes their model would be the one to follow.

Wonderful when you can provide me with the numbers I'll be willing to conceed.

OK, fine, you didn't like the hernia example - what about cataract surgery? When is that ever an emergency? Regular eye exams should catch these long before they seriously impact vision, allowing for ample time to schedule.

As I've already noted there are some elective procedures, likewise there are some procedures where delay carries less risk than others. Not having seen the numbers, it might be possible that the risks of delay are negligable. For the vast, vast majority of surgeries delay has a stasticly significant adverse effect on patient outcome.

How about cochlear implants - now THERE's an expensive technology which is, arguably, entirely elective. Sure, they can improve quality of life and, in the early deafened, promote much better verbal skills but what the hell, hearing aids and sign language work, too - except those aren't covered by insurance. So there are health insurance companies that will pay for extensive surgery and all the risks connected to that, expensive technology, and the follow up rehab required... but they won't pay for a simple hearing aid. Ah, yes, that a really rational approach to medical care, isn't it?

You know the difference between ancedote and data, right? Yes some banalities exist in US insurance; I will take those any day over the greater mortality risk in British cancer treatment.

I once knew someone who's "maternity coverage" would pay not one penny for a normal pregnancy and delivery, but would cover up to 90% of a "complicated" pregnancy or a Ceasarian. Wow, you should have seen the "complication rate" for the pregnant women under that policy. There was enormous incentive to find problems and intervene because few people can cough up the money on the spot to pay the retail price of pregnancy and delivery in this country. Wow, the free market strikes again!

Do you really want the entire diatribe about the origins of the current American healthcare system, its social impact, and disparate social groups shaping policy? In any event if you want to play for tit for tat I see you one idiotic coverage scheme during pregnancy and raise you coverage of nebulized medicines but none for pills under the government run system.

unable, in fact, that the government instituted a socialized, government-run safety net of last resort to minimize the number of people lying in the gutter and expiring of treatable conditions.

You know only Rand and a few other free marketeers deify the free market. I want some limited amount of regulation to prevent things like fraud, monopoly, racism, etc. Likewise I have no problem with a minimalist social safety net with incentives to transition people back to society. My problem is I abhor monopoly, be it government or private. Yes some specific counter examples exist, but generally speaking monopolies and monopsonies suck. Rather throw up hands in the air and scream that monoposony or oligopsony is the ONLY rational choice; I'd prefer to preserve competition if at all possible.

The mere fact they need subsidizing shows that the sickest can't afford insurance, not on their own.

Thank you captain obvious, in other news water is wet. Or was this part of your impression that I'm a cold callous bastard who'd rather let them die to reduce the surplus population?

Not all R&D is created equal. It's useful only if the studies are well designed, well done, and you get intelligible results.

A LOT of "R&D" done in the US is funded by drug companies and compares one drug to another over a very short term. Even when published in a peer-reviewed journal it's not always useful in the sense of actually helping patients.

There is a nigh unto infinite field in which to spend R&D money. Some vetting process must be used to manage limited resources. Comparing two drugs does let us know, for instance, when a COX II is superior to a NSAID. Likewise comparative retroviral studies let us better tailor cocktails to, you now, extend life expectancy.

When my husband was hospitalized last year with a condition that carries a 30% mortality rate under the best of conditions I wasn't interested in the "long, global view". I was interested in whether or not I'd be taking him home on his own two feet or in a box within a fortnight.

Best of luck to your husband.

The trouble is that in the short term I can spend the entire medical budget of the free world on things that WILL extend life expectancy. At some point care for today must not trump research for tommorrow.

It's quite simple - if we had not had insurance we WOULD be bankrupt by now.

And then what? You'd have been forgiven your debts, your credit ratings would drop and you'd be unable to use normal bankruptcy channels for a period of time. Okay, in my state you'd get to keep your house and car and you start fresh.

How would your situation be any different than a family whose home and business is tossed a few football fields by a tornado - sans insurance? How is it different than a tree farmer whose income for the next 5 years is consumed in a wildfire - sans insurance? How is it any different than a car salesman who loses his yearly income to a hail storm?

The truth is bankruptcy is a social institution for the relief of debt. It carries some penalties to try to prevent gaming the system, but it does what it was designed to do - give people a fresh start when situations beyond their control, or even the product of their own stupidity in some cases, impose insurmountable finicials burdens.

