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I think the global problem is that medicine has improved so much that, unlike a hundred years ago, it's impossible to provide the full extent of modern medicine

I think the global problem is that medicine has improved so much that, unlike a hundred years ago, it's impossible to provide the full extent of modern medicine (which is huge!) to everyone, so some form of rationing/filtering is inevitable and necessary. You can do the rationing through market forces, where people who can't afford it get less care; you can do the rationing through some other allocation system (e.g. priority systems, or long queues, or lottery, or committee allocation) which in effect still mean that not all people get everything. If you want to say "In our society, everyone gets healthcare" then you have do define "healthcare" narrowly, which includes some services but not everything technically possible - I mean, if we have services that take more than a man-month of labor for each month of prolonged life (and there are some) then that's not possible to provide for everyone always even from a purely mathematical standpoint. On the other hand, if you want to attempt to provide (nearly) everything to (nearly) everyone and avoid planned rationing of the available healthcare resources (which still comes up to more care for more people than it was 50 or 100 years ago) then the overload catches up to you as described in this article, and you get a collapse of the system.

maxerickson 4y ago
In the US, it's arguable that medicine barely existed in 1900, so I think you make a good point. The thing is, we aren't even doing the simple thing of making sure that the medical care that is delivered is done so somewhere close to the best possible cost. We heavily regulate supply and then pretend that we have a market. Or like we have laws like EMTALA, which requires stabilizing care, which is expensive, that leads to hospital systems making walk in clinics that aren't subject to the law, and then encouraging their patients to figure what level of treatment the need. Like my PCP has little placards in their rooms explaining the difference. There's no law that the ER can't triage down to a lower level of care, but it would cost them revenue. It's fucked.
- shigawire 4y ago
  From working in and around EDs, I highly doubt any ED is purposefully taking up beds with low acuity cases for revenue. Most EDs are swamped constantly and will tell you to go to Urgent Care because their halls are already filled with boarders waiting for inpatient beds.
  - maxerickson 4y ago
    Sure. That's not the point. My hospital system built an urgent care clinic adjacent to the ER, at about the same time they renovated the ER. They aren't separate to do patients any favors! Any hospital built in the last 20 years that has a MOB on site probably has a pretty similar setup.
mattigames 4y ago
There is a important variable in that you don't touch in your comment, and I know even mentioning its source of controversies and strong emotional responses but it's the elephant in the room, and it is the population number, it shouldn't be that controversial to say that 8 billion people is way too many people and that something should be done to create incentives (NOT force) to reduce that number, and obviously I don't mean doing anything about living people but the generations to come, so it's more about related to the subjects of natality and government than anything.
- int_19h 4y ago
  Why would the absolute population number matter in this context? More people overall also means more healthcare workers, and healthcare is labor-intensive, so that's where most of the costs ought to be.
  - mikrotikker 4y ago
    Better to ban the like button and turn off tiktok etc so kids don't grow up wanting to be famous instead of being a nurse or doctor. Know what, just turn off the Internet, it was a mistake.
  - FormerBandmate 4y ago
    Residencies are an artificial cap on healthcare workers. We could, and should, have more
  - mattigames 4y ago
    Because a virus that propagates itself based on proximity would have a harder time propagating itself if there were less people in the world.
    - oblio 4y ago
      And most healthcare expenses are for chronic diseases, not for pandemies...
- 4y ago
cameronh90 4y ago
I completely agree. I personally think at a certain point we need to start factoring age into our calculations on whether we provide expensive medical care for particular conditions. At the moment, we sort of try to reduce medical care to elderly people by trying to get them and their family to agree it would be more humane to let them go naturally, but we still spend an extraordinary amount of money trying to slightly extend the life of nonagenarians, for example. Unfortunately, something like this is bound to be extremely unpopular and controversial. I think most people probably agree that if you had two people with cancer and could only afford to treat one of them, it would be better to treat the 22 year old and not the 92 year old. However, when you scale that up to an entire country, abstract it all away behind insurance or tax, and it's YOUR grandmother on the line, things get more difficult to reason about in such a utilitarian fashion. It's probably better for society to withdraw all non-palliative care from over-80s and spend all that money on teenage mental health, but I can't imagine any politician being willing to attack their voter base like that.
- giraffe_lady 4y ago
  The reason people won't like this is that it's essentially a eugenicist argument and this sort of utilitarianism slides easily into straight up eugenics. Replace the 92-year-old in your hypothetical with a 22-year old blind person in a wheelchair and "most people" would probably withhold treatment in that case. But they would conclude that based on stereotypes and assumptions about what life "must be like" with those disabilities, not on whether or not that person finds their life worth living. To change this you need to make it so that so that people actively choose, for themselves, less resource-intensive courses. Which is absolutely a thing, most people if well-informed would choose a slightly shorter life with higher quality of life, still part of their families and communities rather than medically segregated from them. There are powerful reasons people don't make these choices right now, and that needs to be addressed, rather than snatching the choice away from them and putting it in the hands of forces that will inevitably use it for atrocities.
  - cameronh90 4y ago
    Saying we shouldn't spend a ton of money treating a 90 year old isn't even close to eugenics. It's just an acceptance of reality: they are going to die very soon and all the money in the world won't prevent that, so why spend it? Maybe you'll restart the heart, maybe you'll get their cancer into remission, but then they'll just die of pneumonia in a few months anyway. At least in my country, healthcare is paid for with taxes, so I don't think there's anything wrong with withdrawing the government funding for the more expensive treatments past a certain age. If someone chooses against that and wants to save up over their life to pay for extraordinary interventions in their later life, I have no issue with that, but I don't think it's a sensible thing for society in general to pay for when we are in a funding constrained situation. Socialised medicine already makes funding decisions regarding who gets healthcare, for example in the mental health example, that is really poorly funded relative to the amount of benefit it provides compared to cancer care for the elderly. We actually already do incorporate the concept of "quality adjusted life years" into calculating whether to fund a medication, it's just that decision is only made once, at approval time, using the average impacted patient's age/health. However, that has the even worse side effect of causing very effective treatments for diseases that mostly only affect the extremely elderly to not be approved, meaning the odd 35 year old who gets that disease can't get treated without the paperwork of an individual funding request. That is to say, this choice is already in the hands of other forces - and actually in the UK, it's up to the medical team, not the individual or their family to decide whether to withdraw care, but typically (though not always) they do what the family requests.

