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June 27, 2006

Comparing cases
Posted by Teresa at 11:09 PM * 158 comments

From News of the Weird:

Wheelchair-confined Richard Paey committed almost exactly the same violations of Florida prescription drug laws that radio personality Rush Limbaugh did, with a different result: Limbaugh’s sentence, in May, was addiction treatment, and Paey’s, in 2004, was 25 years in prison. Both illegally possessed large quantities of painkillers for personal use, which Paey defiantly argued was (and will be) necessary to relieve nearly constant pain from unsuccessful spinal surgeries after an auto accident, but which Limbaugh admitted was simply the result of addiction. (In fact, if Limbaugh complies with his plea bargain, his conviction will be erased.) Paey’s sentence now rests with a state Court of Appeal. [Tampa Tribune, 2-8-06]

Comments on Comparing cases:
#1 ::: Richard Parker ::: (view all by) ::: June 27, 2006, 11:57 PM:

With wealth comes the advantage of being able to afford the services of a topflight criminal defense attorney who can negotiate a great deal.

#2 ::: Seth Breidbart ::: (view all by) ::: June 28, 2006, 12:04 AM:

So it looks like Limbaugh loses his deal on his previous charge, too.

We'll see how much justice he can afford this time.

#3 ::: Paula Helm Murray ::: (view all by) ::: June 28, 2006, 12:36 AM:

it just goes to show that justice, especially on drug cases, belongs to the rich and well-connected. If you're poor, screw it, you're going to prison no matter what you try and do. Your legal-aid lawyer will either be a drunk/drugged ne'er do well or non-existant because of budget cuts.

good luck.

Mr. Limbaugh (the professional comedian per Jon Stewart) should have known better. I always have my drugs bottled in their right bottles when I go through airport security, especially internationally. When I get to my destination I sort them back out into the Sun-Sat pillbox (in my credit, I only take two blood pressure meds daily plus an as-needed asthma inhaler that are presciption only). If I'm crossing borders, I also make sure my generic benedryl is in the right bottle and my ibuprophen is in the right bottle. Mr. Limbaugh is an idiot as far as I can tell and he just added to his stupidity in my eyes.

#4 ::: Writerious ::: (view all by) ::: June 28, 2006, 12:40 AM:

If you're part of the right-wing upper eschelon, you're allowed to get away with anything at all, because, hey, you support the right wing "cause" -- family values and all that. Not that you have to actually practice family values yourself. You just support them. For other people. You're already one of the annointed ones so you don't have to participate like all those little people out there.

This is all so, so twisted.

#5 ::: Charlie Stross ::: (view all by) ::: June 28, 2006, 05:53 AM:

Assuming for the moment that Rush is guilty of illegally procuring V*gr*, how many brain cells does it take to go out and buy some inkjet labels? It's not exactly rocket science to peel the label off a pill bottle, scan it, and substitute your own name. (I don't know about you, but if I was facing an expensive trial and possible imprisonment for a drugs possession offense, I'd have a strong incentive to make any subsequent compulsive infractions inconspicuous -- and having the right labels on the bottle to pass a cursory inspection is a good start.)

In fact, it sounds as if Rush got caught because he was breathtakingly stupid. I mean, how hard is it to get a private prescription for the aforementioned substance? Even from a court-approved doctor who's monitoring your compliance with a probation order? The stuff's not exactly illegal in and of itself ...

#6 ::: Fragano Ledgister ::: (view all by) ::: June 28, 2006, 07:23 AM:

We should be reminded that 'privilege' originally meant 'private law', i.e. the exemptions from common or civil law possessed by some persons because of their wealth or status. There have always been some people who have believed that wealth, fame,or status should mean that they are above the law. It isn't surprising that a blowhard like Limbaugh is in that category.

#7 ::: fidelio ::: (view all by) ::: June 28, 2006, 09:13 AM:

Of course Rush is blindingly stupid--he always has been. He was raised in a town in Missouri where his father was someone important, grew up with the conviction that he was entitled to better treatment than other people, and never got behind the idea that he would have to work to get anywhere in the world. He dropped out of the local state university after one year, because they expected him to show up to classes and do the work necessary to pass them. He would still be an announcer at some small radio station in the midwest if he hadn't become blindingly lucky, and if he hadn't been helped along by people who knew a useful tool when they saw one. He's a spoiled brat who has never absorbed the concept that the rules that apply to me and thee must also apply to him.

Make up a fake label for his pills? That's work! As far as Rush is concerned, work is something other people do.

#8 ::: Skwid ::: (view all by) ::: June 28, 2006, 09:19 AM:

Damn, Richard. I was so hoping your second link would point to The Chewbacca Defense.

#9 ::: Avram ::: (view all by) ::: June 28, 2006, 11:02 AM:

Just as much as the next liberal, I like seeing Rush made miserable, but I also just want to point out here that a significant chunk of what's making him miserable here is laws that make a whole lot of other people miserable too.

Does it strike anybody else here as odd to have to sort and package your medications for the convenience of and inspection by people whose business it really shouldn't be? That obsessing about what pills people might be bringing into or out of a country is somewhat tyrannical?

#10 ::: Charlie Stross ::: (view all by) ::: June 28, 2006, 11:15 AM:

Avram: yes. (It's one of the secondary reasons why I'm not a pharmacist any more.) Obsessing about what pills people are taking -- beyond the degree that's necessary in order to impose quality control on substances that can be quite toxic if misused -- is repugnant. It's like earlier generations obsessing about what other people are doing in bed, and with whom -- or about what language they use to recite their prayers in private (to the same god, no less! Just using the wrong language was enough to get people hanged in this country, only two and a half centuries ago).

Unfortunately it's a situation we're stuck with, and Rush -- as a beneficiary and booster of the status quo -- should be no less constrained by it than the rest of us. See definition of "privilege" above ...

#11 ::: John M. Burt ::: (view all by) ::: June 28, 2006, 12:24 PM:

Avram: hear, hear!

Perhaps the best thing that might come from this sleazy little case is a re-examination of the monstrous system that produced it.

Yeah, right, and maybe they'll count all the votes in November.

#12 ::: Marna ::: (view all by) ::: June 28, 2006, 01:43 PM:

Does it strike anybody else here as odd to have to sort and package your medications for the convenience of and inspection by people whose business it really shouldn't be? That obsessing about what pills people might be bringing into or out of a country is somewhat tyrannical?

Yes.

I had to explain my medical conditions in grim detail when I crossed the border this time, admittedly to a pleasant and kindly lady who did NOT make me feel like a criminal for having to carry that much medication for two week's travel, and who was perfectly okay with me having the prescription bottles in the suitcase and a mixed pillcase in my handbag.

It still irked hell out of me.

#13 ::: Margaret Organ-Kean ::: (view all by) ::: June 28, 2006, 01:54 PM:

My prescription 'medication' is a very expensive machine - and I just adore watching the security personnel thump it around and pack it back up by jamming it in its case backwards.

#14 ::: Greg London ::: (view all by) ::: June 28, 2006, 02:00 PM:

I know someone who had severe spinal damage years ago (fractured vertbrate, compressed disks, back brace for a year) and is suffering nearly constant pain now. And this person is always having trouble with the doctors trying to cut off their pain medication. I suggested kneecapping the doc in a dark alley so they may understand that even though you can't see pain, you can still feel it. There's a lot of cover-your-ass stupidity around meds.

#15 ::: Lydia Nickerson ::: (view all by) ::: June 28, 2006, 05:25 PM:

I think that it is especially delicious to see that "what comes around goes around" when it happens to a proponent of a particularly unjust law.

I'm not real patient with the drug laws in this country, gods know, but I don't feel any logical or emotional connection between the injustice of those laws and watching Rush hoist by his own petard. It has the same special charm as catching Jimmy Swaggart in a cheap motel with an even cheaper whore. How can you not take a deep, abiding satisfaction in watching the self-righteous bastard take it in his moral shorts?

The drug laws are evil. What they do to people who aren't Rush is evil. The contrast between the two is evil. But the embarrassment that Rush is experiencing is satisfying.

If only they'd put Rush's ass where his mouth was. But that's an issue of law and justice. It's not karma.

#16 ::: kathryn from Sunnyvale ::: (view all by) ::: June 28, 2006, 09:12 PM:

Margaret-

See my post on the other Rush thread. From the link I found, you definitely have the right to be present when they inspect your equipment. They are required to change gloves- put on fresh gloves- when touching your equipment if you request it.

I have also seen, but can't find a link, the possibility of a rule that says you have to be the one first opening up your equipment, not them.

Of course, the 20 minute question is how do you ask security to follow the rules without them getting snippy. (There's always the ones who want you to not only be polite, but to be subservient in the face of the TSA.) I'm going to ask that on the other thread.

#17 ::: Kathryn from Sunnyvale ::: (view all by) ::: June 28, 2006, 09:17 PM:

If you've traveled with "exceptional supplies" (medical, fragile, photographic),
And security asked to search it,
And you got security to follow the rules,

how did you do it? What phrasing did you use to request that the TSA follow their own rules without the TSA agent getting snippy and angry?

For example, you can ask for the agent to put on fresh gloves before searching your medical equipment. I bet many people want to ask for this, but are afraid of what could happen. How would you / did you phrase this reasonable request?

#18 ::: Lis Carey ::: (view all by) ::: June 28, 2006, 10:32 PM:

Just as much as the next liberal, I like seeing Rush made miserable, but I also just want to point out here that a significant chunk of what's making him miserable here is laws that make a whole lot of other people miserable too.

Yes, Avram, and he's strongly in favor of those laws--when they are making other people miserable.

Hoist on his own petard--except that, somehow or other, he won't be. He'll get off.

#19 ::: Jessica ::: (view all by) ::: June 29, 2006, 04:07 AM:

It is ridiculous how so many things are judged one way or another depending upon who they are or aren't, and how much "justice" they can afford. In deifferent places all over the country, you can do one thing and go to jail and then another be applauded.. it's crazy really.

#20 ::: Teresa Nielsen Hayden ::: (view all by) ::: June 29, 2006, 08:24 AM:

I have a document, a couple of decades old at this point, that was prepared for me by the staff of the neurologist who formally diagnosed me as having narcolepsy. It's a "to whom it may concern" letter, on his formal letterhead, which explains that I really do have narcolepsy, and that there really are legitimate therapeutic reasons for me to be carrying whatever medications I'm currently using. This is on top of having legitimate, fully labeled prescription packaging for my drugs. It's to keep some border official from deciding on his or her own steam that nobody takes those drugs for any but recreational purposes.

Patrick's had long frustrating phonecalls with people at insurance companies, and wound walking them through the PDR to get to the paragraph in the description of one of my drugs that lists "narcolepsy" as one of the conditions for which it's prescribed. They'd up and decided on their own that nobody takes those drugs for legitimate therapeutic reasons.

When I'm medicated -- and boy, is that a sore point right now -- doctors habitually underprescribe, to the detriment of my life and health, because they get harassed by law enforcement officials who want to make sure that narcoleptics aren't getting more drugs than they strictly need. In consequence, we get less drugs than we strictly need.

Greg London's friend who's in constant pain from his seriously messed-up spine, and who's constantly threatened with having his pain medications withdrawn, is living with the same problem I do. He's far from being the only one I know of who's in that position.

We all live with the constant, artificially imposed need to calculate how and where to allocate inadequate doses of essential medications. Some of us scrounge extras from kindly friends. As far as I can tell, we all anxiously hoard little stashes of extra medications against the day the pharmacy unexpectedly closes early, or our physician takes off on a long vacation without writing our latest round of standard prescriptions, or some dorkbrain at the insurance company decides our standard meds aren't eligible for standard coverage, and until we can get that misunderstanding cleared up, we're faced with the choice of either paying for our prescriptions out of pocket, or paying our rent.

We live on a short leash. Our class of medications -- the ones where the prescription has to be written out on multicopy NCR forms -- are hedged around with massively inconvenient restrictions. I used to have to spend one entire workday per month picking up my new prescriptions from my neurologist up in White Plains, then getting them filled by a pharmacist in the Bronx, when I lived in Staten Island. Trips lasting more than a few days always have the potential problem of overlapping the end of one prescription-month and the beginning of another. Can I get it filled early? Don't even ask.

The best pharmacist I've ever known gets a lot of business from NYC kids who have sickle-cell anemia. It's a very painful condition, and it takes major painkillers to treat it. But if a seventeen-year-old black kid walks in the door of a pharmacy with an unquestionably legitimate prescription for Vicodin or Oxycontin, he's likely to be turned away without his meds. This pharmacist I know has sickle-cell patients coming in from all over the city, just because he'll scrupulously fill a legit prescription no matter what it's for or who brings it in. (And why was I there? Same reason.)

I think the drug laws are stupid. I think our emphasis on interdiction, rather than treatment, is stupid squared and cubed. I think forcing health care professionals to be drug enforcement agents is insane. But Rush Limbaugh is exactly the kind of drug abuser all this BS is set up to catch. He's the reason the rest of us have to live with it.

The extent of Limbaugh's Oxycontin abuse was seriously nontrivial. He was doctor-shopping, and he got off absurdly easy. And now he's turning up with a bottle of prescription meds written from one doctor to another, not to him. After all that's happened, this man is still playing games with the system. I have no sympathy, none, zero, zip: no sympathy whatsoever.

#21 ::: Jo Walton ::: (view all by) ::: June 29, 2006, 08:39 AM:

Teresa -- This kind of thing makes me want to bite someone. I think you should explain to Tom Doherty that swimming pools in Montreal are free. Then he might be persuaded to move all of Tor here, including your job, and you could have access to a less stupid medical system. (Not perfect, but less stupid about this stuff. A friend of mine from Boston was visiting, and she was part way through a course of prescription anti-biotics for a tooth infection. She'd forgotten to bring them, so we went to a walk-in clinic and explained. The doctor gave her a prescription and asked her if she needed a prescription of something for the pain as well. She was astonished that this was offered.)

#22 ::: Hamadryad ::: (view all by) ::: June 29, 2006, 09:40 AM:

I'm with Jo Walton. No, it's not perfect here. I've heard that patients are still under-treated for pain (although for different reasons than they are in the U.S. I think), but at least the war on drugs hasn't made everybody completely insane.

*pets Canada*

#23 ::: Greg London ::: (view all by) ::: June 29, 2006, 10:10 AM:

(hears purring sound coming from the north)

#24 ::: Nancy Lebovitz ::: (view all by) ::: June 29, 2006, 10:24 AM:

Thanks, Avram. That expanded nicely on how I feel about it.

I'm not sure how one balances respect for the rule of law (something I'm pretty ambivalent about) with very bad laws.

Would it be excessively obnoxious to suggest to Limbaugh that he reconsider his stand in favor of strict enforcement of drug laws?

If you want to keep track of outrageous enforcement practices (frequently about drugs) check out http://www.theagitator.com.

I believe that the drug plan system is going to be a much livelier black market in prescription drugs. There is *no* *way* that people can predict a year in advance which drugs they're going to need, and the drug plan system is new enough that this hasn't really begun to kick in yet.

#25 ::: Greg London ::: (view all by) ::: June 29, 2006, 10:28 AM:

I think forcing health care professionals to be drug enforcement agents is insane.

That is the root cause of the problem. Some bureaucrat, hiding behind a desk, buried in some office, decides that they know better than a suffering patient or their doctor and decrees that its better that some people suffer than to have even one Rush Limbaugh get his fix.

It's better that ten guilty men go free than to have one innocent man go to jail. But for some reason, it's better to have ten people who need medication be denied than to have one addict get drugs.

Fat Bastard should go to prison, not for the drugs he abused, but for being an over-inflated windbag who caused real suffering for countless people who had legitimate need for meds and were denied because of his hypocritical self-righteousness.

Hm, I like the sound of that. Rush Limbaugh: the new Fat Bastard. Pass it on.

#26 ::: the exile ::: (view all by) ::: June 29, 2006, 10:51 AM:

How come nobody is asking what Rush was doing bringing Viagra to the Dominican Republic, a notorious destination for sex-tourism, including underage sex-tourism? Was he travelling alone or with female company? Are any reporters interviewing the local prostitutes to see if any of them spent a night with a fat American blowhard?

#27 ::: alex ::: (view all by) ::: June 29, 2006, 11:06 AM:

Well, the rationale for the tight restrictions on some drugs is pretty easy to understand if you look at it from the right angle. After reading a great deal of drug-war propaganda, much of it can distilled to the following precepts:

1. People who abuse drugs are defiling the temple that is their body and are bound for hell.

2. People who aid and abet such drug abusers make the baby Jesus cry and are likewise bound for hell.

I remember reading somewhere that in the late nineties the city of San Francisco was spending six million dollars a year treating infected needle sites alone, never mind incidental costs associated with IV drug abuse. That problem could have been reduced by a factor of twenty with a needle-exchange program, but that would "send the wrong message".

People denied medication live in pain and die early. But they're going to heaven! And most importantly, so are the people who make the rules!

Reason #11,004 why the religous right makes me gag.

#28 ::: Jacob Davies ::: (view all by) ::: June 29, 2006, 02:21 PM:

Teresa, thank you for the excellent point that manipulative abusers like Limbaugh are the reason that those who a real need for potentially-abusable drugs have such a hard time getting them.

That angle hadn't occurred to me at all.

#29 ::: Jacob Davies ::: (view all by) ::: June 29, 2006, 02:34 PM:

(I quoted it - with a link - in a discussion of this on the Well. Hope that's okay.)

#30 ::: Lenora Rose ::: (view all by) ::: June 29, 2006, 02:58 PM:

the exile:

It's been speculated on multiple times here.

I think the reasoning was to avoid clogging this thread with the discussion from that thread.

#31 ::: Xopher ::: (view all by) ::: June 29, 2006, 02:58 PM:

After all that's happened, this man is still playing games with the system. I have no sympathy, none, zero, zip: no sympathy whatsoever.

I have no more sympathy than you. And yet I must say that the absolute value of my sympathy is far, far greater than zero!

#32 ::: albatross ::: (view all by) ::: June 29, 2006, 05:16 PM:

Nobody gets justice from the current set of drug laws. But rich people can often buy their way out of much of the injustice, and well-connected people can often use pull to get themselves out of much of the injustice.

Rush Limbaugh is a pretty uniformly bad influence on the world, and I wouldn't be sad to see him unable to find work on the radio. But he absolutely shouldn't go to jail for this nonsense, any more than anyone else should. Similarly, if he's found having sex with a man, he shouldn't be jailed for sodomy, even if he supports such idiotic laws.

#33 ::: Xopher ::: (view all by) ::: June 29, 2006, 05:30 PM:

I disagree, albatross. I think the punishment he wishes upon others should be visited upon him.

No, that isn't justice. Just karma.