If you don't see what's wrong with a system where a family that earns more than the average, that has no debt other than a single car loan, and six months of living expenses in the bank can be beggered by a week long stay in the hospital that didn't require elaborate interventions, surgery, or cutting edge drugs then ... well, I really don't know what to say, other than I sincerely hope you don't have a rude awakening in your future.

Madame I've plenty of rude awakenings, starting with a family member who died of cancer due to late detection that would never have happened in the US. You are looking at the healthcare issue through the lens of your own personal experiences which are decidedly atypical and honestly I cannot fault you for so doing. However do not fault me for looking at the hard data and recognizing the human cost of insufficient R&D.

[Patrick Degan]

Other fun issues include disincentive for the government to protect and promote intellectual property - it costs orders of magnitude more money to get and defend intellectual property in Europe than the US. Also there is brain drain where technologists who have a bright idea go abroad to develop, market, and reap profits in the society which is most generous to their selfish motives - I know of a venture capital fund that does nothing but bring European and Asian brains to the US.

Hmm...

Wednesday, April 13, 2005

Developing a medical milestone: the Salk polio vaccine
The Salk vaccine: 50 years later / First of two parts

Sunday, April 03, 2005
By Byron Spice, Pittsburgh Post-Gazette


Julius Youngner: Working for years in a
basement laboratory in Oakland, he and a group
of dogged researchers assembled by
Dr. Jonas Salk at the University of Pittsburgh
School of Medicine produced polio vaccine.


When Julius Youngner was growing up in New York City in the 1920s and '30s, his grandmother wouldn't let him go out to play without first hanging a cube of camphor around his neck.

"My grandmother always believed, to her dying day, that she prevented me from getting polio," Youngner said recently. She was convinced the pungent hunk of camphor, the smelly stuff in mothballs, would ward off the virus that had crippled so many other children.

"What she didn't know," Youngner, 84, said, "is that every time I left the house, I took it off and put it in the mailbox."

Camphor cakes weren't much of a weapon against polio, but Americans had been desperate for some measure of protection since 1916, when the first major polio epidemic claimed 27,000 lives. They tried gargling with salt water, killing the family cat, scrubbing the toilet, bagging ashes from the coal stove, serving less meat, all to no avail.

The size of the epidemics varied from summer to summer, but by the time Youngner reached manhood, between 13,000 and 20,000 Americans, mostly children and adolescents, were being paralyzed by polio each year. Some suffered a profound form, called bulbar polio, which left them unable to breathe and dependent on a coffin-size breathing machine called an iron lung.

In the late 1940s, however, medical science produced the tools needed to conquer the polio virus and Youngner, then beginning his career as a microbiologist, was in position to exploit them.

Working for years in a basement laboratory in Oakland, he and a group of dogged researchers assembled by Dr. Jonas Salk at the University of Pittsburgh School of Medicine mastered those tools to produce a polio vaccine.

Some of the finest minds of American medicine in the early '50s insisted that the vaccine, which used killed polio virus, would never work.

Nevertheless, thousands of Pittsburgh schoolchildren offered up their arms to be injected with the experimental solution, providing enough evidence of its effectiveness to launch a large-scale trial of 1.8 million children.

Fifty years ago, on April 12, 1955, the leader of that national trial, Dr. Thomas Francis, of the University of Michigan, made the much-awaited pronouncement: The polio vaccine was "safe, effective and potent."

It was an electrifying moment in medical history. A terrifying, incurable disease that had existed for thousands of years had yielded to the targeted efforts of scientists, bankrolled by the contributions of more than 100 million Americans to March of Dimes campaigns.

"It proved that you could control polio and stop human-to-human transmission," said Dr. David Heymann, director of communicable diseases for the World Health Organization. Cases plummeted as the Salk vaccine was rolled out and plummeted again when an oral vaccine developed by Salk's rival, Dr. Albert Sabin, was introduced in the early '60s.

The last U.S. cases caused by the wild polio virus occurred in 1979, and today, polio is on the verge of eradication worldwide. It could be wiped out by as early as the end of this year, Heymann said, depending on the success of mass vaccination campaigns this spring in Africa and Asia.

The vaccine's success made Salk a household name. Even after the Sabin vaccine eclipsed the Salk vaccine, it was Salk's name that remained inextricably linked with the notion of a polio vaccine.

