The question that very few people on the screamy, sound bitey ends of the health care debate remembers is the very simple one:
This is the place that almost all health care reform plans hit a block. The block is not exactly aided by the fact that the last few weeks or months of a persons life are typically the ones where his medical bills are the greatest. This is, of course, not the case for people who die in accidents and may not be true for those who end up surviving chronic diseases like cancer. But it is sufficiently common that the obvious way to cut the costs of any medical service is to not treat people who are really ill.
Since, eventually, we all die the mdeical cost of our final weeks of life is something that someone is going to have to pay for and, since we're dead at the end of it, it isn't going to be us unless we made suitable savings. So that means someone else has to pay.
And that is the probem.
Perhaps it is best if the government pays. Perhaps not. Perhaps in fact those nasty calculations about years of future life at what quality have a place here. But not addressing this point means that whatever method you use for paying for healthcare will go bust at some point in the future because you are going to be paying more out than you get in.
Eventually a person, community, nation, world will run out of money to pay for terminal care no matter what. This, combined with the fact that it is extremely hard to tell in advance which medical treatment will be worthwhile, means that some kind of rationing is bound to occur because it is quite simple to show that it is otherwise unaffordable.
Let's do some sums to see how this works. Consider the UK with approx 60million inhabitants. If the average cost of terminal care for each death in the UK is £50,000 beyond what the person contributes in taxes during that time then the UK soon runs out of money. £50,000 is pretty small change for someone dying of cancer - 6 months of £500/week drug chemotherapy cocktails, £20,000 for a hospital stay with surgery, a few £1000 a session MRIs and x-rays and you're there, if there's another last ditch operation or some long term pain relief or hospice care then you can easily see the total heading way up above £50,000. I don't know what a heart operation would cost but I suspect it would not be far of £20,000 either so much the same works for people dying of heart disease after months of intervention and treatment too. Of course the unfortunates who get run over by a bus/drunk drver or overdose on recreational pharamceuticals probably cost rather less and so on but I suspect that £50,000 is not a totally unreasonable average amount for the sort of healthcare that would be available with no rationing of any sort.
Google tells me that UK mortality rate is about 10/1000 or 1% meaning that every year 600,000 inhabitants snuff it. At £50k a pop that works out at £30,000,000,000 (£30 billion if you prefer). Total UK tax/duty revenues are currently around £400 billion making that cost 7.5% of tax revenues or (IIRC) about 5% of current total government expenditure. This is just about manageable if the number remains constant but it won't.
As patients fail to die for longer, thanks to advances in medicine, the total non-recouped expenditure on them will increase so that this year's average of £50,000 turns into say 2020's average of £500,000 (in 2009 prices). Before you scoff at that number and date note that £500,000 is not a difficult terminal care medical bill to run up even today. A friend of my father's has had to put his wife in a care home because (to be blunt) she's a vegetable. That home costs £800/week or over £41,000/year. If she stays in her current semi-vegetative state for 10 years (no reason why not, she's not that old) then right there she's cost someone £400,000. Add in, as above, a few hospital stays or other more expensive medical treatments, which let it be noted is what the non-rationers would want, and we're at £500,000 for a person whose quality of life is pretty limited.
If we're in 2020 and average costs in 2009 prices are £500,000 and we've had c.2%/year real economic growth and hence 2%/year growth in tax receipts that gives us at best a 25% increase in government revenues (this is generous) to £500 billion total. The outlay on non-recoverable healthcare in our notional 2020 £300billion/£500billion = 60% of tax receipts. If growth has been rather more anemic (and 2% is pretty good for recent years) then the proportion rises - if there has been no growth at all then its 75%!
7.5% of government income is something that can be handled more or less, 60%+ is not. So rationing of healthcare will have to happen.
This is true whether we are looking at private cover or public cover. If the average cost per inhabitant increases to even the £200,000+ level it is unaffordable. Cutting drug prices may help but, as my discussion of the care home points out, the real cost is in nursing care. While £800 a week for a patient who needs 24x7 attention seems a lot in fact it is probably not making vast profits once you factor in the cost of nursing, cleaning, catering, building rents, heating etc. It would not surprise me to find that the average ratio of staff to patients in any such home approaches 1:1. Assuming that the average salary of the care home staff is approximately the UK median (£479/wk) and the ratio is 1:1 then that leaves £321/patient/week for food, heat, rent etc. £100 for food, £100 for utilities and rent gives us no more than £121 in profit (15%)
I don't know what the solution is going to be but I'm sure that at some point poor people are going to not get years of spnsored assisted living because it would bankrupt the country.