#34 ::: CHip ::: (view all by) ::: June 29, 2006, 11:39 PM:

Xopher: it's also Xianity: do unto others. He's obviously treated other people the way he wishes to be treated....

#35 ::: Xopher ::: (view all by) ::: June 30, 2006, 12:14 AM:

CHip: and "Judge not, lest ye be judged."

#36 ::: Nathan Williams ::: (view all by) ::: June 30, 2006, 12:20 AM:

Here's something I don't get: who benefits from the prescription status of most medication? I can see the usual drug-war issues for addictive painkillers (they have known "recreational" uses), as much as I disagree with them there as well as with criminalized drugs, and I can see good public-health reasons for restricting the use of antibiotics, but whose interest is served by making (say) Viagra or Prozac anything but a plain over-the-counter product? You can hurt yourself with it, sure, but that's not exactly a standard we apply with any consistency: see Tylenol, low theraputic ratio, overdose of, or just the fascinating toxic/caustic chemicals we sell as cleaning products.

#37 ::: Lizzy L ::: (view all by) ::: June 30, 2006, 12:24 AM:

Would it be excessively obnoxious to suggest to Limbaugh that he reconsider his stand in favor of strict enforcement of drug laws?

Not at all... But it would, I suspect, be a waste of time and purely rhetorical, as was, I think, your question. From what I can tell, Rush Limbaugh thinks that laws which apply to other people (and should, by God, apply to other people) should not apply to him. Fidelio's comment was dead on.

I have sympathy for many people caught in the traps our country provides for its citizens through its insane drug laws. I can't find it in my heart to sympathize with Rush Limbaugh. My bad.

#38 ::: Teresa Nielsen Hayden ::: (view all by) ::: June 30, 2006, 12:42 AM:

Nathan, I could maybe see a system where a person would have to consult with a doctor first, and then could get what are now prescription drugs, but I can't see a system where anyone can buy anything. It's way too easy to kill or maim yourself with the modern pharmacopoeia. Just for starters, we'd have a hellacious problem with misapplied antibiotics.

#39 ::: fidelio ::: (view all by) ::: June 30, 2006, 09:25 AM:

Teresa, I have to agree about that. Given the range of possible side effects and drug interactions out there, getting some input and monitoring of what you take for your condition, and whether you should be taking that, given what else you already have to take is a good plan...my hair curls at the thought of leaving it to chance, and in individual's own ideas about What Would Be Good For This, and it's pinned up in a pretty tight bun today. A pharmacist, even more than a doctor of medicine, could probably explain why counting on the experts here is a good plan, but it is.

I think our legal approach to a lot of medications is idiotic, especially painkillers and stimulants*, but I no more think I should be able to prescribe freely for myself, all across the board, than I should be expected to diagnose all of my medical problems. Calibrating the combination of medications someone with a single complicated illness, like lupus or the other autoimmune disorders will get the best results from is a complicated process that requires continual adjustment--making sure these medications don't mix badly with the others drugs the patient needs just adds to the fun. It's not a game for amateurs. Care to figure out what you need to take to treat that pesky cancer, beyond Really Good Painkillers? I'm not saying that taking what you're prescribed in blind faith, without question or discussion is smart either, of course.

And yes, I'd have liked having something more effective for the headache I had Monday than ibuprofen, without getting tagged with "drug-seeking behaviors."

*But the way we advertise medications is as bad. Grrr. Also, Tylenol: grrrr.

#40 ::: Greg London ::: (view all by) ::: June 30, 2006, 10:17 AM:

I just saw a doctor yesterday. Hadn't seen this one before. Was referred to him via someone else. It was the weirdest thing I've ever seen. First of all, the appointment was an hour later than it was scheduled for, so I end up in the waiting room for a long time. The doctor came in with a chip on his shoulder and the attitude that started out with "what are you doing here?" When told of the first problem, he responded with "Why did you come here?" (I don't, because another doctor told me to see you) Apparently that wasn't his specialty. However, he did seem to know enough about the topic to be able to decree "There isn't much you can do about that anyway", which is always encouraging.When communicated the second issue, he said, yes, that can be fixed, you need to see this person. When I asked for further information about the first topic, he went on a pity-party telling me he was retiring soon, wasn't looking to take on new patients, and decreed again that there isn't anything that can be done anyway.

All of this delivered with an emotional subtext of "you idiot. why are you bothering me? don't you know anything?"

At first, I thought I must be reading him wrong. Then I thought he was trying to be funny in a no-skills-for-being-funny sort of way. When I finally got that he was just an asshole, I was already being hurried out the door.

I swear I'm going to get a hidden video camera and tape this crap from now on. Why he had the attitude, I have no clue, but it was clear he had it when he stepped in the room. And it may be that he wasnt' the guy to see for the problem, but why he was mad at me I have no clue.

I can only hope that on his deathbed he realizes his mistake, but can't do anything about it because he's lost the ability to speak and he's getting the same bedside manner from his doctor that he gave me.

#41 ::: Greg London ::: (view all by) ::: June 30, 2006, 10:28 AM:

That should be:

(I don't know, because another doctor told me to see you)

#42 ::: mythago ::: (view all by) ::: June 30, 2006, 11:15 AM:

Your legal-aid lawyer will either be a drunk/drugged ne'er do well or non-existant because of budget cuts.

You know, I think we can talk about the imbalance in the justice system without needlessly crapping on the people who do very difficult work for very little pay under extremely trying circumstances. You also seem to be confusing Legal Aid, which is a specific, government-funded "poverty law" corporation, with the various public-defender and assigned-counsel systems for criminal defendants.

As for "drunk or drugged", if you think that's a characteristic of the idealists who scratch out a living at Legal Aid, you've clearly never seen a bunch of corporate lawyers booze it up at a Continuing Legal Education seminar.

#43 ::: fidelio ::: (view all by) ::: June 30, 2006, 11:22 AM:

Greg, my brother-in-law has had the unpleasant good fortune of being treated by a brilliant neurologist with the social skills of a seed case from a sweetgum tree, or possibly an armload of branches from a honey locust tree. He was great at dealing with the disease, but the effort involved in dealing with him was taxing. Thre are more than few physicians who meet that description out there.

As for the one you had to deal with, it sounds like it may be past time he retired. I hope you gave your referring physician an earful about the encounter.

#44 ::: Ken ::: (view all by) ::: June 30, 2006, 12:15 PM:

"Nathan, I could maybe see a system where a person would have to consult with a doctor first, and then could get what are now prescription drugs, but I can't see a system where anyone can buy anything. It's way too easy to kill or maim yourself with the modern pharmacopoeia. Just for starters, we'd have a hellacious problem with misapplied antibiotics."

Antibiotics aside (since they can breed superbugs that spread), why does stopping idiots from hurting themselves justify any restrictions on medicine? It's not like idiots are an endangered species that actually need to be protected.

#45 ::: Michael Weholt ::: (view all by) ::: June 30, 2006, 12:36 PM:

Why he had the attitude, I have no clue, but it was clear he had it when he stepped in the room.

I have the good or bad fortune of having a doctor who expresses to me his contempt for patients other than me. He's actually a pretty good guy under most circumstances, but he does like to speak (generally, no names) of the dopey behavior of a number of his patients. This is generally in the context of letting me know he can say this stuff to me because I am not (at least in his opinion) one of his dumb ones. Of course, he probably talks about what a dope I am to his other patients. Which is fine with me, actually, since I don't have to experience it myself.

I did have one doctor, a specialist, who treated me like the way you describe. He was supposed to be A Big Shot In His Field. He turned out to have neglected to order one relatively minor blood test that would have given a definitive diagnosis of my problem. This was an oversight that delayed diagnosis of my condition for two years and cost my insurance company thousands of dollars in additional, very complicated tests. Most of which did not go to him, by the way. Which is to say he didn't screw up on purpose to get more money; he screwed up because he was the sort of dope he was thinking I was.

Heh. I'd love to bump into him again some day and explain to him what an incompetent, dopey Big Shot In His Field he is.

#46 ::: Michael Weholt ::: (view all by) ::: June 30, 2006, 12:45 PM:

Ken: Antibiotics aside (since they can breed superbugs that spread), why does stopping idiots from hurting themselves justify any restrictions on medicine? It's not like idiots are an endangered species that actually need to be protected.

Because we will all be stuck with the cost of saving their idiot asses once they discover they weren't the experts in modern pharmacopoeia they thought they were?

Oh, wait. I get it. They are supposed to die of their stupidity. The invisible hand of the darwinian marketplace and all that.

#47 ::: Ken ::: (view all by) ::: June 30, 2006, 01:36 PM:

"Because we will all be stuck with the cost of saving their idiot asses once they discover they weren't the experts in modern pharmacopoeia they thought they were?"

Well, we're paying anyway in higher medical costs, plus paying for the idiots when they find some other way to hurt themselves, and paying in restricted access to medicine, plus paying ever-higher costs as society continues its futile quest to eliminate all the myriad ways that idiots can hurt themselves.

And the idiots themselves breed faster than we do, so all those costs themselves go up over time.

#48 ::: fidelio ::: (view all by) ::: June 30, 2006, 01:40 PM:

Antibiotics aside (since they can breed superbugs that spread), why does stopping idiots from hurting themselves justify any restrictions on medicine? It's not like idiots are an endangered species that actually need to be protected.

Because one of those idiots might be me. It might be someone you are fond of. It might even be you.

Medical diagnosis and treatment is at least as complicated as rocket science. While I don't support the notion that we, the patients, should consent to be passive recipients of care from the Wise Ones, when and as they choose, I do have to admit that there are moments when I should shut up and defer to expertise. I also feel, having some knowledge of the history of drug production and dispensation in the last couple of centuries, that I'd someone with a Big Stick making sure the treatments provided were effiacious and reasonably safe.

#49 ::: Avram ::: (view all by) ::: June 30, 2006, 01:41 PM:

I was gonna write something about how possibly the number of lives that would be saved by allowing people to buy whatever meds they wanted might be greater than the number that would be lost, as I have a vague memory of David Friedman arguing that the number of people who die due to lack of medication that hasn't been approved yet by the FDA is larger than the FDA's estimate of the number that are saved by the FDA having a strict approval process.

But while googling around for supporting evidence, it occurred to me that Friedman's argument probably rests on estimates rather than actual numbers, and besides that wasn't quite the issue under discussion.

But in the meantime, I discovered that Wikipedia's page on the FDA contains the phrase "Gansevoort Destructor Plant", which makes me feel like I'm living in a weird space opera parody. I think the next mech I design for Mechaton will be called the Gansevoort Destructor.

#50 ::: Xopher ::: (view all by) ::: June 30, 2006, 01:43 PM:

Ken, prevention is cheaper than fixing it after the fact. If you're of the "they did something stupid, so the Ship of Society gets to throw them overboard" school, please note that they don't necessarily go away; they revenge themselves on the society that abandoned them by becoming desperate criminals.

It's cheaper to stop them up front than it is to fix them, imprison them, or clean up the messes they make of OTHER PEOPLE's lives, including people who aren't stupid, and aren't related to them.

#51 ::: Fledgist ::: (view all by) ::: June 30, 2006, 01:59 PM:

Xopher:

To write a sonnet cycle with no plot
Is to be avant-garde and not mediæval,
Sticking to narrative line is simply evil,
Imperialist, fascistic, the whole lot
Of oppressive structures misbegot
Upon our language by the sickening weevil.
To tell, as we turn it on the bevel,
A story we can follow -- tommyrot!

Petrarch himself would scarcely recognise
What we have here constructed with our power
To manifest our mental lucubrations
In such obscurity that we seem wise,
The very men and women of the hour,
Keeping base novelists in their proper stations.

#52 ::: Jacob Davies ::: (view all by) ::: June 30, 2006, 02:07 PM:

A few drugs seem to be prescription-only that don't really need to be, but the gatekeeper aspect that makes you consult with a doctor and then a pharmacist seems quite useful for most prescription drugs, even ones with little potential for abuse. A lot of them have interactions with other drugs or side-effects to watch for, and of course your doctor being an expert, they may have an idea as to what will work the best for you. These days you can already walk into your doctor's office with an informed understanding of what drugs might help, and in my experience at least, most doctors are quite willing to listen to that.

I don't really care about the drug-war aspects of it all, and I think we'd all be safer & better-off if you could go to your doctor and get a prescription for MDMA or LSD, should you want it that much - you'd know what you were taking was pure & what you expected and your doctor would be in the loop, just as your doctor might know about your drinking or smoking (ick - considerably more dangerous than most illegal drugs, of course, so you'd expect your doctor to try really hard to get you to stop).

Maybe the same should be true of other drugs that lack the potential for public-health harm - you could insist on being prescribed Viagra or Prozac, for example. But at least your doctor would know and have a chance to discuss it with you. Making them OTC would take that away.

#53 ::: adamsj ::: (view all by) ::: June 30, 2006, 02:25 PM:

Ken, the next time you're feverish, and not thinking entirely straight, maybe you'll be the idiot in question.

#54 ::: Teresa Nielsen Hayden ::: (view all by) ::: June 30, 2006, 02:55 PM:

Ken: To listen to you talk, you'd think the worst thing that could ever happen to anyone would be to have to pay their taxes.

Why not make all drugs OTC? Because I don't want to be the kind of person who's indifferent to the sufferings of kids whose mother made what might have been a trifling error but in her case turned out to be fatal. I don't want to shrug and write off people whose lives, and contributions to society, have been cut to a fraction of what they might have been because messed up with drugs and took out their eyesight, or their liver, or gave themselves a stroke. I don't want to have to read the childhood memoirs of people whose parents had Munchausen's-by-proxy and could get hold of any drug they fancied. I don't want to meet a car on the highway that's being driven by a person who belongs to the tiny fraction of the population that experiences wild delusional anxiety when they take a certain commonly prescribed antibiotic. I don't want to sit in a funeral home and hold the hand of someone who gave what he thought was good, solid, 100% safe advice about medications to his best friend. And finally, because I don't think we'd be better off if advertisements paid for by drug companies were the single biggest source of medical information for the general public.

#55 ::: Lenora Rose ::: (view all by) ::: June 30, 2006, 02:57 PM:

Ken: Ignorance, poor assumptions, or poor research skills are not stupidity, and do not deserve to be treated as such. For that matter, stupid does not equal thoughtless, indecent, wrong, unkind, incompetent, unproductive, unloved, without family or friends, useless, criminal or undesirable. A person pretty much has to be every single one of the above before I would even consider saying "too bad, you're on your own, no safety regulations, ake whatever drugs and antibiotics you want for your condition." And even with all the above, I'd probably still err on the side of advising them to check with an expert.

There are some ways in which our society is overprotective against our many methods of idiocy. While some aspects of the war on drugs do fit under this, the entirety of the pharmaceutical system does NOT.

The pharmaceutical system is more like those annoying people who insist on certain building codes. It's inconvenient for a skilled, safe, but idiosyncratic electrician, or people who don't want to pay for a permit just to put up a garage, but you don't want the building codes to go away.

#56 ::: mary ::: (view all by) ::: June 30, 2006, 03:06 PM:

Why not make all drugs OTC? Because...

Game, Set, Match to Teresa.

#57 ::: Michael Weholt ::: (view all by) ::: June 30, 2006, 03:17 PM:

And the idiots themselves breed faster than we do...

Who's "we" here?

Over the years, I've been hearing more and more of this social darwinism thing so you can understand my confusion about which group of idiots is breeding the fastest.

#58 ::: Greg London ::: (view all by) ::: June 30, 2006, 04:39 PM:

a brilliant neurologist with the social skills of a seed case from a sweetgum tree

At least he was brilliant. The guy I saw couldn't do anything useful for me other than to point me somewhere else.

#59 ::: Lizzy L ::: (view all by) ::: June 30, 2006, 04:40 PM:

I don't mean to pile on here , but I do want to point out that comments about idiots breeding faster than those who are not idiots can often mean: "people who have more children than I approve of are idiots."

Actually, I guess I am piling on, since Teresa has already sliced and diced the commentator into something resembling potato sticks.

#60 ::: Greg London ::: (view all by) ::: June 30, 2006, 04:56 PM:

people who have more children than I approve of

I set my approval rate at .75 children per adult, but I don't think they're idiots if they break that number, I just know we all create the world that the next generation inherits. Personally, I think one-billion people on this planet would be a nice round number to make as a long term goal. But I'm not holding my breath for it.

#61 ::: Bob Oldendorf ::: (view all by) ::: June 30, 2006, 05:19 PM:

Oh, hell, I'll pile on.
Michael Weholt and Lizzie L both beat me to it - but as I'd already formulated a reply, here it is anyway:

Ken, if you're a hard Darwinist, then logically you cannot regard successful breeders as "idiots".

If you insist upon considering society from a Darwinian perspective, then the ones who actually pass their genes on are the ones who are "winning" - and the ones standing on the sidelines sneering at the intelligence of others aren't.

The part of Darwinism that you've overlooked is the part about variation: society needs everybody. We don't actually know who or why, but we need to try out as many possibilities as we can. We may even need the ones who think that "idiots" are outbreeding "us".

#62 ::: Jacob Davies ::: (view all by) ::: June 30, 2006, 06:00 PM:

One billion doesn't seem enough for the rate of progress I'd like to see. I think anywhere from five to ten billion will work out fine.

I know the um, nerdier types (which I count myself among) tend to be pretty down on population, but if a large population can be educated, liberal, and live in a fairly sustainable way (and I realize that last is the major point of contention), there are many advantages to having a lot of people. I'm pretty excited to see what China & India will be able to do with tens of millions of scientists and engineers, if they can achieve economic take-off. And of course, tens of millions of artists, writers, chefs, and god knows what other kinds of creative people; and billions of people just living happy & productive lives.

In a world of one billion, absent technological change that makes everyone able to be a brilliant scientist without needing someone to cook, clean the toilets and take out the garbage, the sheer number of people who can devote their time to progress will obviously be much smaller; in fact probably disproportionately smaller, because of economies of scale that apply when you cram a lot of people together; and the rate of progress probably disproportionately slower too because there would be fewer people to interact with. Leonardo da Vinci would have been a lot more productive if there had been five more people just like him around to talk to.

The sustainability question is the big one. I'm an optimist, and I think a determined effort to make continual progress in efficiency will let the whole population of the world (even as it grows to somewhere under ten billion) live in conditions like the West in a fairly sustainable way - or at least one that isn't always about to cause a global catastrophe. Speaking of which, most of this depends on making it past climate change in the immediate future. Fingers crossed, eh?

Um, so how about that Rush Limbaugh.