And Pittsburgh basked in Salk's reflected glory. Boosting the profile of Pitt's quiet medical school, after all, had been one of the reasons Salk had been recruited in 1947. Community leaders, energized by the city's first Renaissance, had provided Salk with additional space and money.

"I don't think that if I'd been anyplace else that things would have happened as they did," Salk said in an interview with the Pittsburgh Post-Gazette in 1994, a year before his death at 80. "Why? Because of the concatenation of circumstances. The magic."

For Youngner, the last surviving member of Salk's core research group, the polio work was just the beginning of a distinguished career as a microbiologist, but also was its highlight.

"I consider myself blessed by good fortune to have played a part in this creation of a medical milestone," he said in February as he accepted Pitt's highest honor, an honorary degree in public service.

Classic whiz kid

Youngner was a gifted child. Growing up on Manhattan's East Side, he leapfrogged his way through elementary and high school and had earned a bachelor's degree from New York University by age 18.

But he was no nerd. He was a pretty good athlete, and his prowess on the baseball field helped bridge what otherwise could have been a social gap with his older classmates. And he was just ornery enough to give his grandmother fits, showing up late for dinner, or failing to tell her where he was going.

"My mother always wanted me to be a brain surgeon. She had high hopes for me," he said. His interest in medicine also was primed by his medical history. "I had every possible disease a child could have," he recalled, including an almost fatal bout of double pneumonia when he was 7.

But a conversation with his family doctor's nephew, who had just earned a degree in bacteriology from the University of Michigan, convinced him that he should shift his focus from clinical medicine to research. Youngner enrolled at Michigan, earning his master's in 1941 and his doctorate in bacteriology in 1944.

In between degrees, he became smitten with an underclassman named Tula -- "It was love at first sight" -- and married her in 1943.

The newly minted bacteriologist entered the Army in 1944. After basic training, he was dispatched with sealed orders to a train station in Knoxville, Tenn. From there, he was hauled to a place called Oak Ridge. He thus became part of the Manhattan Project, the secret program to develop the atomic bomb, and was assigned to a toxicology unit monitoring workers at Oak Ridge's giant uranium enrichment plant.

After his Army stint, he moved over to the U.S. Navy and the Public Health Service in 1947, becoming one of the first science officers at the National Cancer Institute in Bethesda, Md. He worked with cell cultures and was particularly interested in cell cultures for viruses, then a new area that made some researchers nervous.

His interest eventually attracted the notice of Jonas Salk, who, in 1947, had taken charge of the virus laboratory at the University of Pittsburgh.

Salk and Youngner had followed parallel career trajectories, but had never met. Salk grew up in the Bronx. When Youngner was working on his bachelor's degree at NYU, Salk was completing his medical degree in the NYU medical school. In the early '40s, when Youngner was studying bacteriology at Michigan, Salk was working with Tommy Francis, the chief of epidemiology, in the medical school there.

By the time he met Youngner in Bethesda, Salk had secured major funding for his Pitt lab from the National Foundation for Infantile Paralysis. Work on a vaccine was in the offing and Salk needed somebody who knew about cell cultures. Cell cultures would make it easier to study polio virus and eventually would be necessary for producing virus for a vaccine.

"You can work with any virus you want," Salk told Youngner, "but among them, please among them, have polio."

"I said, 'That's a no-brainer, because polio is a very easy virus to work with.' I knew his money was coming from the national foundation." The deal was sealed and Youngner soon became Salk's right hand man.

Sanitation made polio worse

It was an Englishman, Michael Underwood, who first described the crippling disease now recognized as polio, or poliomyelitis, in 1789. But descriptions of similar diseases can be found in literature stretching back thousands of years.

Although not new to humankind in the late 19th and early 20th centuries, the disease was then presenting itself in troubling new ways. Rather than occurring sporadically in infants, polio was causing epidemics, often striking older children and young adults.

Ironically, improved public sanitation was to blame.

Polio spreads because those who have the virus excrete it in their feces, sometimes for weeks. Other people become infected when they drink water contaminated with sewage or eat food contaminated by someone with dirty hands.

About one out of every 200 people exposed to the polio virus develops polio symptoms, usually beginning with a flu-like illness. Everyone exposed to the virus, however, develops lifelong immunity.