One thing that fascinates me now that I'm doing quite a lot of running is the difference between male and female performance. The difference is reasonably consistent across all distances as this table of world recods by distance shows (taken from the IAAF).
Hicham El Guerrouj
Hicham El Guerrouj
Hicham El Guerrouj
Micah Kipkemboi Kogo
Samuel Kamau Wanjiru
Paul Malakwen Kosgei
*One hour is distance in km travelling in one hour hence the difference ratio is reversed
If you graph this you see that for the most part the female records are 12-14% slower (with some outliers) but that the trend distinctly drops at the ends. Particulalrly at the long end where the 100km time is far more equal. Also of interest is that while female record holders are from a variety of ethnic backgrounds (though no Indians) the male ones all come from an African background except for Takahiro Sunada in the 100km cetegory and Takatuki Matsumia in the 30km one. [Actually there are 2 other Japanese male record holders in the 25,000 meters and the 30,000 meters - I omitted these times in the comparison since it seems clear these are distances are weird in that these track records are significantly slower than the road equivalents for both sexes.]
Just to put these numbers in persepctive. I personally can run from 5km to marathon at times that are approximately 50% longer - (19 minutes 5-km, 39 mins 10km, 1h26 for half marathon and 3h15 for the full) - than the male world record holders. I also generally finish in the top 10-20% of finishers. Slower runners often take more than 50% longer to finish than I do so.
I suspect that outside of professional athletics the m-f difference is on average larger. For example when I look at the times for the first female finisher compared to the winner (always male) in the smaller races I take part in the difference seems to be larger than 10-15%. Indeed I quite often beat - or come in close behind - the leading woman in these smaller races).
One reason why I'm going on about this is that people generally accept that in sports female competitors/teams at a certain level will be beaten by male ones at the same level. Indeed think of all the controversy about Caster Semenya just now. In fact I'm not in fact aware of any major sport which relies on human muscles where women compete on equal terms ot men. On the other hand there is huge controversy over potential intellectual differences. William Briggs has a series of posts discussing "Fads and Fallacies in the Social Sciences" by Steven Goldberg where the statistics about that possible difference (mean IQs same, males show higher varience hence more males as outliers at the top and bottom of the range) and how people refuse to accept evidence that points to the difference or the consequences of such a difference.
The other reason I'm thinking about this is because of fictional books where the heroine is some kind of physical superwoman. Unless she's genetically engineered like Friday or Honor Harrington this is going to be hard to swallow unless there are clear compensatory reasons such as coming from a different ethnic group where both sexes are generally bigger and stronger (think N Europe vs SE Asia for example).
The WSJ reports today that, just as many free marketeers and other folks predicted, increasing tax rates and regulations causes those who are affected to move to somewhere with lower rates and regulations.
A stream of hedge-fund managers and other financial-services professionals are quitting the U.K., following plans to raise top personal tax rates to 51%.
Lawyers estimate hedge funds managing close to $15 billion have moved to Switzerland in the past year, with more possibly to come. David Butler, founder of professional-services firm Kinetic Partners, said his company had advised 23 hedge funds on leaving the U.K. in the 15 months to April. An additional 15 are close to quitting the U.K., he said.
Since the UK doesn't have much in the way of revenue earning private enterprise outside of the financial services sector this is not good news for the UK treasury and public debt. The article goes on to show that the gnomes of Zürich aren't stupid enough to miss an opportunity to benefit from the HMG's stupidity:
Matthew Feargrieve, London-based partner at offshore law firm Mourant du Feu & Jeune said the combination of higher taxes and prospective EU rule tightening was potent. The Swiss cantons of Zug and Zurich plan U.K. shows designed to lure businesses from London.
Swiss cantons are prepared to agree to ultralow tax rates with people bringing business to the country. Even without discounts, Zug's tax charge is just 14%.
As the article finishes
Fiona Sheffield, a partner in the hedge-funds tax practice at accounting firm Ernst & Young, said in June: "We have had most of the 250 hedge-fund managers we provide services for talking about the pros and cons of leaving the U.K. for Switzerland."