#63 ::: bellatrys ::: (view all by) ::: June 30, 2006, 07:20 PM:

Anyone at all tempted to the "I can do it all safely myself" view (let alone Ken's Scrooge-like "and anyone who can't should just die and decrease the surplus population") should just take a look at what nurses have to study to make sure they don't accidentally give bad combinations of drugs that are contraindicated for specific conditions to particular patients with multiple diseases who have multiple doctors prescribing treatments for those pre-existing conditions after they've been admitted to the hospital.

The encyclopedic lists of contraindications are mind-boggling. And when they're accidentally not followed - can result in death. And yes, there are handheld computers that will help. But you have to know what the medical names of all the conditions are, and which drugs are the generics of which, and...

#64 ::: mythago ::: (view all by) ::: June 30, 2006, 07:44 PM:

Oh, but TNH, that's because you're improperly soft and bleedy-hearted. Here, how about you read this copy of The Fountainhead? Then Ken's jibbering will all make sense.

#65 ::: Xopher ::: (view all by) ::: June 30, 2006, 11:19 PM:

Fledgist...*bows*

But this is the wrong thread, isn't it?

Teresa has already sliced and diced the commentator into something resembling potato sticks.

I disagree. I thought Teresa was very civil, and stuck to the points he raised. She demolished his points, but completely avoided personal attack. He's not the piñata of this thread by any means. He made a fairly foolish suggestion which Teresa showed him was fairly foolish. That's all.

I hope next time I say something dumb (which will NOT be the first time), I'm dealt with as civilly. I'm less pleased with the pileon that has followed. But then I'm one of these bleeding-heart types!

#66 ::: J Thomas ::: (view all by) ::: July 01, 2006, 10:09 AM:

why does stopping idiots from hurting themselves justify any restrictions on medicine?

Entirely apart from the arguments about people who are incompetent to take care of themselves but try anyway....

I don't want malicious people to have easy access to every drug. Roofies. Poisons. Etc. I'm perhaps slightly paranoid but I dislike the custom that lets casual acquaintances push food and drink on me as a form of politeness. It would be far worse if anybody could easily get whatever drugs they like.

The issue isn't just people who choose to self-medicate who shouldn't. The current system helps protect you from random or specific people who might choose to medicate you.

I think the current system is bad in various ways. An unknown but probably large part of our medical problems are side effects of bad medical care. Many others are caused by environmental conditions we have created in the last hundred years or so -- carcinogenic fossil fuel residues, a chemical industry that makes over a million unprecedented compounds, etc. To a large extent we'd do better to prevent the problems than to palliate them with new poorly-tested drugs.

For that matter we'd probably do better to eliminate drug patents. Fund drug research with donations and research grants, let the government do the testing. (Maybe have free government-supplied health care for anyone who wants it, except they don't tell you whether you're in the control group or the experimental group.) It's wrong to have the companies that will get giant profits from success to run the testing, and it's silly to measure progress by the number of new drugs they get approved.

The current system is very bad in many details, but I do not think simple deregulation is the answer.

There's a factoid that gets brought up every so often which claims that Christian Scientists and other people who refuse medical treatment are on average just as healthy and live just as long as people who get the latest medical technology. I haven't checked to see whether it's still true. But imagine that it is. Then our spending on pharmaceuticals, which increases considerably faster than the rest of the economy along with drug company profits, might on average be useless. For each drug that palliates an existing condition there's another that creates a new condition to treat.

I guess I'm just grumpy. A year ago I had a filling that the dentist said came too close to the pulp, she said there was a 50:50 chance it would need a root canal. It hurt a little and then completely settled down for 8 months. Then it started hurting occasionally. It started hurting when I got a sinus infection, and it stopped when the sinus infection stopped. A previous dentist had said that the roots stuck up into the sinus cavity and there was only a tough membrane separating them, and I imagined that sinus pressure might be the problem. Three times I got a sinus infection, the tooth hurt, I went to my new dentist, he said my bite needed adjusting and ground down the tooth, I'd get an antibiotics prescription, the sinus infection would go away and so would the tooth pain. I asked the dentist why the tooth would shift position and he'd shrug and say it just happened. I imagined that sinus pressure on the tooth made it change position.

The last time I took one antibiotic for two days. A few hours after I started the tooth pain stopped. A few hours after I stopped it the tooth pain came back. I took another antibiotic for 5 days and it went away a few hours after I started. I went back to the dentist and told him that. He said I probably needed a root canal, that the roots of the teeth are separated by a thick layer of bone from the sinus, that by far the most usual cause for these symptoms is a dead tooth that's rotting like a dead pig. He sent me to a specialist to diagnose.

The specialist looked at the x-ray and started to numb my mouth. I asked him what was going on and he said, "You're here for a root canal, aren't you?" I had thought I was there for a diagnosis. He said that a filling that touched the nerve always needed a root canal, it would always go bad, no point in putting it off, he'd have it done in half an hour. When I wasn't sure he said to think it over and he left the room. I felt like I'd asked my barber whether I needed a haircut, but I didn't see what to do. It made sense he was probably right. I looked at the x-rays which didn't show anything in particular to me, and told the dental assistant I'd go ahead with it. Hardly more than an hour later I had a $1400 root canal.

And now I have another sinus infection and my tooth hurts. I feel so stupid.

#67 ::: Fragano Ledgister ::: (view all by) ::: July 01, 2006, 11:04 AM:

Xopher: My error. I was having trouble with my connection and ended up plopping the sonnet in the wrong thread.

#68 ::: Charlie Stross ::: (view all by) ::: July 01, 2006, 11:38 AM:

(Coming in late, due to travel) ...

Ken: Antibiotics aside (since they can breed superbugs that spread), why does stopping idiots from hurting themselves justify any restrictions on medicine?

Because a lot of those medicines have side-effects that include impaired judgement. And a lot of those "idiots" are going get behind the wheel of an automobile and kill or maim innocent third parties.

Are you beginning to get the picture?

Medical problems have no externalities: it's one of those fields where the free market is not only not the optimal solution, but actively wrong and harmful. The invisible hand is flailing around blindly with a scalpel and if you're not lucky you'll get cut. Etcetera.

#69 ::: mythago ::: (view all by) ::: July 01, 2006, 02:37 PM:

I haven't checked to see whether it's still true.

Or whether it was ever true in the first place. I guess it also depends on whether you think that palliative care has any value.

#70 ::: hamadryad ::: (view all by) ::: July 01, 2006, 05:39 PM:

But then I'm one of these bleeding-heart types!

They have drugs to help you with that now.

#71 ::: hamadryad ::: (view all by) ::: July 01, 2006, 06:06 PM:

Antibiotics aside (since they can breed superbugs that spread), why does stopping idiots from hurting themselves justify any restrictions on medicine? It's not like idiots are an endangered species that actually need to be protected.

Becoming a licensed pharmacist in Canada requires a Bachelor's degree, a national board examination and an apprenticeship/internship. I don't know how much training is required to become a licensed physician, but I'm sure it's no less rigorous.

Most of the people in my circle of acquaintances are not idiots. Most of them are highly intelligent. And not one of them has the knowledge they would need to be able to safely prescribe their own medicines.

And now a bit of trivia, because I'm a trivia pack-rat. According to the Ontario Medical Student Association:

The average human body contains enough: iron to make a 3 inch nail, sulfur to kill all fleas on an average dog, carbon to make 900 pencils, potassium to fire a toy cannon, fat to make 7 bars of soap, phosphorous to make 2,200 match heads, and water to fill a ten-gallon tank.

#72 ::: J Thomas ::: (view all by) ::: July 01, 2006, 06:26 PM:

Mythago, there are a collection of such factoids floating around. For example, people diagnosed as psychotic seem to recover at about the same rate on average no matter which psychiatric treatment they get, and no metter whether they get any treatment. Back in the days I associated with psychiatrists and clinical psychologists, they mostly agreed that sure, that's true on *average*, but the good ones (like them) do a lot of good and the bad ones do a lot of harm, and so the results average out.

The psychiatric studies were actually done and occasionally replicated with reasonably large samples. They don't mean as much as the factoid seems to imply. Maybe psychotics tend not to pay attention to talk therapy, which could still be good for some other problems. And the studies didn't show that no therapy made any difference. They showed only that therapy made so little difference on average that those particular studies couldn't detect the difference. Perhaps larger studies might detect a difference that was too small for these studies to notice.

My old epidemiology teacher claimed that improvements in average lifespan came from increased standard of living, and mostly not from improved medical care. At least it correlated with that much better, the improved living conditions tended to come before the increased medical care. Better water, refrigeration, window screens, gas or electric stoves, vitamins, etc. People didn't get badly sick as often and they died of their sickness at an older age. Because they were healthier generally.

Now, consider how effective the medical profession is about anything that's nonroutine. Have you ever had a nonroutine problem, and you studied up on it, and soon you found you knew more about it than all but a few specialists? You'd go to an MD who didn't understand anything? You found one specialist who knew more than you did, and that's the one you trusted. Out of a hundred people who had your problem, how many do you think found the one right guy? Mostly the system is broken for things that aren't routine.

For things that are routine we have a cost spiral. Cheap drugs that are used by large numbers of people have lots of chances for side effects to show up. That's a great opening to replace them with something new and expensive. There are tremendous financial incentives to do that. There are tremendous financial incentives to cheat on the process. The MDs are as swamped with information (and misinformation) as you are. The system is broken.

The bottom line is, as your standard of living drops your life expectancy will drop too, pretty much independent of the state of your health insurance.

But then, this is entirely a handwaving argument. It makes sense but it doesn't have to be true. Maybe the large majority of MDs are spending the 4 hours a day they need to keep up with their field. Maybe the pharmaceutical industry is run almost entirely by humanitarians who put aside self-interest for the good of humanity, who resolutely refuse to cheat on their science even when it costs them many millions of dollars. Maybe most MDs are good enough at science and statistics that they read the research closely and disbelieve incorrect claims. It doesn't have to be true just because it makes sense.

#73 ::: Larry Brennan ::: (view all by) ::: July 01, 2006, 07:16 PM:

I did a bit of light websearching because I recall having heard that Christian Scientists do have a statistically significantly lower lifespan than the general population.

From http://biochemistry.louisville.edu/education/faith05.pdf (not building a link since it's a PDF) I found the following:

A 1950's study found, however, higher than average death rates due to malignancy and heart disease, and a lower than average life expectancy, for Christian Scientists. A more recent study (JAMA 262, 1657-1658 (1989)) also concluded a higher death rate.

I haven't dug deeper of found the original cite simply because I'm lazy, but I'd bet that someone with more energy than I would find really solid evidence that being a Christian Scientist is bad for your health.

For what it's worth, I not only favor keeping pharmacists as gatekeepers to the modern pharmacopoeia, I favor single payer so people on limited incomes can use ONE pharmacist and not spread their business all over town trying to save money. A few years ago, during a bit of a health-care intervention my cousin gathered up all of my grandmother's meds and took the list to a pharmacist. He immediately found a potentially dangerous interaction (which thankfully hadn't happened) and worked with three different doctors to get the whole thing sorted, even though he only got a little bit of the resulting business.

Pharmacists (except when they're anti-birth control moralists) tend to be a great resource.

#74 ::: mythago ::: (view all by) ::: July 01, 2006, 09:04 PM:

My old epidemiology teacher claimed that improvements in average lifespan came from increased standard of living, and mostly not from improved medical care.

What, he didn't tell you the story about the pump handle? I think you are confusing 'common public health measures' with 'standard of living'. Two hundred years ago, the richest of the rich had servants, but they didn't have laws that limited the amount of lead in your water.

I'm about the last person to say nice things about Big Pharma, since I'm one of its natural enemies. But I'm also one of the last people to try and pretend that medicine and drugs are useless, and all you need is clean living and over-the-counter stuff you read about on the Internet.

#75 ::: Alan Yee ::: (view all by) ::: July 01, 2006, 09:29 PM:

I didn't read this discussion until today, but I have total sympathy for the poor guy with the spinal injury who definitely needed his meds for the constant pain.

One of my prescription drugs (I have a mild version of Asperger's Syndrome, and a version of ADHD) is one of the most easily-abused drugs out there, and there's even an entire illegal drug trade for this one drug. The black market for this drug is so huge that my parents' insurance companies won't cover for it. It's Adderall, which I desperately need to function properly, especially during the school year, or else I can't get any work done.

I'm 14, turn 15 in October, and start high school in September. To succeed in high school, I will need my Adderall to make myself able to focus. I know of other people who take Adderall, but I don't believe for a second that most of them need it as much as I do. I personally don't think the security at the airport would react well if they found a bottle of Adderall in my suitcase, regardless of the official diagnosis from my doctor.

If I don't have my Adderall, my Geodon, and my Citalopram, every day, in the correct doses, and take them at the right times, expect some strange behavior and spontaneous emotional outbursts. That happened recently on AW, on the day I accidentally only took 1 Citalopram pill instead of 1 1/2. Let's just say, I got confused about two rep comments I received, and posted a thread about it, which Jenna had to close. That's just one example of what happens if I don't get my medicine. If I don't get my Geodon at the correct time in the evening, I can't get any sleep at all for the entire night, or I'm a groggy zombie in the morning when I have to get ready for school.

It would be terrible if I couldn't get the correct doses legally, because my doctor's current combo of meds has made me much more stable than I've been in years. Do I still have outbursts once in a while? Hell yeah, you can never completely stop that. But because of it, I talk to other people more often, more people like to talk to me, and I have a bunch of friends, online and offline, male and female, fellow teens and other adults of a variety of ages. You wouldn't want to deprive a 14-year-old kid with Asperger's of all that, at the point in their lives where the neurological disorder affects them most negatively, and where they are getting closer to the point where Asperger's becomes much more easier to handle, would you?

Rush Limbaugh is a dirty aristocratic snothead who thinks he's above the law because of his wealth and status, and who makes people who actually desperately need their meds suffer. That poor guy who's living in excruciating pain shouldn't go to jail for 25 years. How about he goes free and gets his desperately-needed meds, and Rush gets serious major jailtime?

Ah, if only that truly happens. I really hope it does, though.

#76 ::: J Thomas ::: (view all by) ::: July 02, 2006, 01:54 AM:

Larry, thank you for the link!

I found only the abstract, not the actual study, or the published errata, or the published comment. I can't tell much about what the author did, except that he compared known deaths among graduates of a small college that accepted only christian scientists versus a large school that had mostly others. The obvious possibility is that the large school did not track alumni deaths as carefully.

The author of the study is a computer scientist
http://www.emporia.edu/math-cs/faculty/profiles/simpsonb.htm
who got a BA in business administration from the christian science school and a PhD in Special Studies from the second school. He is one of the data points in his own study, which was not funded.

A CDC study covered similar data.
http://www.cdc.gov/mmwr/preview/mmwrhtml/00015022.htm
They compared the same christian science school with a seventh-day adventist school. The 7th day adventist school had lower mortality even when they assumed that all the missing christian science alumni were alived but the missing 7th day adventist alumni were dead at the same frequency as the known population.

Both groups suggest no smoking or drinking, but the 7th day group also avoids some foods (pork and shellfish etc) and limits all meat to less than once a week.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=10496509&query_hl=8&itool=pubmed_docsum
Here's a phone survey of christian science and others. The CS guys report significantly less illness etc. The study has obvious errors from the abstract, but Similar proportions of Christian Scientists and non-Christian Scientists used some type of conventional medicine (74% vs. 78%, respectively), although Christian Scientists were less likely to take prescription medications than non-Christian Scientists (p = .034). These are not people who are utterly rejecting conventional medicine. Don't take the p=.034 too seriously, for another question the difference between 73% and 80% was .05 and 67% versus 42% was .00001. In this particular sample fewer christian scientists had taken prescription drugs than others, but it wasn't a whole lot fewer.

I found an abstract about old amish.
Am J Epidemiol. 1981 Dec;114(6):845-61.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=7315833

Death certificates and Amish censuses were used to determine mortality risks, which were summarized using age-adjusted mortality ratio (MRs). Amish mortality patterns were not systematically higher or lower than those of the non-Amish, but differed by age, sex, and cause. Amish males had slightly higher all-cause MRs as children and significantly lower MRs over the age of 40, due primarily to lower rates of cancer (MR = 0.44, age 40-69), and cardiovascular diseases (MR = 0.65, age 40-69). Amish females MRs for all causes of death were lower from age 10-39, not different from 40-69, and higher over age 69.

I put about an hour and a half into looking, and haven't gotten anything at all definitive yet whether being christian scientist is bad for your health. It's hard to figure out what questions to ask about methodology errors without having the whole papers. So much medical research is poorly thought out....

#77 ::: CHip ::: (view all by) ::: July 02, 2006, 09:42 AM:

wrt Christian Scientists: one variable the studies would need to control for is economic class. The children of the well-off, and even the doing-ok, have significant advantages: they're better nourished and aren't exposed to as many environmental toxins. (They may also develop somewhat healthier habits; I get the impression that all levels watch too much TV, but it's even more common in the poor because the TV is an affordable child-sitter. This is not a quotable statistic.) All of this makes a difference in later health and lifespan. (There were Christian Scientists in my mother's family; she commented that CS she knew (of) tended to be the well-off, who confused their economic health advantage with God's favor; cf Ann Richards's comment about Shrub being born on 3rd base thinking he'd hit a triple. This is even more anecdotal than the above.)

Popping a level: I suspect many people don't realize just how complicated prescribing the right drugs is -- or how complicated any other profession is. From a political view, I stand mostly opposite the current administration's position, and I don't have a strong logical position for it; much of their regulation is devoted to preventing people from getting high, which I'd think was no business at all of theirs* if it weren't for the fact that careless users of the most common intoxicant are known to kill other people as well as themselves.** There are plenty of useful drugs that have turned out to be dangerous; unfortunately there's no good formula for balancing danger against value. To make matters worse, the high-value drugs seem to be mostly the ones that can be prescribed for a wide-spread but minor condition (pain, weight, ...); there's less economic incentive to test a drug that is critical for a relatively small number of people. There is "orphan drug" legislation for extreme cases; I don't know where it stands or what its effect is / would-be. There's been very little government willingness to do disinterested testing even before the current all-tax-cuts-are-good-tax-cuts administration. But the market is an even worse regulator, because the market hasn't even a pretense to disinterest.

(*) cf Tom Lehrer in the intro to "Smut": "It's matter of freedom of pleasure, which \isn't/ guaranteed in the Constitution."

(**) Other intoxicants don't get a pass; IME they just aren't as well-studied because they aren't supposed to be used at all. Back when I was flying light planes one of the magazines claimed that people high on marijuana would fly a perfect simulated instrument approach because they were focused -- so focused that they forgot to flare for a landing.