Once improved sanitation came along, it prevented babies from being routinely exposed to polio virus at an early age, and many more children grew up without this immunity.

And that set the stage for devastating epidemics.

Most polio cases did not cause paralysis, but virus that reached the central nervous system could destroy nerve cells that controlled muscle movements. Infections in the spinal cord -- spinal polio -- caused weakness and paralysis in the legs. Infections of the brain stem -- bulbar polio -- could damage the cranial nerves that controlled breathing.

This ancient disease, so long overshadowed by killers such as typhoid fever, hepatitis and cholera, suddenly was terrorizing people throughout Europe and America. And it often seemed to strike hardest in prosperous communities and families, those who enjoyed the best sanitation.

"My family was certainly scared to death in the summertime," Youngner said. "Worried about going to pools, worried even about going to the movies." Everybody knew somebody who had polio.

Like other viral diseases, no treatment was available for polio. Doctors could only stand by and let the disease run its course. Then, patients could be fitted with leg braces and undergo rehabilitation to strengthen whatever muscles still functioned.

Franklin D. Roosevelt, who was stricken at age 39 in the summer of 1921, when the general public was still just learning about polio, would be its most famous and influential victim. In 1937, during his presidency, he established the National Foundation for Infantile Paralysis and installed his friend Basil O'Connor as its head.

With fund-raising events such as Birthday Balls and the March of Dimes, the foundation tapped into the generosity of both large and small donors. The well-financed foundation thus was positioned to exert unprecedented influence as a private organization on research into polio prevention.

Crucial role of monkeys

When Youngner joined Salk's Virus Research Laboratory in 1949, it was well along on its first major project. Pitt and three other universities were funded by the national foundation to test every known strain of polio virus to see how many types existed, a necessary first step for developing a vaccine.

"They already knew there were three types," Youngner said. "But what if there were five? What if there were seven? That would make [a vaccine] much more complicated."

The lab was once confined to the basement of Oakland's Municipal Hospital for Infectious Diseases, a building that now houses Pitt's pharmacy school and is known as Salk Hall. But now it filled two floors; elsewhere in the hospital, the largest ward housed young polio patients.

And much of the lab was now lined with cages for monkeys, the animals that were key to the typing effort.

L. James Lewis, a bacteriologist and Waynesburg College graduate, had been working for a pharmaceutical company when Salk recruited him to oversee the monkey experiments. "That was a key part of the effort," Youngner said, and Lewis tackled his tough job with boundless energy.

It was brutal work. One method involved injecting fecal samples of an untyped polio strain into the brain of a monkey; once the monkey showed signs of disease, it was destroyed and the polio-infected neural tissue removed. This tissue was processed and injected into the brain of a monkey that already had developed immunity to a known polio type, such as Type I.

If the monkey resisted infection, then the unknown strain must be Type I, too. If the monkey got sick, then the process was repeated with monkeys immune to other types until researchers were confident that the strain was a Type I, II or III, or knew they had found another type.

The foundation's typing studies required 17,000 monkeys. "The monkeys were the heroes of this thing," Youngner said.

The typing project produced good news for vaccine developers: Three types of polio existed.

While his colleagues were slogging through the typing experiments, Youngner was setting up his cell culture lab with the help of his technician, Elsie Ward, a zoologist. Until this time, the assumption in the field had been that polio could grow only in neural tissue, a circumstance that both necessitated the use of live monkeys and limited the prospects for growing virus in the quantities necessary for manufacturing vaccine.

But in 1949, John Enders, of Harvard University, announced that he had been able to grow polio virus in a culture of embryonic cells. The finding would win Enders and two junior colleagues the 1954 Nobel Prize in Medicine.

"That was the discovery that made Salk's work possible," said Vincent Racaniello, a microbiologist at Columbia University and a leading polio researcher today.

But Enders had grown his virus in a culture of human embryonic kidney cells, which posed its own set of problems. Use of human embryonic cells was no less controversial in 1949 than the extraction of stem cells from human embryos is today. Youngner had to find a more suitable source of cells for his cell cultures.

He tried to use cells from monkey testes, which at least would be easy to obtain. But the tissue didn't produce a lot of cells.