I'll be happy to give some pros and cons on Swiss living myself but compared to the UK I'd move over in a heartbeat even without the tax issues. Zurich is a far niceer city than London.
I took this photo ages ago near Auribeau/Siagne but for various reason snever got around to making it a Olive Tree Blogging post. I thought it was interesting because it shows an interesting mixedland use with olive trees in rows between rows of vegetables (I think artichokes). As always click on the image to see it enlarged and don't forget to visit of the olive tree blogging archives for further reminders of how nice olive trees are.
One of my favorite authors is Dave Freer. He writes all kinds of stuff - both Fantasy and Science Fiction - and mostly in a somewhat humourous vein. I've recommended him a few times on my blog and reviewed his latest book - Slowtrain to Arcturus - last year. I also intend to review the one out next month in a week or two. Its a great book too.
Dave currently lives in South Africa, as has his family for generations, but the political/economic situation there has worsened to the extent that on Friday, his fiftieth birthday, he sold his house. The plan (and he's got all the visas etc.) is to embark on a transoceanic trek from South Africa to Finders Island, Australia and live there from now on. Upping sticks and moving lock stock and barrel like this is, of course, not cheap and things like exchange rate fluctuations mean that he's got a minor problemette: what to do with the family cats and dogs.
However, as he explains at his new website (http://savethedragons.nu/ ), for him and his wife this isn't such a minor detail:
Only, if you’re us, that’s a huge Godzilla-size problem. They’re not a responsibility we take lightly or just abandon.
You see if we're to take them with us - which we really want to do - they have to stay in quarantine and that's expen$ive, we'd kind of budgeted for it but what budgeted isn't enough given how the exchange rates have moved. Hence this site to try and make up the shortfall
The Storyteller's Bowl
The idea is simple and borrowed from Schezerade and her companions of ages past: I tell you all a story and at critical moments I pass the hat around. When you've given me enough money I continue.
In fact I'm modifying this slightly - the idea is to put up a chapter a week of my latest book "Save the Dragons" assuming that I've received enough donations (the thermometers at the left tells you where we are). The book has 25 chapters plus an epilog. You get the first one free and then I collect $400 (US) per chapter (and per week).
If and when the book is published anyone who contributes more (in total) than $25 will get a personalized signed copy in Hardback posted to them (or if it doesn’t ever come out in hardback - all but my first book have done - in the next most expensive format). And no matter what all the money raised goes to keeping the Freer furry animals together with their servants - that would be us - as we head off in search of a new life.
The book itself is great. As I'm the webmaster I was forced to read it and make sure it was OK. I'm pleased to say it is much more than OK and there are a few spots which caused me to laugh out loud for an extened period of time.
Dave's blurb for the book is:
The book is one that both myself and my friend and co-author Eric Flint love. It was to be serialized in Jim Baen’s Universe, but sadly the magazine is closing down. Therefore, I have a book to sell. Um. It does break lots of rules. It’s not very PC and as I was told by a leading agent that I couldn’t sell books that have a black hero -- if that’s an opinion you share, don’t read it. On the other hand it’s a pretty equal opportunity barbeque of everyone’s sacred cows rather like Rats Bats and Vats or Pyramid Scheme. Yes, it is satire, but it’s a galumphing adventure story too -- about an unfortunate alchemy student, a wicked plot for domination of the spheres of existence, and of course the extermination of dragons. It has a cast of low IQ heroes and a few that are too bright for their own good, a broad selection of villains, a villainous selections of broads (in every sense of the word) and a transplanted hand with a mind of its own, haunted by a prognosticating foul-mouthed fowl. There’s an claustrophobic dwarf and a cast of millions... well at least tens, of vampires, werewolves and bartenders - off to save the dragons, the universe and of course, their true loves.
All of this is basically accurate but I'd go further. Dave, shy retiring bloke that he is, would be embarrassed to say it but his satirical books remind me quite strongly of the great Pterry at his midseason best. He also reminds me of that other British comic writer Tom Holt. Indeed anyone who enjoyed the first few Tom Holts (such as Expecting Someone Taller) will feel right at home in a Dave Freer universe and very much at home in this book. Mind you Dave is by no means derivative, he has a uniquely twisted view of things, but I suspect the sorts of people who enjoy Messrs Pratchett and Holt will also enjoy this book.