#78 ::: Teresa Nielsen Hayden ::: (view all by) ::: July 02, 2006, 03:42 PM:

Greg London:

"I just saw a doctor yesterday. ... At first, I thought I must be reading him wrong. Then I thought he was trying to be funny in a no-skills-for-being-funny sort of way. When I finally got that he was just an asshole, I was already being hurried out the door."
Been there. Hated that. If you ever wind up in that situation again, think about phoning the referring doctor, ideally while the doctor who's being a jerk is within earshot, and say "Dr. [Jerk] is giving me a hard time. He says he can't see why you sent me here." Doctors who think nothing of mistreating patients will often be much more thoughtful when other doctors are in the mix.

Of course, what they should do is phone the referring doctor themselves. But they won't, because they're being jerks.

When I was first diagnosed with narcolepsy, they told me as a matter of objective fact that three times as many men as women have the syndrome. They don't say that any more. It's not a gender-biased disorder. What was happening was that women were being intimidated and treated dismissively to a disproportionate degree.

Fidelio:

"Greg, my brother-in-law has had the unpleasant good fortune of being treated by a brilliant neurologist with the social skills of a seed case from a sweetgum tree, or possibly an armload of branches from a honey locust tree. He was great at dealing with the disease, but the effort involved in dealing with him was taxing. Thre are more than few physicians who meet that description out there."
I was sitting there, nodding in agreement, until I got to the word "physicians". I was sure you were talking about neurologists as a class. Not all of them are that bad, but they seem to get more than their share of brilliant doctors with terrible interpersonal skills.

You'd think that med students who don't like dealing with anecdotal data, or analyzing detailed vernacular descriptions of the shifts of tendencies and manifestations in these poorly-understood conditions, or working with patients who are sometimes hazy or confused, would pick a different specialty. If they don't like dealing with the human condition in all its pixel-by-pixel glory, clinical neurology is not where they belong.

Fledgist, that was lovely, but are you sure you didn't intend it for the Kim Stanley Robinson discussion?

Jacob Davies, a possible model I've kicked around in my mind is one where you have to go to a doctor for your first prescription for some medication, and he'd have some say about whether it could be prescribed on that occasion. Thereafter, you'd have to talk to him, but he'd have to issue you your chit for a refill. I can also see retaining the whole prescription system for classes of drugs where you really do need to be an expert to prescribe them properly.

However, there are scenarios where that model doesn't work. For instance, teenage boys have inadequate judgement about the advisability of taking steroids. People who suffer from morbid anxiety about cancer would be able to dose themselves with anti-cancer drugs, many of which are toxic. Schizophrenics are famously unable to judge which drugs they should or shouldn't be taking, and they have eccentric notions of the ills they may be suffering from. True hypochondriacs need treatment for their mental problems, not for the diseases they imagine they have. Patients with long-term infections needing consistent antibiotic treatment over long periods really do need to be monitored for compliance. Pediatric pharmacology is a demanding specialty, a whole separate thing: small children are like a different species. And then there's parental misuse of drugs for children. I know that in the 1960s, when we had a more lax attitude toward tranquilizers, some parents would casually dose their children with Seconal or the like during long car trips -- so much pleasanter to travel with kids who stay quiet all day.

We need to figure this stuff out as a society because our medicine is increasingly powerful. Having full and fair access to the full range of pharmacological options is going to matter more and more.

Mythago: "Oh, but TNH, that's because you're improperly soft and bleedy-hearted. Here, how about you read this copy of The Fountainhead? Then Ken's jibbering will all make sense."

Have you ever noticed that in Rand's universe, the good guys never get sick, or get pregnant, or suffer debilitating accidents, or even have to deal with tooth decay? You can practically gauge the state of someone's soul by looking at their complexion. Whiny collectivist thoughts will turn it sallow and saggy in no time at all.

J. Thomas, one of my dentists once talked to me about patients he gets who've been grossly mishandled by other dentists. It happens. The dentist who gave you the root canal was right. I speak here as someone who's had many, many root canals. Fillings can't touch nerves. If they do, the tooth will go bad. When they diagnosed you as needing a root canal, they were looking at your x-rays, and it doesn't sound like there was much question about what needed to be done. You should see what happens when it doesn't get treated. You can wind up in the hospital getting part of your jaw reconstructed.

Once you've had your root canal, the tooth by definition can't hurt -- they gouge the nerve out in scraps, using teeny little hand-turned steel drills. No nerve, no pain. There might be some residual tenderness from the work itself, but that's all. What you're feeling is your sinuses. They have enough nerve endings to supply any amount of pain.

Re another one of your comments, psychosis wasn't responsive to standard psychotherapy because it isn't a cognitive/behavioral condition. It's hardware, not software. At the time that that statement was formulated, narcolepsy and obsessive-compulsive disorder were also classed as psychiatric disorders. The stats on all three have improved. I know modern antipsychotic drugs do some good, just now how much, but narcolepsy and OCD are greatly improved. There've been some downright dramatic OCD cases who've been returned to something close to normal functioning.

We live in the dawn of effective, scientific medicine. Our doctors find a new button to push and they push it a lot. The 50s and 60s were way big on psychology. In some cases, it did a lot of good. In other cases, it did no good at all, because it wasn't the right treatment for that condition.

"Have you ever had a nonroutine problem...?"
(Laughs bitterly.) Guy, I messed up the standard definition of narcolepsy. It cost years of my life and a mountain of trouble, but eventually we got things sorted out. If I'm tempted to feel sorry for myself, I can go talk to Marilee Laymon about it. She had a nonstandard problem that cost her a lot more than mine did me.

Medicine nevertheless works. Not always, not perfectly, not in every case, not with every illness. But it does work. I suspect the biggest problem with epidemiological studies of Christian Scientists is that it's a religion that selects for adherents who are basically healthy to start with, and who cultivate healthy habits. If you're looking at what adherents died of, you're losing all the people who said "To hell with this, I'm going to see a doctor." And if you're studying the later lives of young Christian Scientists who are the children of Christian Scientists, you've got a sample that's skewed not only by self-selection and ingrained behavior, but by genetic inheritance.

You get the same problem with Seventh-Day Adventists, since you've selected for a population that's living a sufficiently orderly, diet-conscious life to observe that denomination's various guidelines and prohibitions.

Mormons do those studies too.

Finally, how your epidemiologist could statistically separate "increased standard of living" from "better medical care" or even just "widespread childhood immunization" is beyond my ability to discern, unless he's talking about populations living at a level where "increased standard of living" means "not so many people starve to death." I don't know of a single human population that enjoys a good standard of living but doesn't at least immunize its children, or live among people who do.

Alan Yee, that's a great, great comment. Thank you for posting it. You, and I, and all the other people we know who have chronic illnesses requiring heavily restricted drugs, pay constantly for the misbehavior of rats like Rush Limbaugh. The system doesn't just bear down on cases like that poor guy who got sentenced to 25 years for the same offense that got Limbaugh's wrist slapped, though lord knows it would be bad enough if that were all that happened.

I understand that some of the right-wingers have been comparing Limbaugh to Hunter S. Thompson, a thing they can only safely do because HST is dead. Is it not a wild piece of hypocrisy for them to forgive serious drug abuse if it's one of their guys? If Limbaugh had been poor or black, a handful of Oxycontins in his pocket would have been enough to get him nailed.

By the way, watch out for scare-tactic news stories about the "epidemic" of Adderall use among college students. I see the stories, but I don't see any hard numbers in them, and that makes me extremely wary. The powers that be have been moving generally against the stimulants. (My paranoid theory: it's because they're performance drugs. Only people in power are entitled to a boost.) It can do you and your parents no harm to make sure your doctors know that Adderall is not an optional drug for you, and that wheedling down your dose is not on the menu either.

#79 ::: Clark E Myers ::: (view all by) ::: July 02, 2006, 04:56 PM:

There's an ongoing controversy about drug qualifying chess players mostly using Olympic standards. Many chess players consider such testing both intrusive and irrelevent to chess playing skills.

Others say that using chess players as a field test to find drugs that improve mental performance over the length of a full match sounds like an idea more to be encouraged than discouraged.

Drug testing has dominated.

#80 ::: Ken ::: (view all by) ::: July 02, 2006, 07:44 PM:

"Rush Limbaugh is a dirty aristocratic snothead who thinks he's above the law because of his wealth and status, and who makes people who actually desperately need their meds suffer. That poor guy who's living in excruciating pain shouldn't go to jail for 25 years. How about he goes free and gets his desperately-needed meds, and Rush gets serious major jailtime?"

No, it's the people who think that it's worth paying any price, including condemning innocent people to needless suffering and death, to stop people like Rush Limbaugh from getting his jollies, that make people who actually desperately need their meds suffer.

Now any large system will have cases where things go wrong and people suffer. But I maintain a system where people are more free to solve their problems is superior to a system where people are less free to solve their problems. A system where people who need medicine are never prevented from getting it, but some who are determined to misuse it are not prevented, is superior to one where everyone is protected against their will and a number of people will be deprived by law of treatment that exists and that they can pay for.

Nothing in a deregulated system would prevent people consulting doctors and getting advice on treatment. People who are not smart enough to be their own doctors would be smart enough to consult doctors and take their advice. As for people who won't even use the common sense to do that, it's unfortunate if they hurt themselves, but protecting people who would otherwise be so willfully stupid does not justify condemning anyone who will actually try to solve their problems correctly to excruciating pain, unemployment, mental disability, or other treatable condition.

#81 ::: rhandir ::: (view all by) ::: July 02, 2006, 08:30 PM:

I hear a great whooshing sound, as if millions of nuanced points suddenly soared overhead, and were silenced.

-r.

#82 ::: Margaret Organ-Kean ::: (view all by) ::: July 02, 2006, 09:15 PM:

TNH writes:

"Once you've had your root canal, the tooth by definition can't hurt -- they gouge the nerve out in scraps, using teeny little hand-turned steel drills. No nerve, no pain. There might be some residual tenderness from the work itself, but that's all. What you're feeling is your sinuses. They have enough nerve endings to supply any amount of pain."

This alas, is only the usual case. It is possible to have two root canals on one tooth, even with a very competent endodontist. All that needs to happen is, for example, new decay to open up a new pathway to the root, ending up with an abcess somewhere along the root.

Or, somewhat worse, an apicoectomy (think sideways root canal, through the jaw). I had the later, probably due to a decidedly mutant root with a right angle in it, which was not visible on x-rays. Since I had a crown & titanium post in the tooth, my endodontist was not gung ho on drilling up through the tooth again.

If you have pain in along the roots of a tooth, visiting a good endodontist (get a recommendation from friends or your dentist) is a good idea. They're trained to sort out whether you need a root canal for an abcess or if you have some other problem - TMJ or bruxism for example.

#83 ::: JESR ::: (view all by) ::: July 02, 2006, 09:35 PM:

Rhandir, I believe I'm hearing the same sound.

I've mostly been reading this and nodding my head and rolling my eyes in about equal amounts, but people have been making my points for me.

I'm taking a slew of drugs, about half of which are for tweaking side effects for other drugs. Most of them are for high blood pressure and diabetes, but I have two scripts for class 2 drugs: Adderall, strangely enough, and Hydrocodone. Those are the two for which the dosages are stable and the indications straightforward, and the two which I could probably competantly supply for myself, given a libertarian pharmacy.

The others are another matter: I need regular lab work and office visits to monitor whether the drugs are doing what they're prescribed to do, and just that, and neither more nor less than the degree of effect I need. Even with home testing gear, problems can sneak up on me. Since I'm a patient of that evil collectivist organization, Group Health of Western Washington, I get print-outs from the pharmacy telling me when I need lab work.

Given that I'm trying to keep up with an environment which is unpredictable and prone to sudden crises ("life on the farm is kind of laid back" my saggy middle-aged ass) having somebody else keeping track of these things is a necessary component of my health-care; it's tricky enough to deal with keeping my food intake and excersize balanced on a day-to-day basis.

I manage the trees, in other words, and the experts look after the forest.

That's the aside. The point about Rush is that he is a party to a legal agreement under the existing body of law, and by carrying improperly labeled prescription drugs, he has violated his end of that contract. Any discussion of the shoulds of drug policy and regulation is external to his responsibility in the matter.

#84 ::: Xopher ::: (view all by) ::: July 02, 2006, 09:57 PM:

That clattering sound you hear is the scales falling from my eyes.

Oh my. That is a piñata.

#85 ::: Julia Jones ::: (view all by) ::: July 02, 2006, 10:52 PM:

Reasons why your tooth might still hurt after root canal work, apart from referred pain from your sinuses...

Unusually long roots, and the dentist didn't go quite deep enough, resulting in redoing the filling. More than the usual number of canals, especially if you have very narrow canals anyway and they're difficult to spot. An impacted wisdom tooth pressing against the tooth, slowing down or preventing healing of the post-operative tenderness. Nerve damage from removing the wisdom tooth, leading to referred pain and/or phantom limb pain in the treated tooth. A cracked tooth, leading to stress in the ligaments that hold the tooth in the socket.

Go on. Ask me how I know. :-( The extra canal was ruled out during the refill, and the crack was confirmed by the fact that the acute pain rapidly reduced within a few hours of the crown going on (the standard treatment). The rest was never confirmed or eliminated. But yes, if a filling is touching the nerve, you need a root canal filling. Because it can get *much* more exciting than all of the above if you don't have one.

#86 ::: Adina ::: (view all by) ::: July 02, 2006, 10:52 PM:

Another note about root canals: I had one, and my tooth continued to hurt. Long story short, it turns out that it's possible to have more than the usual three roots in a tooth, and they can be faint and hard to see on an X-ray, and someone who's not expecting to see the extra ones may not do so.

#87 ::: mythago ::: (view all by) ::: July 03, 2006, 01:08 AM:

People who are not smart enough to be their own doctors would be smart enough to consult doctors and take their advice.

It's beautiful in its own jaw-droppingly clueless way, isn't it?

I presume that Ken is also in favor of a fully-subsidized medical system, so that "people who need medicine are never prevented from getting it". After all, we wouldn't want anyone prevented from getting medicine just because it costs more than their income.

#88 ::: J Thomas ::: (view all by) ::: July 03, 2006, 03:53 AM:

The dentist who gave you the root canal was right. I speak here as someone who's had many, many root canals.

You seem to me to be generally competent in a wide variety of areas. I pay careful attention to your opinions. But in this particular situation, having a lot of root canals doesn't make you competent about my root canal any more than going through a lot of muggings would make you competent at getting mugged.

When they diagnosed you as needing a root canal, they were looking at your x-rays, and it doesn't sound like there was much question about what needed to be done.

Maybe. I looked at the x-ray my dentist took, which showed considerable space between most of the filling and the pulp except perhaps in one spot that wasn't obvious. He looked only at the x-ray his technician took which was done from a different angle and showed the filling generally in front of the pulp. This endodontist looks at 10,000 times as many x-rays as I do, and he ought to see things I miss. If I knew what percentage of x-rays he looks at and says don't require root-canals, that wouldn't tell me much either. Even if it was 0% that might only mean that dentists are conservative about sending people to him.

He did find the fifth root, I couldn't have begun to see that from the one x-ray which showed them all bunched together in a cone.

You should see what happens when it doesn't get treated. You can wind up in the hospital getting part of your jaw reconstructed.

Yes, the possible consequences of not getting a needed root canal are much worse than for getting an unneeded one. That isn't a good argument for pre-emptive attack.

Once you've had your root canal, the tooth by definition can't hurt -- they gouge the nerve out in scraps, using teeny little hand-turned steel drills. No nerve, no pain. There might be some residual tenderness from the work itself, but that's all. What you're feeling is your sinuses. They have enough nerve endings to supply any amount of pain.

Well, yes. It appears that's what I was feeling all along. $1700 of dental work so far may have been ultimately good for my dental health but was probably unrelated to the symptoms.

We live in the dawn of effective, scientific medicine. Our doctors find a new button to push and they push it a lot.

We have always been in the dawn of effective scientific medicine. Sunrise is a long time coming.

It cost years of my life and a mountain of trouble, but eventually we got things sorted out. [....]

Medicine nevertheless works. Not always, not perfectly, not in every case, not with every illness. But it does work.

The medical industry is a complex system that operates in failure mode. People get hypnotised by it, to the point that they suppose that what the system does for them is what they ought to want. They accept failure mode as the way things are, the best that's possible under the circumstances, still somehow better than no system at all, better than absolute and total failure.

I suspect the biggest problem with epidemiological studies of Christian Scientists is that it's a religion that selects for adherents who are basically healthy to start with, and who cultivate healthy habits.

I dunno. The two people I met randomly that I found out were involved with Christian Science were chronicly sick people who were looking for a cure. They'd each run through modern medicine until they were sick of it and were trying alternatives. I don't know how long either of them stuck with christian science, though. They certainly wouldn't have been part of a study of people who went to a christian science college. They were both trying to cultivate healthy habits.

You get the same problem with Seventh-Day Adventists, since you've selected for a population that's living a sufficiently orderly, diet-conscious life to observe that denomination's various guidelines and prohibitions.

Why is this a problem? I'd think that these effects would be worth measuring.

Finally, how your epidemiologist could statistically separate "increased standard of living" from "better medical care" or even just "widespread childhood immunization" is beyond my ability to discern

I probably stated that too forcefully. He argued that standard of living was most important, but he didn't claim it was proved. Looking over the course material I saw a collection of things that fit that viewpoint. American health and mortality at that time was very different by social class and by race and by income (which all tended to correlate), which could be intepreted as standard of living being important though it could be interpreted as differences in access to medical care. There was the repeated claim that for epidemics etc the number of cases was considerably higher than the number of cases that received medical attention (which itself was higher than the number that the MDs reported -- particularly early in an epidemic lots of cases would be misdiagnosed as something else and not reported as part of the epidemic).

Beyond retail medical care (which happens in a minority of sicknesses and maybe even a minority of life-threatening illnesses) we have improved sanitation, improved water supplies, improved nutrition, refrigeration of food, reduced personal use of coal, for a few diseases mass immunisation, etc.

It seems plausible to me that environmental improvements (better water, food, air, reduced carcinogens etc) plus public health efforts have a much bigger impact on health than the retail medical system, but I wouldn't claim to have definitive proof. How much of our GDP should go to the retail medical system? 10%? 15%? 20%?

#89 ::: Larry Brennan ::: (view all by) ::: July 03, 2006, 04:25 AM:

J Thomas - as someone who has had acute appendicitis, I can say for sure that I wouldn't be here if it weren't for the medical system. We can make it be less bloated and inefficient, but making it go away would be sheer folly.

***

Ken, I'm certain that if I said what I'd really like to say in response to you, it would get disemvowelled. I think your concept of empowering people to buy whatever pharmaceuticals they want is unwise for many reasons completely independent of the war on (some) drugs.