Then he tried chopping up the cortex, or outer layer, of monkey kidneys. Initially, the cells tended to form clots in the test tubes, which made them difficult to grow. But then Youngner tried an old trick used by pathologists. He added a pancreatic enzyme called trypsin to the culture to break the tissue into separate cells.

"The rest is history," Youngner said.

Trypsinization, which would become standard in producing cell cultures, made it possible to produce mass quantities of polio virus for vaccine production.

Monkeys still had to be sacrificed to obtain kidneys, but the cell cultures drastically reduced the need for monkey testing.

"He invented modern cell cultures," said Patricia Whitaker-Dowling, a Pitt microbiologist who began working with Youngner in 1979.

Killed virus or live virus?

While Youngner had been studying the dangers of inhaled uranium salts for the Manhattan Project, Salk had been working during World War II with his mentor at Michigan, Tommy Francis, to develop the first influenza vaccine for the Army.

Almost as many U.S. soldiers died in the great influenza epidemic of 1918 as died on the battlefield that year, and the Army was concerned about the possibility of another pandemic during World War II. Though most immunologists believed that only a low-grade, natural infection could trigger immunity against a virus, Francis had done work to suggest that a killed virus also could stimulate the production of antibodies. The killed-virus approach appealed to the Army, which worried that use of a weakened, live virus would always carry the danger of sparking an epidemic.

The flu vaccine, the same used for today's flu shots, was successful in clinical trials. Salk became a believer in Francis' killed-virus approach and in a method used to inactivate the influenza viruses using a formaldehyde-based solution called formalin.

When Dr. William McEllroy , dean of the Pitt Medical School, persuaded Salk to come to Pittsburgh in 1947, the young researcher brought his interest in killed-virus vaccines with him. But no consensus existed within the National Foundation for Infantile Paralysis that a polio vaccine should be a near-term goal or that a killed-virus vaccine would be the best way to immunize people against polio.

Two polio vaccine trials sponsored by the foundation in the mid-1930s had been disasters, causing polio in some cases and violent allergic reactions in others. No one was eager to repeat that debacle.

Moreover, the nation's leading immunologists, Dr. Albert Sabin, of the University of Cincinnati, and Dr. Hilary Koprowski, of Lederle Laboratories, were actively working on live virus vaccines.

Using a weakened but active virus, they argued, would cause a low-grade infection that would trigger all of the body's immune mechanisms, providing a more complete, long-lasting immunity than would be possible with a killed-virus vaccine.

A killed-virus vaccine, Salk argued, could work, as long as the virus was killed in such a way that it retained the proteins necessary to trigger the body to create antibodies against them.

"We were convinced we had the answer," Youngner said.

But Salk had to battle constantly with the skeptics. "There was a very powerful group of senior virologists and epidemiologists, not just Albert Sabin, but a whole bunch of them, who believed that the killed vaccine would never work against polio, that it would have to be a live vaccine, like what Sabin was working on," he said.

The killed-virus vaccine could be dangerous, critics said, if all of the virus wasn't killed. The immunity would be more short-lived than possible with a live vaccine, necessitating booster shots. And the vaccine would have to be administered in a shot, not as an oral vaccine.

But none of those cautions would dissuade the Salk team, which was working furiously in Oakland to develop the vaccine and get it ready for testing.

Tomorrow: Salk's team defeats the skeptics and changes medical research forever

(Post-Gazette science editor Byron Spice can be reached at bspice@post-gazette.com or 412-263-1578.)

Copyright ©1997-2005 PG Publishing Co., Inc. All Rights Reserved.

My my, what a concept —successful biomedical research being conducted by an entity other than a huge pharmaceutical company, with no particular concern for the profit motive or protection of intellectual property, and actually producing an effective cure in less than ten years to a disease which had been a bane to humankind for thousands of years and was killing 50,000 per year when it reached America in 1916.

I wonder what their incentive was...?

[Xon]

Other fun issues include disincentive for the government to protect and promote intellectual property - it costs orders of magnitude more money to get and defend intellectual property in Europe than the US.

Statements like this make me laugh.

Defend intellectual property? If you call the fucking circus thats is the US patent office and the results of America's patenting & IP laws a good thing, I've got a nice lake in central Western Australia I want to sell you...

That companies can make a living sueing other companies and clients for implementing an algorithm which they bought the rights too 2-3 mergers & selloffs ago a good thing makes me want to weep for the world.