#90 ::: J Thomas ::: (view all by) ::: July 03, 2006, 04:46 AM:

Now any large system will have cases where things go wrong and people suffer. But I maintain a system where people are more free to solve their problems is superior to a system where people are less free to solve their problems. A system where people who need medicine are never prevented from getting it, but some who are determined to misuse it are not prevented, is superior to one where everyone is protected against their will and a number of people will be deprived by law of treatment that exists and that they can pay for.

Ken, I have a lot of sympathy for your approach. In general I prefer freedom to being controlled. When things are set up so that authorities of various sorts personally benefit by exercising their authority, I get suspicious of them. Are they doing their jobs for my benefit or for their benefit?

But there's a limit to how much we can trust the disorganised public, too. Free access to dangerous drugs is more dangerous than free access to guns. If you shoot somebody, it makes a loud noise that anybody nearby will hear. It puts a hole in the victim that's usually obvious. If you get tested within hours it's provable whether you have fired a gun. If you don't throw the gun away it can often be tested whether the bullet that made the hole in somebody came from your gun.

None of this is true for drugs. There is a bewildering variety of drugs with a bewildering variety of symptoms. Anybody who can manage to administer a drug to you can hurt you in ways that may kill you immediately or not for weeks, give you temporary or permanent mental impairment, etc. Many drugs can be aerosolized. Some can be made to soak through your skin. Modern injectors don't leave a mark and make only a little noise.

We already have a potential giant problem with this. There's already a black market in the drugs that are widely known to be most useful. Various sexual deviants manage to get roofies, and most bartenders can administer mickeys if needed. But wouldn't it be a hundred times worse if everybody had easy access to every drug?

Incidentally, I tried a quick google search to find out how many prescription drugs there are. In five minutes I didn't find out. Does anybody know that number?

Anyway, I'm not ready to talk about whether people should have restricted access to drugs for their own good, until we've settled whether other people should have restricted access to drugs for my good. I'm willing to put up with a lot of restrictions on my access to dangerous drugs if it makes it harder for other people to have access to dangerous drugs. I'm not just concerned about them turning into dangerous drivers. I'm concerned about people using them as weapons.

If it was just a matter of overconfident people hurting themselves with drugs, then I'd have a lot of sympathy. When I was looking for the number of prescription drugs I saw the factoid that 7% of all US hospital admissions already come from people who got wrong dosages or drug interactions of prescription drugs. If the professionals are already messing up that bad, would the amateurs do so very much worse? But in this particular case the stupid people are less a problem to me than the mean ones. We aren't ready for that kind of weapon.

#91 ::: J Thomas ::: (view all by) ::: July 03, 2006, 04:55 AM:

Larry Brennan, yes, I agree. It would be silly to try to ban all retail medical care. That would be even sillier than Prohibition or the War on Drugs.

I've never met anybody who believed their life had been saved by alcohol or street drugs. Very unlikely we could get a consensus for banning the medical profession even if the case could be made that it was a good idea. ;)

#92 ::: J Thomas ::: (view all by) ::: July 03, 2006, 05:23 AM:

After all, we wouldn't want anyone prevented from getting medicine just because it costs more than their income.

That's what we're faced with, though.

"If life were a thing that money could buy, the rich would live and the poor would die...."

People want more medical care than they can afford. They think they'll die without it.

So we got catastrophic health insurance. The theory was that the people who need it get it, and the rest pay for more than they get. Like a lottery, except you'd rather not win, better to be healthy than have your health insurance pay off.

The insurance companies could bargain with hospitals. Individual patients could not. Insurance companies got low rates, uninsured customers got high rates to make up the difference. If you didn't have catastrophic health insurance you were out of luck.

It worked for catastrophic health, why not expand it? Insurance companies could bargain for low rates on routine healthcare and pharmaceuticals etc. Individual customers could not. Insurance companies got low rates and individuals got high rates to make up the difference. If you didn't have health insurance you were out of luck generally.

Insurance rates went up to the point that most people couldn't afford them. But employers could afford them. Now you were out of luck if no one in your immediate family was employed.

But insurance rates kept going up, to the point that more and more employers couldn't afford them either. Now we're talking about having the government pay for it. If the government can't afford it, who can?

About a third of our healthcare costs currently go to insurance companies who spend much of the money deciding what to pay for. I went to grad school with a guy who'd done that. He'd had a job as a manager, he worked in a windowless building in Chicago, managing a team of girls who looked at physicians' records from all over the country deciding which expenses to approve. It took a lot of training for them to do that, and they had databases of precedents to follow too. He got tired of it and decided he wanted to get a masters degree and do something else.

In a way this is money well spent. Collectively we want more medical care than we can pay for, and so we have to have somebody to decide who doesn't get treated. If it's a girl in a windowless room in Chicago, and she doesn't sign the refusal, you can blame the insurance company. And there's nothing you can do about it. You could perhaps sue, but if your expensive untreated medical problems will kill you in any reasonable time they can delay until you're dead.

If the government steps in and chooses who gets treatment, it can probably do it for 40% or less of the current cost. We get a lot of duplication of effort now, and profit, etc. That might be enough right there to drop the costs from 15% of GDP to 12%. But if your benefits are denied you know who to blame. You'll blame the government. Is that worth 3% of GDP? That's a political choice, and we're paying it now. We may not have realised that was the choice we were making, but it's the choice we've made.

After all, we wouldn't want anyone prevented from getting medicine just because it costs more than their income.

We're collectively doing just that. We're paying more than we can afford and we're preventing some people from getting medicine because it costs more than we can afford. We do it because we don't want to die any earlier than we have to, and we don't want to consciously choose who to deny "benefits" to.

#93 ::: Susan ::: (view all by) ::: July 03, 2006, 11:56 AM:

You'd think that med students who don't like dealing with anecdotal data, or analyzing detailed vernacular descriptions of the shifts of tendencies and manifestations in these poorly-understood conditions, or working with patients who are sometimes hazy or confused, would pick a different specialty. If they don't like dealing with the human condition in all its pixel-by-pixel glory, clinical neurology is not where they belong.

Around here, we are only sort of joking when we say that med students with no people skills wind up in pathology, where the average patient is either dead or arrives in very small pieces (as a freestanding organ or stained fuschia and on a slide.) Either way, you don't have to talk to them.

That I consider the lack of patients to be a big plus in this day job no doubt says something about my personality and/or people skills as well.

#94 ::: Bob Oldendorf ::: (view all by) ::: July 03, 2006, 12:38 PM:

J Thomas: I tried a quick google search to find out how many prescription drugs there are. In five minutes I didn't find out. Does anybody know that number?

There are 4,000-odd drugs listed in the current PDR, but
a) there's a great deal of redundancy -- that includes all the sizes and flavors and brand-names of any given drug;
and
b) not quite every drug is listed.

#95 ::: Lenora Rose ::: (view all by) ::: July 03, 2006, 12:42 PM:

Xopher: I was feeling sort of like you did: a bit guilty about my post appearing right after Teresa's excellent summation (Even though hers hadn't shown up before I hit post), and particularly bad that so many others added to the fray.

Until he posted again.

Ken: how can you justify condemning anyone and everyone who ever accidentally takes the wrong drug to a horrible death?

If you can brush off every other protest made against your point, answer this. Why do you want to condemn to possible heart failure an 80-some year old lady who's still sharp in the mind, still stubborn, still very much active and alive, still happy, delighted at her children, grandchildren and great grandchildren, surrounded by loving family, and tough enough she ended up taking a bus to the hospital when she broke her hip? This woman has buried two husbands, survived breast cancer, and now a second broken hip, and still knows how to laugh, and still does everything she can to take care of herself. Her own mother lived to 99, and we know she's got some years in her still.

Do you know how many pills my grandmother takes? Fewer tham most people her age. She's still managed to get in serious trouble because of them at least once that I know of, and that's with all the protections and monitors possible.

And don't you dare to brush *her* off with a facile "Well, just because she doesn't have to get a doctor's prescription doesn't mean she won't consult one -"

Because one thing smart-but-stubborn people do is look into OTC solutions for as long as they can before they have to admit it's a problem the doctor has to see. Sometimes for years. It seems like half the people I know with major medical issues have admitted to a certain amount of doctor or hospital phobia. If all drugs are OTC, how much more often would that delay happen?

I think you're imagining all people who'd misdiagnose or mis-prescribe themselves as brash, heavy jawed fools with no family or friends. It isn't so. Sometimes a mis-prescription, too, isn't even the wrong drug. It's 30mg too much, or 30 mg too little, of the right one.

You don't have the right to decide whether my grandmother lives or dies because to you, a pharmaceutical system is a limit of your freedom.

#96 ::: mary ::: (view all by) ::: July 03, 2006, 12:53 PM:

By the way, watch out for scare-tactic news stories about the "epidemic" of Adderall use among college students. I see the stories, but I don't see any hard numbers in them, and that makes me extremely wary.

I've been waiting for someone else to respond to this because I dread doing so myself, but no one else has...I personally know college students who take Adderall as a performance enhancing drug...my son has done it. Friends of his have been doing it for years to get through finals. Before taking the LSAT (Law School Admission Test) he met with a tutor a few times, and when he told her he was considering taking Adderall for the test, she confessed that she does it herself.

According to him, friends who get Adderall by prescription don't take it every day--they stockpile it and share it with friends. Of course this is anecdotal, and I don't know enough to be able to call it an epidemic. But as a parent, I'm inclined to think that if my son does it, everybody is doing it, or at least it's very common. I can't see my son being in the vanguard of anything like this.

The powers that be have been moving generally against the stimulants. (My paranoid theory: it's because they're performance drugs. Only people in power are entitled to a boost.)

I'm not sure I understand what you're saying here. That stimulants are being prescribed as a boost to Ivy League kids but not to kids at State U? Or that they're not being prescribed anymore, but people with kids in Ivy League schools can still get them? My gut feeling is that the kids themselves are seeking out these drugs, and that if the parents find out about it they are, like me, extremely wary if not downright adamantly opposed.

When it comes to expressing my opposition, I'm a toothless dog: when I was in college I experimented with drugs, although not with performance enhancing drugs. My son knows this. I also know, by the way, that he's smoked weed. I've expressed minimal surprise. I can't muster or justify much more surprise over Adderall, which he says helps him concentrate ("It's like putting blinders on a horse"), than over weed or, for that matter, Red Bull and vodka (gag).

It can do you and your parents no harm to make sure your doctors know that Adderall is not an optional drug for you, and that wheedling down your dose is not on the menu either.

I agree wholeheartedly. If there's one good argument against the use of Adderall as a performance enhancing drug, it's that an epidemic of misuse could (would? will?) make it harder for those who really need the drug to get it.

#97 ::: Graydon ::: (view all by) ::: July 03, 2006, 12:59 PM:

J Thomas --

It would be silly to try to ban all retail medical care.

We (Canada) did, at least for everything covered under the Canada Health Act.

It was the right thing to do, and unless you are immune to utilitarian arguments, it would be the right thing for you to do, too.

Various highly class conscious people hate with a burning passion the idea that they can't pay to jump the line or to get better treatment just for the important people, but, well, that's their problem for being a contemptible soulless husk.

People want more medical care than they can afford. They think they'll die without it.

How do you know?

And, more importantly, is that any reason not to optimize the delivery of medical care for net cost efficiency?

Sometimes they're right about the dying part. I had no income whatsoever when I last needed major (complex diagnostics, hospitalization, abdominal surgery) medical care. If I had lived in the United States, I would be dead, and I would have died in a slow and agonizing way. (Never mind the "ER, gotta treat you" rule; by the time things would have been grounds for emergency treatment, I would not have survived. There are a lot of things like that, where if you catch them early they're not much trouble and if you catch them late it's a question of palliative care.)

I have since paid lots and lots of taxes, and will keep right on paying lots and lots of taxes; it's amazing how much better people work when they're not in incapacitating pain.

Going to come up with an argument that it would have been better for me to die? If so, whom would that have served?

On the question of diagnosing and prescribing correctly; this is already a serious, serious problem for the professionals because individual human brains can't keep track of it all. There are fixes for that -- big data filters, for a start -- but the medical profession tends to be highly resistant to them.

Amateurs, well, no. Specialization and the division of labour is real. No individual can possibly know the tenth part of what is involved in the whole civilization around them, and that is a feature. Individuals who can do everything their culture can do live, if very, very lucky, in mud huts full of shit.

#98 ::: fidelio ::: (view all by) ::: July 03, 2006, 01:11 PM:

I get teh distinct impression that Ken's personal experience with drugs is, in fact, limited to antibiotics and occasional painkillers. What he's had to say doesn't suggest anyone with much knowledge of, or experience with, medicating complex health problems, and it certainly doesn't sound as if he has much depth of knowledge where the world of pharmaceuticals is concerned. While I could wish there were less of a knee-jerk reaction in American society where both painkillers and stimulants are concerned, I don't regret that we are expected to rely on professional guidance when it's time to treat conditions that require constant monitoring, or careful calibration as to the exact amount of medication required. I'm also glad that well-trained and clueful medical professionals are aware that some times medication, or medication alone, isn't the best treatment for certain problems, and that the ones I've dealt with for my own health problems have been prepared to go after the cause of the problem, and not just try and mask it with painkillers.

Teresa: I've heard that there are some very odd people in neurology and neurosurgery--and some of the people telling me this have been neurologists! Maybe they're so seduced by the complexity of the field that they convince themselves that dealing with the actual patients won't be a problem. However, it seems that every branch of the medical profession has its members who are not adjusted to the world with actual humans in it--and I have worked with several of them here in the disability business, including a pediatrician who's not able to cope well with actual children. They cry, you see, and this is upsetting.

Susan: Other specialities that attract members who'd rather not deal with people include radiology and anesthesiology, I'm told, although the only anesthesiologist I've dealt with closely was a dear.

#99 ::: Michael Weholt ::: (view all by) ::: July 03, 2006, 02:12 PM:

Graydon: Going to come up with an argument that it would have been better for me to die? If so, whom would that have served?

The infamous nomadic cannibals of Ontario, I should think. Though there may be fewer of them than there used to be, now that we know human flesh is pretty bad for your cholesterol.

#100 ::: Graydon ::: (view all by) ::: July 03, 2006, 02:23 PM:

Michael --

I'm fairly sure that's an argument about who it would have benefited for me to be hunted down, killed, and eaten, rather than for it having benefited someone for me to die.

(And that's an easy answer, most of the time -- black bears are the usual culprit.)

#101 ::: Michael Weholt ::: (view all by) ::: July 03, 2006, 02:26 PM:

Oh dear, have they closed down all the Recently Dead Buffets? I'm so behind the times. It's been so long since I've been to Canada...

#102 ::: Lexica ::: (view all by) ::: July 03, 2006, 02:50 PM:

I've never met anybody who believed their life had been saved by alcohol or street drugs.

Then either you don't know any patients who use medical marijuana, or you're defining medical marijuana as not being a street drug.

#103 ::: Graydon ::: (view all by) ::: July 03, 2006, 03:32 PM:

Michael --

It was the ice storm, see; the price of real maple syrup went way up and the folks as ran the buffet started using the fake syrup, and well, if you've ever had brains and fake maple syrup you'll understand why the Recently Dead Buffets went right straight out of business.

#104 ::: J Thomas ::: (view all by) ::: July 03, 2006, 03:40 PM:

"It would be silly to try to ban all retail medical care."

We (Canada) did, at least for everything covered under the Canada Health Act.

Graydon, canada is still performing the retail services, you just changed who decides whether you get them and who pays for them. I guess I wasn't clear enough, I was talking in terms of banning all retail medical services the way you might ban abortion. I think it's a bad idea.

"People want more medical care than they can afford. They think they'll die without it."

How do you know?

Lots of anecdotal evidence. Lots of people have told me it was true for them. Including you.

And, more importantly, is that any reason not to optimize the delivery of medical care for net cost efficiency?

I have the feeling you're talking to somebody else. Like I was so unclear that you think I said something completely different from what I tried to say. I agree, it's good to optimise delivery of medical care. If we somehow did optimise that we'd be doing a lot more public health stuff. As you point out, it's better to catch problems when they're small. And it's even better to catch them before they start.

Now, if the elected government will pay the bills, then it turns into a political question how much to pay. However much that is, we will have perceived need for more. As in canada (or maybe in a way that's somehow different), somebody will have to decide whose treatment gets put off. This ought to be decided by technocrats but it might turn political too. I see problems here, but these are problems to face and not reasons to stay stuck to the current system which is even more badly broken.

Going to come up with an argument that it would have been better for me to die?

No. However, I claim that when it turns into a political question how much money to put into individual healthcare, there will not be enough to go around. And then it could be argued that it's better to let some people die who'll otherwise cost a tremendous amount of money for strictly limited benefits. This is a political question but one that we don't want to have in polite company. And so we are likely to decide it by some sort of default, to find some way to arrange things so the decision gets made by faceless administrators who aren't directly responsible to anybody -- certainly not to voters. As it is now. I don't have any good suggestion what to do about that. The current USA approach is not good. We let MDs come up with whatever new procedures they want, no matter how expensive, and then they can offer them to anyone who has the money or whose insurance will pay for it.

In many cases (for example for fancy surgeries) it takes 5 years to collect the data that shows the procedures do not actually have a net benefit. (For various heart surgeries there is a fine benefit to the winners, and the losers are hurt further or die. How do you compare the years of improved life versus the early deaths?) So after 5 or so years the statisticians determine that the expensive procedures had no good effect on average, but by that time the surgeons have *new* *improved* procedures that are even better and which require a new 5 year study.

Our medical care system is designed for adventurous rich people but we try to arrange for others to participate too. Somebody has to put limits on it. As it is, if you lack insurance your savings are the limit. If you have insurance your faceless insurance adjuster sets the limit. And with single-payer a government agency will set the limit. We will have to get used to the idea that there is less medical care available than there could be, under any system. That someday you will die, and when you do there *could* be medical care available that would keep you alive for days or weeks or maybe even years longer, but it will not be available to you.

On the question of diagnosing and prescribing correctly; this is already a serious, serious problem for the professionals because individual human brains can't keep track of it all.

Yes. The system is broken. We have run up against limits we don't really know how to transcend yet. Our response is to trust MDs to be superhuman, to do things they can't. They deserve the big bucks because they try to do things nobody else could do. Things they can't do either.

Amateurs, well, no.

That would be broken too. Assuming amateurs tried to keep up. If they settled for what they were sure they understood, and settled for tried-and-true remedies, they might do more good and less damage than the current system. But what are the chances they'd do that?

Do you know how many pills my grandmother takes? Fewer tham most people her age. She's still managed to get in serious trouble because of them at least once that I know of, and that's with all the protections and monitors possible.

Yes, Lenora. The system is broken. We have gone past the level of complexity we're capable of dealing with.

#105 ::: Graydon ::: (view all by) ::: July 03, 2006, 04:14 PM:

Now, if the elected government will pay the bills, then it turns into a political question how much to pay. However much that is, we will have perceived need for more.

Not reliably the case; there's a tension between how much is being paid in medical bills and how high taxes are. It is a political question, but it's not lacking in feedback.

As in canada (or maybe in a way that's somehow different), somebody will have to decide whose treatment gets put off.

Generally, this is a tussle between the doctors and the provincial medical administrators. It typically works out OK in the case of individual care decisions. The habit of rewarding the administrators for not spending money is and continues to be a serious problem.

We have gone past the level of complexity we're capable of dealing with.

Gods, no; we've got past the level of complexity the means being employed can handle, but that's not at all the same thing. There are other options than doing quill-pen-and-ledger equivalents very, very fast.

If you've been around for any length of time, you've seen me recommend Stafford Beer's Platform for Change. Highly recommended on the subject of handling complexity.

#106 ::: Larry Brennan ::: (view all by) ::: July 03, 2006, 04:20 PM:

J Thomas: The system is broken. We have gone past the level of complexity we're capable of dealing with.

Sorry, but this is one of the most ridiculous points I've seen made on just about any topic in a long time. One of the key defining points of modern society is its complexity. Everything from power distribution to getting dinner onto your plate every day meets your text of "more complexity that we're capable of dealing with."

It's specialization that enables improved standards of living. I focus one thing and get paid for it. I, in turn spend money on goods and services produced by other specialists. I can't fly an airplane, don't have a deep understanding of air traffic control, capacity planning, aeronautics or air safety. Yet I still expect to get onto an airplane that costs more than I'll ever make in a lifetime and be surrounded by experts who manage more complexity than I can deal with, and get to my destination safely.

Health care as a system has a whole bunch of other factors at play, including public health/epidemiology, that should be driving us towards a less market driven (yet oddly more efficient) health care system. Just look at pretty much every other industrialized country and you'll see cheaper healthcare (as a portion of GDP) and in many cases longer life expectancy and in most countries lower infant mortality.

Yes, our system is broken, but throwing out controls that work because of complexity is simply abusurd.

#107 ::: Marilee ::: (view all by) ::: July 03, 2006, 07:35 PM:

JESR, I do labs every six weeks (for three docs), but I can do them earlier if I think I need to. I have four meds that I can adjust myself within an approved range, I just have to call the doctor's staff and tell them I did it.

Susan, I was once offered complete payment for college & med school if I'd come back to work for neurosurgeons. I wasn't very tempted, I keow how I'd deal with patients and if I was a doctor, I'd have to be a pathologist.

My neurologist doesn't have much bedside manner, but she's a great doctor. She's the only doctor who has ever requested all the parts of my chart and read all of them.

#108 ::: CHip ::: (view all by) ::: July 03, 2006, 11:33 PM:

You'd think that med students who don't like dealing with anecdotal data, or analyzing detailed vernacular descriptions of the shifts of tendencies and manifestations in these poorly-understood conditions, or working with patients who are sometimes hazy or confused, would pick a different specialty.

Maybe they thought they were going to teach and do research? Or maybe you got someone who was already doing research and preferred that to patients. Thirty years ago I worked for someone who was a great technician, possibly a good researcher, and a Harvard professor (not yet tenured); that was long enough ago that I don't worry any longer about being assigned to his "care", which possibility used to frighten me. I get the impression that MDs today get more training in practice and less deliberate abuse, but I don't \know/ how true that is. The aforementioned actually said at one point that surviving internship taught people they could survive anything; the vague thoughts of med school that led me to take freshman bio as a senior, just so I wouldn't be immediately disqualified, disappeared in the few months I worked for him.

I've occasionally thought that a system like English law, in which there are multiple recognized levels of practice, would work well in medicine; we're close to such a system now, with clinical nurses doing much "routine" care, but it has the defect that doctors can't take enough time to learn their patients and nurses are (IMO) discouraged from acquiring such knowledge, partly by doctors' egos and partly by a system which assumes they're extensions of doctors rather than independent intelligences.

Ken conflates two largely discrete sets of people: those who wish to regulate drugs of pleasure, and those wish regulation to assure safety and effect. Libertarianism doesn't \have/ to be stupid, but this is.

#109 ::: J Thomas ::: (view all by) ::: July 04, 2006, 10:17 AM:

"We have gone past the level of complexity we're capable of dealing with."

Gods, no; we've got past the level of complexity the means being employed can handle, but that's not at all the same thing.

Some other system might be able to handle our current level of complexity. I'm saying that the system we have is broken.

It's specialization that enables improved standards of living.

Sure. And we manage to split things up so that the specialists cooperate in ways that get all the bases covered. So we don't build nuclear power plants on fault lines and we don't grow too much of any one kind of corn or potatoes, and we graduate the right number of each kind of engineer to fit our projected needs.

But we make medical choices without that much planning. Lots of the drugs that are routinely prescribed are *dangerous*. Many of them need other drugs to balance out their worst effects. This sort of thing deserves careful mathematical modelling, but usually what it gets is a physician prescribing more-or-less blindly. He notes the patients' weight and whether there's kidney or liver damage. It's only for the most dangerous drugs that they bother to monitor and test -- which is reasonable because monitoring is extremely intrusive and also expensive.

Now consider that it isn't all that unusual for patients who are enthusiastic about getting medical care to have a dozen different prescribed drugs interacting. Some of those patients are not completely alert all the time, and usually nobody tracks what they actually are taking, even at autopsy. If this treatment regime were to increase the average lifespan -- wouldn't it be a surprise?

Surgery is a different matter. Don't even go there.

Health care as a system has a whole bunch of other factors at play, including public health/epidemiology, that should be driving us towards a less market driven (yet oddly more efficient) health care system. Just look at pretty much every other industrialized country and you'll see cheaper healthcare (as a portion of GDP) and in many cases longer life expectancy and in most countries lower infant mortality.

Agreed. Our system gives worse results for more money. Part of that is that we give particularly bad medical care to poor people, fitting in with their bad environment and bad nutrition etc. We could do better than we're doing even without changing the medical part of the healthcare system.

Yes, our system is broken, but throwing out controls that work because of complexity is simply abusurd.

Agreed. Our prescription system has a lot of problems, but at this point no-system-at-all would be worse.

#110 ::: Faren Miller ::: (view all by) ::: July 04, 2006, 11:34 AM:

My mother was raised in a family that pretty much believed in a Christian Science approach to doctors. She was quite willing to go to professionals back when she was pregnant with me, but later on neglected to get the checkups that would have told her about her problems with bone density and hypothyroidism -- so she had to break a hip and have manifest systems of the thyroid problem before she finally got treatment. I've inherited both problems, but they've been found much sooner so I may come out with less bodily damage. Of course my neurological disease wasn't discovered till I'd driven off a road and totalled my car (without much personal damage), so there are some things average testing won't find.

My current neurologist seems to have reasonable "people skills". I just wish I didn't have to pay so much for the minimal examinations he does in my bi-yearly checkups, but that gripe has more to do with insurance deductibles than with him. In the absence of socialized medicine here in the US, I admit I'm tempted sometimes to forgo doctor visits, in the old family tradition. Specialists can be booked up for months in advance, and my GP hasn't really done anything to help my current case of hives. Still, the tests he ordered found the bone and thyroid problems, so at least I'll be treated for those woes of middle age -- with cheap pills, luckily. So the system sucks, but it's still better than nothing.

#111 ::: mythago ::: (view all by) ::: July 04, 2006, 06:30 PM:

It worked for catastrophic health

Catastrophic-health policies work fine if you are young and healthy, and either are entitled to them (say, through your employer); not so well otherwise. Health insurance 'works' because healthy, less-risky people are subsidizing the risk of the sicker ones. When you get your insurance through work or through an affinity group, the risk is spread out enough that the insurance company can afford to let everybody in. If you come off the street, they're a lot pickier.

Another thing that leads me to suspect you're young and haven't a health issue in the world is your insistence that people just think they need more health care than they actually do. Anecdotally speaking, if you've never had to make the choice between getting a test your doctor thinks is urgent and paying the electric bill, or trying to determine whether that nagging pain is serious or not, you have no idea what you're talking about.

#112 ::: Marilee ::: (view all by) ::: July 04, 2006, 09:07 PM:

I have Medicare, and therefore Plan D. My total med cost (Kaiser & mine) so far this year is $2290. I'm going to hit the "donut hole" in August, probably. Fortunately, the Kaiser version of Plan D has only a $600 donut hole, and after that, I get catastrophic help with meds.

#113 ::: Susan ::: (view all by) ::: July 04, 2006, 09:27 PM:

I get the impression that MDs today get more training in practice and less deliberate abuse, but I don't \know/ how true that is.

My day job is in GME, if that wasn't previously clear, and I would say that things have improved dramatically. That doesn't mean a medical residency isn't still a grueling marathon, but there are a rules in place nowadays with mechanisms to enforce them. Individual attendings may be abusive jerks - there are just as many in medicine as in any other field - but there are plenty who are dedicated educators and mentors and programs as a whole are focused on training not on hazing.

Of course, some fields have notably easier residencies than others - surgery and emergency medicine are probably the worst for long hours, as is to be expected for specialties that deal with sudden crises.

#114 ::: J Thomas ::: (view all by) ::: July 04, 2006, 09:40 PM:

Health insurance 'works' because healthy, less-risky people are subsidizing the risk of the sicker ones.

That was the rationale. I think we're using "works" in different ways. Catastrophic health insurance "worked" in the sense that people were willing to buy into it to the point that it became standard, so that insurance companies could demand discounts that must be made up by the uninsured. Catastrophic health insurance worked for insurance companies.

Another thing that leads me to suspect you're young and haven't a health issue in the world is your insistence that people just think they need more health care than they actually do.

I didn't say that people think they need more health care than they actually need. My claim is that people think they need more health care than they can actually afford. I say this is pretty much universally true for americans over their lifespan, though it sometimes isn't true while they're young and healthy. And with it true for most people over their lifespans, and even worse than usual as the boomers age, the result is that the population as a whole has a perceived need for more healthcare than we can afford. Oh! Maybe it was that word "perceived" that made it seem like I was saying that people don't actually need as much healthcare as they think they do. I was trying to dodge a big complex issue I didn't want to discuss, and you took my dodge as a position. Sorry about that.

At any rate, if we collectively think we need more healthcare than we can afford, we can't pay for it with insurance that depends on the healthy to pay for the unhealthy. Because there simply aren't enough of us who are that healthy. I have the impression you may have been heading toward that point too.

I'll step through the logic again. People in general appear to need more healthcare over their lifetimes than they can pay for. If they try to pay for it themselves then at some point they run out of money and must live on whatever charity provides before they die.

Health insurance doesn't solve the problem because there are too many old or sick people and not enough healthy people to pay the difference. It doesn't provide enough money to go around so somebody has to lose out.

The natural next step is for the government to pay. This is potentially cheaper than private insurance because it removes some duplication of effort and some advertising etc. People who don't believe government can be efficient will believe it will be worse and more expensive than private insurance. I claim that if we can't pay for our diagnosed healthcosts either individually or collectively, then the government can't pay for them either. At some point we're talking about cutting costs, hospice instead of intensive care for some people, etc. I don't say this is a good thing. I say I see no alternative short of cutting back our expectations or creating a new medical technology.

#115 ::: James D. Macdonald ::: (view all by) ::: July 04, 2006, 10:08 PM:

I didn't say that people think they need more health care than they actually need. My claim is that people think they need more health care than they can actually afford.

Try affording a broken arm without insurance. Try convincing yourself that getting the bone set is more healthcare than you need.

#116 ::: Xopher ::: (view all by) ::: July 04, 2006, 10:25 PM:

But Jim, you might need it but not be able to afford it. Read J again. J's saying people actually need healthcare that they cannot afford. For example, J says

People in general appear to need more healthcare over their lifetimes than they can pay for. If they try to pay for it themselves then at some point they run out of money and must live on whatever charity provides before they die.

Yeah, if you break your arm you get the bone set. Then you can't pay. All outcomes are bad after that.

#117 ::: Paula Helm Murray ::: (view all by) ::: July 04, 2006, 10:44 PM:

Yeah, Jim got the edge of his finger with an Xacto blade at his work. The bill was over $3,000. Fortunately his employer paid because it was work-related. Since it did hit an small artery, if he'd done it accidentally and we had no insurance, he still would have ended up in the E.R. and we would have had to figure out how to pay for it. (I've got the 'insurance' job, he's always worked for small businesses)

#118 ::: Larry Brennan ::: (view all by) ::: July 04, 2006, 10:59 PM:

J Thomas (sarcastically): The natural next step is for the government to pay.

Me: (seriously) Yes, it is.

J Thomas: I claim that if we can't pay for our diagnosed healthcosts either individually or collectively, then the government can't pay for them either.

Who says we can't? If you cut out the profit (as painful as that might be - here's a shot of bourbon and a rag to bite down on while we make the incision) that the insurance companies skim off the top, we certainly can afford it. If the Canadians can, why can't we? (Citations of God's Will will result in automatic deduction of points.)

#119 ::: Clifton Royston ::: (view all by) ::: July 05, 2006, 12:01 AM:

It's specialization that enables improved standards of living.

J. Thomas: Sure. And we manage to split things up so that the specialists cooperate in ways that get all the bases covered. So we don't build nuclear power plants on fault lines and we don't grow too much of any one kind of corn or potatoes, and we graduate the right number of each kind of engineer to fit our projected needs.

Given your choice of examples, I'm guessing you're being sarcastic or ironic, and that it is flying over the head of most people.

For those missing the point: as I recall, the "market" did manage to site a nuclear power plant directly adjoining a major fault in California, we presently have major monoculture issues with staple crops due in part to centralization of seed producers, and the US graduates nowhere near the number of engineers we need, which is one reason technology companies are either going quietly nuts over the increased immigration restrictions or just planning to outsource still more design to India et al.

So, ummm... given that I honestly don't know how to take the rest of the points you are making. To take one at face value, though, the fact that person X or group X can not afford health-care as presently structured in the US is no indication that we could not collectively afford it if otherwise structured - or even that person X could not afford it. The estimates I've seen are that fully half our health-care costs are going to fund the cost of the paperwork and of bureaucrats and lawyers to try to push payment off on someone else. Take that half out and X can afford twice as much, right?

#120 ::: Clark E Myers ::: (view all by) ::: July 05, 2006, 01:06 AM:

If you cut out the profit (as painful as that might be - here's a shot of bourbon and a rag to bite down on while we make the incision) that the insurance companies skim off the top, we certainly can afford it.*?

Looking at say Aetna's financials in recent years - and their stock price - I'd doubt it.

One of the issues in the general area and perhaps a failure of forecasting and so a failure of the market is the transition from a true insurance model to a level pay system.

Long ago medical insurance was administered much like other forms of insurance. Given a statistical universe of customers and competent actuaries profits were as certain as the house winning in Las Vegas - with competition putting a cap on premiums just as competition between houses kept down roulette wheels with triple zero as well as zero and double zero and so profits had a cap.

A typical major medical insurance company would promote mostly male successful salesmen to management and have a pink collar ghetto someplace doing back office work. Just like say a CATV system, profits = constant X number of customers so more customers was the key to more profits.

With the transition from a catastrophic model of insurance to a level pay system of continuous premium for continuous service (see e.g. putting birth control on the plans by statute for a sign of the shift of paradigm) the insurance companies began to be a medical service bureau (the AMA has copyright on all the medical billing forms see e.g. billing-coding.com for an overview of current industry practice as they actually are in the United States). The insurance companies began to process $10 payments for flu shots from Dr. Doe to patient Roe with a couple transposed digits in the ID numbers - profits no longer subject to any statistical laws beyond do it faster. In the United States all the actors in the system are facing declining profits.

Sadly a search at say the BEEB.com (actual news.bbc.co.uk) for NHS gets as the first hit: Doubts over NHS community plans - 3h 58m ago sorted by time and nothing but bad news on the first page of hits. There is no utopia and no clear choice in health plans. There is no reason to think any of the current models be they from Canada, the UK, Switzerland or Scandinavia or anyplace else would still be working well after the time it would take to get them up and running in the United States. That is the system in each and every one of those countries is showing major problems.

Globe and Mail: 'Unsound' health plans led deputy to resign
By ROD MICKLEBURGH
Saturday, June 24, 2006, Page S1
VANCOUVER -- Controversy mounted yesterday over the abrupt resignation of Penny Ballem, B.C.'s high-powered deputy health minister for the past five years......

Notice also that in the United States Dwight David Eisenhower proposed a national health system and the Democrats killed it as the then dominant unions (esp Walter Reuther) wanted to make health care a union benefit. Nixon proposed a plan and Ted Kennedy, among others, thought he could do better and so killed it. Hilary Clinton couldn't sell anything when her chance came. There is no clear choice - no dominant plan - of each person pays a few dollars more and everybody gets coverage.

I'd be tempted to expand the space available services at the VA to non-veterans and let the voters scream for adequate funding as my best guess for a system that could be implemented and made to work.

It would no more be quality care than the emergency room at Grady in Atlanta or Denver General in Colorado or anyplace else but it would be something more than we have now.

#121 ::: JESR ::: (view all by) ::: July 05, 2006, 02:16 AM:

Marilee: it's possible if I needed labs more than twice a year, I might be better at remembering when I need them, but six months is long enough that I forget.

I just had an enlightening talk with my Uncle Mervie about Vic..., oops,Aceta-Hydro... that won't work either He's worked as a carpenter and general contractor for over fifty years, and, having fallen through a few framed houses, roof to basement, is dealing with pain from old breaks in his ankles and back. He takes the stuff when he hurts too much to sleep, which is the same rule I need. Neither of us can understand why anyone finds the stuff actively pleasurable.

If everyone was like us, opiates could be OTC; unfortunately, some people think they're really fun.

(And any name for that artificial opiate is forbidden, which must make any discussion on this server of the habits of Gregory House, MD a bit complicated )

#122 ::: J Thomas ::: (view all by) ::: July 05, 2006, 10:53 AM:

To take one at face value, though, the fact that person X or group X can not afford health-care as presently structured in the US is no indication that we could not collectively afford it if otherwise structured - or even that person X could not afford it.

Agreed, but when -- as it appears to me -- the vast majority of the population can't afford the healthcare that competent physicians would offer them (if they could afford the physicians to make the diagnosis and prescription in the first place) that gives me the strong impression that we can't collectively afford it.

The estimates I've seen are that fully half our health-care costs are going to fund the cost of the paperwork and of bureaucrats and lawyers to try to push payment off on someone else. Take that half out and X can afford twice as much, right?

Yes, supposing that we could efficiently transpose the resources. (which is a quibble and a side issue that I'd have fun with but that isn't important.)

We might be able to get rid of the lawyers, but we can't get rid of the bureaucrats -- somebody has to do some planning and organising, and that's them. I've seen estimates that we could cut the bureaucrats from a third of the total to a nineth. That's another quibble, the total cost would still be close to half what it is now.

At present something like 40% of the population is uninsured. Presumably all of them are undermedicated. A whole lot of the other 60% are under-insured and they are probably somewhat undermedicated.

So for example, I've often seen the recommendation that anyone over 30 should get a yearly dermatologist exam to look for melanomas etc. (I just checked on the web and one source said only people with risk factors should do that.) Every time I've done that, the dermatologist has cut out whichever mole looks most suspicious to him, and sent it out for inspection.

Once I had my appointment when I was recently unemployed and without insurance -- the dermatologist's fee was $140 for coming into the office, $270 for looking at me, and $1300 for excising a mole. I angrily paid the $140 and cancelled the appointment.

I started writing this with the assumption that my experience was typical but it probably isn't. Oh well, I'll continue. If we could reduce the cost to $500 (dropping the premium for not having insurance, and also the legal and bureauccratic fees, and cutting the consultation cost for the biopsy), then everybody over 30 could get this treatment at a cost of a bit less than $100 billion a year. For one procedure. And we have a lot of items on the suggested yearly exam.

My example is not that good, though. I think it's likely that they cut out a mole each time for legal reasons -- if I get a melanoma and want to sue, they can point out that they weren't negligent, they did biopsy the one that looked worst. If the legal angle was removed it might be cheaper. And it isn't really everybody over 30. And some GPs feel competent to inspect for moles and only pass the patient on to a specialist if there's something suspicious. So in this particular example the cost might be a whole lot less. But there are a lot of examples like it, where a good half the population doesn't get the care that the MDs say they should.

So OK, currently the bill is about 15% of GDP, heading toward 18% or maybe 20%. We can't afford 20% of GDP. If we could reform the payment system we might cut the cost in half, to 8% heading toward 10%. But if we actually supplied the medical care to the whole population that we say is needed, that would just about double it again.

And the cost of medical care is going up faster than GDP.

Today we could provide 1960's-level medical care to the whole population at a cost we could easily afford. It would be cheaper than it was in 1960 because we've learned about so much of the 1960's medical technology that didn't work or caused active harm -- we could cut those out and cut costs. But we don't want 1960's medical technology. We want the best. We want to live active, productive lives as long as we can and we don't want to die.

And being good people, we want the best for everybody. But we started with a laissez-faire free-enterprise medical system (not counting the not-for-profit hospitals etc, OK, this claim is not exactly true but bear with me) and a lot of our medical technology is designed for customers for whom cost doesn't matter. We can't afford to give everybody medical procedures that were designed for rich people. So even while we reform the payment system, we also need to reform the medical technology. If we can provide competent medical care and also reduce routine costs to a level that most of the population can afford, then it becomes much less an issue who's going to pay for it.

#123 ::: Michelle K ::: (view all by) ::: July 05, 2006, 12:20 PM:

Couple things about health care in the United States that I picked up from my policy class in public health (I apologize for lacking references, but these were from a class lecture.)

First, as far as private insurance being more efficient than a government program... The overhead for Medicare/Medicare is between two and three percent. The overhead for private insurance companies is around 20 to 30% or higher. So private insurance companies are NOT more efficient or cost effective than Medicare/Medicaid.

Second, I don't understand the opposition to government funded health care. We're ALREADY paying for health care in this country, so why not make the system equitable?

When we discussed it in class, the stat was that when you buy a car you pay more for employee benefits than you do for the steel in the price of the car.

Secondly, everyone who uses health care is already subsidizing health care for those who lack insurance. Hospitals can end up eating the costs of patients who are indigent and end up in the emergency room (since emergency rooms cannot turn people away). When the patients can't pay, the hosptial has to cover those costs themselves.

(Additionally, I remember hearing a news report a couple of years ago about emergency rooms in poverty stricken areas closing, because their their costs were out of control.)

Then consider the fact that if someone had primary care, they might make an office visit to take care of their blood pressure or diabetes or the flu. But they don't, so instead they end up in the emergency room and then the hospital for a stroke or heart attack or pneumonia or a diabetic coma.

If we're already paying these costs, doesn't it make more sense to pay for preventive care than for emergency care an an extended hospital stay?

And that doesn't consider reduced productivity and other problems associated with an unhealthy workforce.

#124 ::: Clifton Royston ::: (view all by) ::: July 05, 2006, 01:40 PM:

J. Thomas:
I think I see where you're coming from. The factoid I've read - no direct experience - is that all doctors offices price their services to those without insurance based on the assumption that they need to make up their thin margin or losses on Medicare patients with those uninsured patients, and that most of them will not end up paying the whole thing, so they need to overcharge by 100-200%. I've heard if you negotiate fees up front and say "I'm willing to pay cash the amount that insurance would cover", most offices will deal.

This is not part of my experience, in part because I've lived in Hawaii since 1980 and Hawaii requires all employers, large or small, to offer group health coverage with a family coverage option (employee often pays, but it's offered.) It's not perfect, there are gap groups, but it's a darn sight better than most of the country has. (BTW, as a contractor I would be in that gap group were it not for my wife's family coverage.)

I do agree with the other general point you're making, which is that ultimately we are heading for a zone where almost everything is curable at some price. In other words, our health care is bound for the zone of Frederick Pohl's "Major Medical" insurance in the Gateway stories, where billionaires are effectively immortal, and the rest of us are still stuck with the "ills of the flesh." I don't think there's any answer for that - but that has little to do with whether we-as-society can afford to examine suspicious moles. Clearly we can, and as Michelle says it's cheaper to treat at that phase than to treat the consequences.

#125 ::: Lenora Rose ::: (view all by) ::: July 05, 2006, 03:20 PM:

Clark E. Myers: Yes, Canada has some problems keeping up with its health care program. We have bloat and inefficiency and doctors wanting to be paid more or leaving to go into private practice in the US because they want more pay.

All of which are better than Michelle K's described scenario of the person untreated for diabetes ending up in an emergency room in a coma and costing the whole system more.

We don't have a perfect system. We may not even have as good a system as we could have, even accounting for its whole history and subsequent baggage. What we have is a more equitable system.

Something you'd think the US could get behind in its idealism. Except that the bills are never voted on by those who'd benefit most from being able to afford health care. {/cynicism}

It's been said before that if the US is going to fix their health care system (which is just about the worst first-world system), they shouldn't look to Canada -- and I agree there -- but to the Gasp, socialist countries in Europe. Because no system has no problems, but they seem to be doing the best with the least of the crud.

Nonetheless, pointing to articles about people complaining about the difficulty of maintaining our system doesn't automatically make Canada's system worse than the US, which you seem to be implying. Just flawed.

#126 ::: Lori Coulson ::: (view all by) ::: July 05, 2006, 03:37 PM:

Re: Hospitals closing due to cost of care via ER

I know of one hospital in Columbus that closed because of the number of indigent patients that were being treated in the ER. They went broke. So now no one in that area is being served. (Actually, they're having to travel farther to get medical care.)

Another, in a different impoverished section of Columbus, closed that location and moved the hospital to a posh neighborhood. I should note that this was a facility owned and run by an order of nuns, which is/was obligated by their vows to treat all patients regardless of ability to pay.

A third charity hospital sold one of its facilities to Ohio State University.

Under our current system, even the hospitals are going bankrupt....

#127 ::: J Thomas ::: (view all by) ::: July 05, 2006, 04:07 PM:

If you look at it very cynically, when we avoid early treatment for some of our people, and then they wind up in the emergency room costing lots of money, that is not actually costing more.

Because they are likely to die much younger than otherwise and so their lifetime medical costs will be lower.

Paying for one-time emergency treatment while they die is a sop we throw to them, so we feel like we aren't just letting them die.

If poor sick people got the same medical care that rich sick people did, it would cost a whole lot. There would be more of them. Their poor nutrition (and often poorer sanitation, clogged sewers and sanitary sewers overflowing into storm sewers etc) and the general encouragement for unhealthy practices makes them sicker, and sicker more often.

A whole lot of people have at least one expensive medical intervention before they die. The sooner they have it, the less money gets spent on them.

I'm not saying it's good. I'm saying it's what we're doing. We'd save money spending more on public health. If we found ways to persuade everybody to quit smoking, and avoid obesity, and cut down to moderate drug or alcohol use, and get reasonable exercise, and if we cut down on the pollution people get exposed to, then people on average would live longer with perhaps less of the expensive retail medical care. But providing more routine medical care to the poorest 30% of the population wouldn't be cheaper, it would cost more. They would be sick for longer before they died.

If you asked me to document this I'd have trouble doing it. It may even be wrong. But consider that it may be right. It's pleasant to believe that we could do the right thing and it would cost less than what we're doing now. But it's likely that doing right would only cost less if we could get value from our poor people to match the cost of keeping them alive. That would be true if we had good jobs for them.

#128 ::: Lori Coulson ::: (view all by) ::: July 05, 2006, 04:31 PM:

J Thomas: In ***every*** study done on this issue, preventive care has proved to be less expensive than treating the diseases once they manifest.

Routine check-ups, exams and immunizations would save lives and money.

Speaking of public health, avian flu seems to have dropped off the media radar -- I'm not sure if that's good news or bad.

#129 ::: J Thomas ::: (view all by) ::: July 05, 2006, 09:09 PM:

Lori, I agree, in every study preventive care has been cheaper than full-scale last-minute intervention.

However, those studies are comparing the cost of preventive care versus the cost of late intervention. They are not looking at the cost of medical care over the victim's lifetime.

Over the victim's whole lifetime, the less money spent per year the less that victim costs. And the fewer years the victim lives, the less it costs.

Something is going to kill each one, eventually. If a victim dies young of something preventable, and particularly if he doesn't actually get the full intervention that might temporarily save his life, he will cost less than if he lived longer and had multiple costly interventions of various sorts.

I'm certainly not arguing that it's a good thing for poor people to die younger than rich people. What I'm arguing is that we actually do spend less money on poor people, and we do it by cutting corners at all levels. If they don't get preventive care, the preventive care they didn't get is a reduced cost. Then if they get into serious trouble with something that wasn't prevented and the EMTs are late getting to them because there aren't enough EMTs serving their area, that's another reduced cost. So they get to the ER and wait 6 hours or so because the ER isn't staffed at a level that would see them taken care of, and that's reduced cost. Then they get a start at an expensive intervention and they die before it's gotten very far. The costs stop.

Sure, it would have been cheaper to prevent the problem than to spend a lot of money fixing it. It might even be cheaper to prevent the problem than to spend a moderate amount of money while they die of it. But that isn't the relevant question. The question is, will their lifetime medical care cost more if you do things to prevent problems, or will it cost more if they are allowed to develop problems that kill them?

So, say a poor old woman has diabetes. She can't afford expensive palliative treatment, and Medicare is kind of spotty about getting her taken care of. So she shows up at the ER and they see they need to amputate her feet. That could be expensive -- prosthetic replacement, physical therapy, lots of expensive treatment. But it doesn't have to be so expensive. Just cut her feet off, put her in a wheelchair and find somebody to call to wheel her away.

Balancing state-of-the-art care on both sides, it's far cheaper to do preventive care. That just isn't the trade-off we're actually making.

#130 ::: Teresa Nielsen Hayden ::: (view all by) ::: July 05, 2006, 10:43 PM:

Rhandir, your comment was bleepin' lyrical.

I suspect Ken's emotional commitment is to the idea that all complex social problems can be reduced or even cured by the application (by someone sitting a great distance away) of freedom of choice and logical self-interest.

J Thomas, I spoke too soon about your root canal. And your description of the interactions of insurance companies, hospitals, uninsured patients, etc., is a working model that not only fits but explains the data I know.

People who denounce the idea of government bureaucracies running the health care system cannot have spent much time dealing with insurance companies. I can't deal with insurance companies. I'm literally phobic: I turn pale, and my hands shake. I think it's the cumulative effect of decades of exposure to documents which could be written in natural English but aren't, and which cannot be accurately decoded using standard, publicly available means such as dictionaries. I used to be a bureaucrat, and I think I can recognize documents which aren't intended to be understood by the people whose lives are configured by them.

And: thank you for explaining what you meant about patients, perception, and treatment costs.

Graydon, Michael, never think I didn't notice that.

Marilee, I don't even want to think about your medication costs per year -- which, come to think of it, is hardly fair of me, seeing as how you never get to forget them. I have no idea what mine cost, since I only see the co-payment. Occasionally I ask the retail price of one of my medications. I never remember it afterward. Call it hysterical amnesia.

Clark, discussions of national health care policy were the cradle of astroturf. Here's what we know: Canada doesn't go broke providing decent medical care for its citizens. France has a splendid public health system. Britain's public health system has administrative problems, not (as far as anyone can tell) basic concept problems. We're the only supposedly first-world country that hasn't managed to get its collective thumb unstuck and come up with a first-order working plan for national health care.

This is the biggest reason people refer to us as an extremely rich third-world nation, and they're right to do so.

It wasn't the Democrats who killed national health care. It was relentless and well-funded lobbying by the AMA and other providers, who labeled it "socialized medicine" and did their level best to scare everyone into believing that it would yield third-rate care.

JESR: As I keep saying, there should be no content-based message blocking in this weblog. Which opiate are you talking about?

J Thomas again:

"At present something like 40% of the population is uninsured. Presumably all of them are undermedicated. A whole lot of the other 60% are under-insured and they are probably somewhat undermedicated."
And they're years behind on dental work. They also get less sleep and less exercise, suffer more stress, eat worse food, are likelier to be exposed to harmful substances, and have fragmented and poorly documented medical records rather than a long-term relationship with a competent GP.
"So for example, I've often seen the recommendation that anyone over 30 should get a yearly dermatologist exam to look for melanomas etc. (I just checked on the web and one source said only people with risk factors should do that.) Every time I've done that, the dermatologist has cut out whichever mole looks most suspicious to him, and sent it out for inspection."
That didn't happen to me, but I went in with a different dermatological condition, so he got to Do Something without having to do that.
"Once I had my appointment when I was recently unemployed and without insurance--the dermatologist's fee was $140 for coming into the office, $270 for looking at me, and $1300 for excising a mole. I angrily paid the $140 and cancelled the appointment.

I started writing this with the assumption that my experience was typical but it probably isn't."

It's typical as far as I'm concerned, only what needed doing couldn't be put off, and the basic tests cost roughly $5,000 in the early 1980s. It's a lot easier to find a doctor or clinic or hospital that'll diagnose narcolepsy than it is to find one that'll treat it. Treatment's penny-ante stuff, and it can expose you to the unwelcome attention of drug enforcement agents. Diagnosis, on the other hand, is downright lucrative.
"Oh well, I'll continue. If we could reduce the cost to $500 (dropping the premium for not having insurance, and also the legal and bureauccratic fees, and cutting the consultation cost for the biopsy), then everybody over 30 could get this treatment at a cost of a bit less than $100 billion a year. For one procedure. And we have a lot of items on the suggested yearly exam."
What's the overall annual cost of not-screened-for skin cancer? That's a genuine question.
"My example is not that good, though. I think it's likely that they cut out a mole each time for legal reasons -- if I get a melanoma and want to sue, they can point out that they weren't negligent, they did biopsy the one that looked worst. If the legal angle was removed it might be cheaper. And it isn't really everybody over 30. And some GPs feel competent to inspect for moles and only pass the patient on to a specialist if there's something suspicious. So in this particular example the cost might be a whole lot less. But there are a lot of examples like it, where a good half the population doesn't get the care that the MDs say they should."
I know. I've seen 'em in the waiting rooms of emergency clinics. They couldn't afford the modest cost of early treatment, so now it's a much nastier condition but someone else will pay for it. The best example I know is filling cavities in your teeth. It's bound to be needed. Having it done isn't cheap. If you can't afford it, or your insurance plan doesn't cover it, you wait until the decay eats down into the inner tooth and becomes an emergency, for which emergency medical agencies and cheapskate insurance companies will pay.
"So OK, currently the bill is about 15% of GDP, heading toward 18% or maybe 20%. We can't afford 20% of GDP."
I remember when computers were monstrously expensive cutting-edge technology. The cutting edge is always expensive. We live in the dawn of medicine. We're just starting to be able to do stuff. That means it's all cutting-edge technology, and thus very expensive. But who wouldn't want it, if it can help cure our ills and give us longer, better lives?
"If we could reform the payment system we might cut the cost in half, to 8% heading toward 10%. But if we actually supplied the medical care to the whole population that we say is needed, that would just about double it again.

And the cost of medical care is going up faster than GDP.

Today we could provide 1960's-level medical care to the whole population at a cost we could easily afford. It would be cheaper than it was in 1960 because we've learned about so much of the 1960's medical technology that didn't work or caused active harm -- we could cut those out and cut costs. But we don't want 1960's medical technology. We want the best. We want to live active, productive lives as long as we can and we don't want to die."

What you said.

* * * * * * * * * *

LESE MAJESTE! I've just had my comment bounced for "questionable content". Let me try this again ...

#131 ::: Teresa Nielsen Hayden ::: (view all by) ::: July 05, 2006, 10:44 PM:

It took hours for my comment to get posted. Somehow the word "insurance" got into the blacklist. That's fixed now.

#132 ::: Lizzy L ::: (view all by) ::: July 05, 2006, 10:55 PM:

Somehow the word "insurance" got into the blacklist. Teresa, that's the best laugh I've had all day. Thank you.

#133 ::: P J Evans ::: (view all by) ::: July 05, 2006, 10:55 PM:

We want the best. We want to live active, productive lives as long as we can and we don't want to die.

Well, maybe. For a lot of people, there's a point at which the cost is more than it's worth, and dying becomes a reasonable choice. (Preferably dying without a great deal of discomfort.)

#134 ::: rhandir ::: (view all by) ::: July 05, 2006, 11:06 PM:

offtopic
TNH,
thank you! Your response produced a feeling of great glee, and has totally made my day. Apparently I am a makinglight fanboy.
end offtopic

Sorry, I have no on-topic content to redeem this post. Please disregard.

-r.

#135 ::: Xopher ::: (view all by) ::: July 06, 2006, 12:25 AM:

rhandir, TNH can correct me if she likes, but I think thanks and appreciations are always on topic.

#136 ::: Christopher Davis ::: (view all by) ::: July 06, 2006, 12:35 AM:

I grew up with government-provided pay-nothing-out-of-pocket health care. If the doctor wrote a prescription, I went to the nearby pharmacy and got it filled for free.

In return, I got to have my father living on the other side of the planet within artillery range of Kim Il Sung's gang for months at a time.

What's scarier than going back to Iraq? Losing your health coverage. SSG Kruger's at Fort Lewis, exactly where I was back then.

#137 ::: James D. Macdonald ::: (view all by) ::: July 06, 2006, 02:55 AM:

It took hours for my comment to get posted. Somehow the word "insurance" got into the blacklist. That's fixed now.

Not "insurance" but "insurance[hyphen]", which is a very common string in comment and trackback spam. Similarly "[hyphen]insurance", "[greater than]insurance", "insurance[less than]", "[underscore]insurance", "insurance[underscore]", "[forward slash]insurance", and "insurance[dot]htm".

#138 ::: Dave Bell ::: (view all by) ::: July 06, 2006, 06:13 AM:

It seems to me that a part of them problem with different health-care systems is how profit and operating-surplus are handled.

I think it can be argued that the good health of the nation is a profit.

The problem with a system based on insurance is that the insurance companies want to take their profit on the total budget. They skim off their percentage on wages of medical staff and on the money paid to suppliers (who will be keeping some of what they do get as earned profit, whether the health system as a whole is funded by government, insurance, or little green men).

Unlike an operating surplus within the healthcare system, the profits taken by the insurance companies don't have the potential to do anything for healthcare. In theory, insurance companies make profits in good years to cover potential losses in bad years. In practice, they have to please the stockmarkets.

I think medical insurance has moved from being a form of betting towardss being a rigged game. So much of what the companies are reported as doing would get them "warned off" if they were bookmakers.

#139 ::: Susan ::: (view all by) ::: July 06, 2006, 09:25 AM:

I think I see where you're coming from. The factoid I've read - no direct experience - is that all doctors offices price their services to those without insurance based on the assumption that they need to make up their thin margin or losses on Medicare patients with those uninsured patients, and that most of them will not end up paying the whole thing, so they need to overcharge by 100-200%. I've heard if you negotiate fees up front and say "I'm willing to pay cash the amount that insurance would cover", most offices will deal.

While I was uninsured my dentist's office charged me less than they charged insurance companies ($62 rather than $80 for a standard visit and cleaning), knowing that I was paying out of pocket. This is a sufficiently good deal that when I got a RealJob and was offered dental insurance, I added it up and decided it wasn't worth having - I can get four visits a year for the same price as the insurance, which would only cover two visits. If I was prone to tooth problems, this might not be a smart gamble, but I've never even had a cavity. I have had a lot of gum surgery, which is why I go so often, but any gum problems would show themselves early enough that I could sign up for the insurance long before needing any more surgery.

I didn't do any special bargaining to get this deal. I didn't even ask for a deal, they just told me the first time I wrote out a check. Apparently it's a standard price for the uninsured.

Logically, it makes more sense to overcharge the insurance companies rather than the uninsured. My limited experience on the clinical side suggests that this is the more common tactic.

#140 ::: rhandir ::: (view all by) ::: July 06, 2006, 09:57 AM:

Okay, I'll chime in. Long ago, I was listening to a bit on the history of health insurance in the US on NPR, and the commentator talked about how in the very beginning, "managed care" was a slight improvement over straight health insurance because for the first time the insurance companies had someone look at the billing and not automatically approve every expense without question. In other words, there was a savings greater than the expenditure needed to support the bureaucracy due to catching simple overcharging, (And presumably fraud) the same way any insurance company does.

He went on to describe the flowering of HMO's into something precisely big enough to capture all of the saved money.

I believe the same program had a followup piece that quantified the number of generic physicals that could be done for the price of a heart transplant - somewhere in the low thousands, I believe - with the implication that many expensive and risky "crisis care" procedures could be avoided by funding basic health care.

I'm not too keen on the idea of socialized health care (maybe just by reflex) but I have become convinced that we really need to provide the basics to everyone, if for no other reason (aside from compassion) than it is cheaper to treat almost anything early, rather than in the emergency room. I am agnostic as to how to pay for "providing the basics" - single payer, nationally pooled insurance, whatever.

Oh, you could make an arguement for nationally funded annual checkups from a conservative/libertarian viewpoint: markets depend on accurate knowlege of the situation. If you provide a person with acccurate knowlege about their health they may plan ahead in their spending/saving to prevent future health problems, ultimately saving taxpayer dollars in ER visits, and increasing the amount of income flowing into the health care industry.

There are some obvious flaws with that proposal - I present it merely as an exercise in packaging.

-r.

#141 ::: JESR ::: (view all by) ::: July 06, 2006, 01:29 PM:

Teresa, the opiate I'm talking about is V!cod!n.

J. Thomas, your touching scenerio of the bottom-line values for treatment of diabetic amputation shows a true 19th century view of the actual medical treatment itself. An amputation for gangrene (which is the actual presenting condition for diabetic amputations) involves up to a month of hospital care, with intervenous antibiotics and intensive nursing. Post-amputation diabetics are at risk for repeated hospitilizations for systemic infection, congestive heart failure, and diabetic coma/insulin shock. Life expectancy for post-amputation diabetics is drastically shortened, and the death process is not cheap, it's not pretty, and it's not quick.

And before you go ascribing all deaths and amputations from Type 2 diabetes to being fat and lazy, let me introduce you to my father, who got a roofing nail in his work-boot when working on a farm structure, and ended up with an infection due to low-level diabetic neuropathy keeping him from feeling the nail; he was in his seventies, had been diabetic for thirty years, and was lean, fit, and otherwise healthy. It took him three years and dozens of hospitalizations to die, all covered by insurance through an ag-based insurance program which, it should be noted, no longer has a medical package.

(Also, sorry for the structural chaos of my last post: I hereby vow never to post within 24 hours of taking any opiate based pain killer).

#142 ::: JESR ::: (view all by) ::: July 06, 2006, 01:39 PM:

Christopher Davis: Fort Lewis, exactly where I was back then.

I'm across the river, and have lived most of my life in what's now called the "Ft. Lewis Noise Impact Zone."

Careers of all sorts get shaped by the availability of health insurance; my husband is pretty much locked in to working for the State, as both he and I now have pre-existing conditions.

#143 ::: Xopher ::: (view all by) ::: July 06, 2006, 02:02 PM:

I thought exclusion of pre-existing conditions was outlawed by the AWDA?

#144 ::: Betsey Langan ::: (view all by) ::: July 06, 2006, 03:12 PM:

Xopher said: I thought exclusion of pre-existing conditions was outlawed by the AWDA?

AFAIK, (and IANAHealthPlanAdministrator), they can't exclude you, but there's no cap on what they can charge you. If you're going from job-A-with-group-health to job-B-with-group-health, you'll likely be OK. If you ever need to buy your own insurance (i.e. after COBRA lapses, or because you're working a job that doesn't come with benefits), you're likely to be scrod.

#145 ::: Clark E Myers ::: (view all by) ::: July 06, 2006, 04:07 PM:

Teresa Nielsen Hayden: "France has a splendid public health system."

Claude Goasguen, député de Paris et porte-parole du groupe UMP:Ecoutez, quand l'aide médicale d'Etat, gratuite pour les étrangers en situation irrégulière, coûte 10 fois la somme prévue initialement, on a le droit de s'interroger!Paru dans L'Express du 04/05/2006

France pays its physicians well under market price and will face problems on that issue alone.

National for the United States implies a scale beyond any of the working systems in Europe. My point supra is that none of the currently working systems has achieved a consensus for national adoption in the United States. There was a time when much of the United States had a working public health system from the bottom up. In Idaho the County Commission would ultimately assume responsibility for indigents in the given County who would be treated in the County Hospital so it was easy to forgive the bill and hold a bake sale to make up short falls. Other states has similar systems but I can speak with authority for the Idaho system - it pretty much worked. It was also true that the law in Idaho was that the standard of care was what was appropriate for the resources - it was not malpractice when the standard of care was below Mass General or Payne Whitney or..... The Idaho system completely failed when folks started being airlifted to Salt Lake and presenting a county of 5,000 people with a bill in the hundreds of thousands of dollars.

Pure anecdote not data I know at least one Canadian - her tribe as a sovereign has treaties across the border and she qualifies for American as well as Canadian benefits although born and raised in Canada - who is treated in the United States for failure of prompt adequate treatment in Canada.

I'm not against a national health care plan - I even have my suggestions. But I worked with Aetna's IS systems and I knew what Boeing budgeted for employee health benefits and how it was allocated and most of the suggestions over promise and under perform

#146 ::: JESR ::: (view all by) ::: July 06, 2006, 05:11 PM:

What can, and often does, happen with preexisting conditions is that they can demand rediagnosis for anything not utterly straightforward, and make you go through meds tests for all scripts. The worst, from my point of view, would be loosing a team of pros who I've finally got trained.

#147 ::: Marilee ::: (view all by) ::: July 06, 2006, 11:44 PM:

JESR, I'm sorry about your dad, but this is why diabetics are supposed to do foot checks and make sure they don't have skin breaks anywhere. I have numb spots I check twice a day.

Saw the substitute doc today, ruled out my idea of walking pneumonia, but he's consulting oncologists. I ruled out non-Hodgkins lymphoma before I went because my glands are normal, but he's not so sure. Bah. The other best possibility is to increase the estrogen in my HRT, but I have to have the mammogram first, so Tuesday I get my breasts squished, extra times because of their size. Tomorrow, I see the nephrologist (but I get to eat at one of my favorite restaurants as long as I'm out that way).

The sub doc is new at Kaiser and is much better than my regular primary. I wonder how much chaos I'd cause if I changed.

#148 ::: JESR ::: (view all by) ::: July 07, 2006, 01:53 PM:

Marilee, it's nice to prescribe proper behavior for other people over the internet, isn't it? Unfortunately, when you're dealing with real people in real time, and they are doing real things, it gets difficult to be inerrant.

Please note above that the patient you're prescribing for had more than thirty years of well-controlled diabetes behind him, and was doing hard physical labor well into his seventies. He also had cataracts, and was uncooperative about waiting to start his day until his wife was ready to do a foot check. It took one missed check to start that infection.

Point being, in an imperfect world, planning for medical usage based on nobody ever making a mistake is not likely to be sucessful, and the proposals above for libertarian management of health care aren't likely to improve mortality and quality of life.

#149 ::: J Thomas ::: (view all by) ::: July 07, 2006, 03:49 PM:

It took one missed check to start that infection.

Point being, in an imperfect world, planning for medical usage based on nobody ever making a mistake is not likely to be sucessful, and the proposals above for libertarian management of health care aren't likely to improve mortality and quality of life.

Consider that. We already have a lot of medical usage based on you never making a mistake. And a very large part of the rest of it depends on your MD never making a mistake and your pharmacist never making a mistake. This is a broken system.

Suppose we found a way that somehow mechanically added extra feedback loops etc that encouraged our failures to fail safe. If we had some sort of hypothetical system like that it might hypothetically allow libertarian-type health care to work adequately too. I wouldn't rule it out.

But I don't want a lot of dangerous drugs freely available because of the social problems they'd cause, independent of their use as intended. We'd need to be spending a whole lot more on forensic medicine and toxicology and such. We aren't ready for anything like complete deregulation even if we get technology that would leave it working better than our current system when used as directed.

An amputation for gangrene (which is the actual presenting condition for diabetic amputations) involves up to a month of hospital care, with intervenous antibiotics and intensive nursing. Post-amputation diabetics are at risk for repeated hospitilizations for systemic infection, congestive heart failure, and diabetic coma/insulin shock. Life expectancy for post-amputation diabetics is drastically shortened, and the death process is not cheap, it's not pretty, and it's not quick.

You are assuming here that indigent patients would actually get the full monte of treatment.

And before you go ascribing all deaths and amputations from Type 2 diabetes to being fat and lazy

Where did that come from? I think people will tend to live longer and be healthier if they exercise and avoid overweight, but that's a far cry from saying that people who have health problems have them because they're fat and lazy.

#150 ::: Larry Brennan ::: (view all by) ::: July 07, 2006, 05:06 PM:

Betsey Langan: If you ever need to buy your own insurance (i.e. after COBRA lapses, or because you're working a job that doesn't come with benefits), you're likely to be scrod.

But not necessarily. When I rolled out of COBRA coverage in 2003, I was able to get insurance through Kaiser Permanente, although I had to appeal to get the normal rates. I still had the option of buying HIPAA qualfied insurance through Kaiser at a rate that was about 60% higher than the standard rate. So, in California anyway (I don't know if anything Federal applies) you can still get insurance that covers pre-existing conditions if you haven't already lapsed and can afford it. (BTW, thank the deity of your choice for Kaiser. Lots of people love to hate them, but they provided good care at a reasonable cost - at leas to me.)

There are also lots of companies that automatically cover pre-existing conditions from day one, even though they don't have to, which gets them back under the HIPAA umbrella eventually. (There's a time period that applies - 3 years of qualifying coverage I think.)

#151 ::: Lizzy L ::: (view all by) ::: July 07, 2006, 06:31 PM:

Larry, I want to join your praise of Kaiser. I have been a Kaiser patient for 35 years; joining Kaiser was one of the best decisions I ever made. Yes, they make mistakes, sometimes very bad ones. Yes, I have had doctors I didn't like, and doctors I did and do like who didn't get it right every time. But in those 35 years my doctors at Kaiser have diagnosed and treated me for innumerable minor problems and several major ones, including hyperthyroidism, a broken leg, a double meniscus tear in a knee, and 5 months ago, a heart attack.

One reason Kaiser works, I think (though not flawlessly, I know) is that it is non-profit. A system which does not have to make a return on investment for its shareholders on a short term basis can put that money into long term, preventative care -- diabetes education, "wellness" clinics, pre-natal classes, a blood pressure clinic, drug management for seniors, nutrition counseling, exercise classes, etc., in order to keep me and everyone else off that gurney. Kaiser actually does that pretty well.

I have no evidence save that of experience -- though I'm sure studies have been done -- but I firmly believe that one reason we do basic (as opposed to emergency) medicine in this country so badly is that the "shopping for the best rate" consumer model does not work when you are talking about medicine. Choosing medical care is not like buying a television. When you are in pain, feverish, semi-conscious, or scared to death for yourself or someone you love, it is extraordinarily difficult to make "informed" decisions. We, as a citizenry, badly need basic medical education. But a company cannot make a profit if its "consumers" end up not needing its product..

#152 ::: JESR ::: (view all by) ::: July 07, 2006, 07:04 PM:

And before you go ascribing all deaths and amputations from Type 2 diabetes to being fat and lazy

Where did that come from?

Sorry, mere reflex; the number of people, including medical pros, who assign that label to all Type 2 diabetics, has trained me to use that disclaimer in all discussions.

As for the question of whether all diabetic amputation patients recieve a full course of treatment: in a medical system where it's easier to find a lawyer who will work for contingency fees than a program that covers testing supplies and exersize programs appropriate to an individuals abilities, there's an unwillingness in most hospitals to release patients with active infections and unhealed wounds.

#153 ::: Marilee ::: (view all by) ::: July 08, 2006, 01:20 AM:

JESR, it took one missed check to start the infection, but the next check would have caught it soon enough. When people choose not to follow important medical directions, they have to live with their choices. I know about this, I'm currently considering not having the flexible sigmoidoscopy because I'm concerned about being that dehydrated.

#154 ::: J Thomas ::: (view all by) ::: July 09, 2006, 03:58 PM:

JESR, it took one missed check to start the infection, but the next check would have caught it soon enough.

Marilee, now you're doing it. A 70+ year old man who has been controlling diabetes for 30+ years. And you're telling us how fast his problem would progress based on no data specific to the case except what the person you're disagreeing with has said.

If it was only that simple, if only it was that simple, the MDs would have a much easier time and the system wouldn't be so badly broken.

#155 ::: Marilee ::: (view all by) ::: July 09, 2006, 08:18 PM:

J Thomas, the check the next day would be soon enough. If the infection progressed fast enough that the next day wasn't soon enough, he would have noticed the smell and goop.

I have lots of experience with this kind of infection.

#156 ::: P J Evans ::: (view all by) ::: July 09, 2006, 08:44 PM:

One of my mothers cousins got gangrene from hitting his toe on the driveway. Yeah, he had diabetes.

#157 ::: Clifton Royston ::: (view all by) ::: July 09, 2006, 11:36 PM:

I have noticed that many bitter disputes (online and otherwise) can suddenly be resolved, or be seen to have never been in conflict, when all involved parties begin adding the phrase "in my experience" to their personal observations of their experiences. Even more can be avoided by those who develop the habit of mentally appending 'in his/her experience' to others' pronouncements. (That's merely in my experience, of course.)

Now I'll hop off that soapbox and expand on the hint I dropped upthread about coverage, based on my personal experience here in Hawaii:

While it's no panacea, it seems to me it would be a huge step in the right direction if all states in the US began mandating that all employers must offer group health insurance as an option to all half-time-or-better employees, including an option for (employee-paid) family coverage, and that insurance companies operating in the state must make corresponding plans available to even small employers.

'Tain't no socialized medicine, but it would be a big improvement over the chaos that seems to prevail in much of the country.

#158 ::: abi ::: (view all by) ::: July 11, 2006, 04:55 AM:

In my experience, the charges to non-citizens seeking medical care in countries with socialised or collectivised medical care are lower than the ones cited above for uninsured people seeking care in the US.

Two data points:

1. In 1991, I set my legs afire with stove fuel on a beach in Spain. (No, not deliberately.) I had 15% second degree burns. I was treated at a first aid clinic, transported by ambulance to the hospital in the nearest big city, and treated in hospital for 8 days. I can't recall the cost in pesetas, but it came out to less than $2000.

2. Last week, when we were in the Netherlands, my 5 year old son was ill enough that we took him to the doctor. That cost less than 40 euros.

In my experience, the NHS has been on its last legs (if you believe the papers) for at least 13 years. In that time, I've had two children in NHS hospitals (with very good antenatal and postnatal care), received a blood transfusion for severe anemia, had two house calls for my husband's illnesses, taken one child to three out of hours clinics and an emergency room, got the children immunised, had the usual checkup schedule for all four of us, and undergone a scan for a suspected tumor. All of those treatments have been free at the point of use.

The conclusions I've drawn from my own experience are:

1. It really is more expensive in the US health system. Somehow.

2. I prefer a system where everyone has a basic standard of care. I live in a deprived area, and the poorest mothers get good antenatal care and as much medical attention during childbirth as I did. That matters to me, somehow.

3. The rich will always get whatever treatment they want. Money economies are like that. The main difference between the US and the UK systems (the two I know best) is that here, the poor get better care than in the US, and the middle class get worse care.

By worse care, I mean that we are less likely to get expensive treatments for rare diseases, and are more likely to get care in less pleasant circumstances than our US equivalents (I was in a 4-bed + 4-cot ward when my daughter was born. 4 newborns waking at random intervals during the night and crying was...not fun.) Speaking purely personally, I am willing to make the latter sacrifice. I have not been faced with the former.

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