maxerickson 4y ago

In the US, it's arguable that medicine barely existed in 1900, so I think you make a good point. The thing is, we aren't even doing the simple thing of making sure that the medical care that is delivered is done so somewhere close to the best possible cost. We heavily regulate supply and then pretend that we have a market. Or like we have laws like EMTALA, which requires stabilizing care, which is expensive, that leads to hospital systems making walk in clinics that aren't subject to the law, and then encouraging their patients to figure what level of treatment the need. Like my PCP has little placards in their rooms explaining the difference. There's no law that the ER can't triage down to a lower level of care, but it would cost them revenue. It's fucked.

shigawire 4y ago
From working in and around EDs, I highly doubt any ED is purposefully taking up beds with low acuity cases for revenue. Most EDs are swamped constantly and will tell you to go to Urgent Care because their halls are already filled with boarders waiting for inpatient beds.
- maxerickson 4y ago
  Sure. That's not the point. My hospital system built an urgent care clinic adjacent to the ER, at about the same time they renovated the ER. They aren't separate to do patients any favors! Any hospital built in the last 20 years that has a MOB on site probably has a pretty similar setup.

mattigames 4y ago

There is a important variable in that you don't touch in your comment, and I know even mentioning its source of controversies and strong emotional responses but it's the elephant in the room, and it is the population number, it shouldn't be that controversial to say that 8 billion people is way too many people and that something should be done to create incentives (NOT force) to reduce that number, and obviously I don't mean doing anything about living people but the generations to come, so it's more about related to the subjects of natality and government than anything.

int_19h 4y ago
Why would the absolute population number matter in this context? More people overall also means more healthcare workers, and healthcare is labor-intensive, so that's where most of the costs ought to be.
- mikrotikker 4y ago
  Better to ban the like button and turn off tiktok etc so kids don't grow up wanting to be famous instead of being a nurse or doctor. Know what, just turn off the Internet, it was a mistake.
- FormerBandmate 4y ago
  Residencies are an artificial cap on healthcare workers. We could, and should, have more
- mattigames 4y ago
  Because a virus that propagates itself based on proximity would have a harder time propagating itself if there were less people in the world.
  - oblio 4y ago
    And most healthcare expenses are for chronic diseases, not for pandemies...
4y ago

cameronh90 4y ago

I completely agree. I personally think at a certain point we need to start factoring age into our calculations on whether we provide expensive medical care for particular conditions. At the moment, we sort of try to reduce medical care to elderly people by trying to get them and their family to agree it would be more humane to let them go naturally, but we still spend an extraordinary amount of money trying to slightly extend the life of nonagenarians, for example. Unfortunately, something like this is bound to be extremely unpopular and controversial. I think most people probably agree that if you had two people with cancer and could only afford to treat one of them, it would be better to treat the 22 year old and not the 92 year old. However, when you scale that up to an entire country, abstract it all away behind insurance or tax, and it's YOUR grandmother on the line, things get more difficult to reason about in such a utilitarian fashion. It's probably better for society to withdraw all non-palliative care from over-80s and spend all that money on teenage mental health, but I can't imagine any politician being willing to attack their voter base like that.

giraffe_lady 4y ago
The reason people won't like this is that it's essentially a eugenicist argument and this sort of utilitarianism slides easily into straight up eugenics. Replace the 92-year-old in your hypothetical with a 22-year old blind person in a wheelchair and "most people" would probably withhold treatment in that case. But they would conclude that based on stereotypes and assumptions about what life "must be like" with those disabilities, not on whether or not that person finds their life worth living. To change this you need to make it so that so that people actively choose, for themselves, less resource-intensive courses. Which is absolutely a thing, most people if well-informed would choose a slightly shorter life with higher quality of life, still part of their families and communities rather than medically segregated from them. There are powerful reasons people don't make these choices right now, and that needs to be addressed, rather than snatching the choice away from them and putting it in the hands of forces that will inevitably use it for atrocities.
- cameronh90 4y ago
  Saying we shouldn't spend a ton of money treating a 90 year old isn't even close to eugenics. It's just an acceptance of reality: they are going to die very soon and all the money in the world won't prevent that, so why spend it? Maybe you'll restart the heart, maybe you'll get their cancer into remission, but then they'll just die of pneumonia in a few months anyway. At least in my country, healthcare is paid for with taxes, so I don't think there's anything wrong with withdrawing the government funding for the more expensive treatments past a certain age. If someone chooses against that and wants to save up over their life to pay for extraordinary interventions in their later life, I have no issue with that, but I don't think it's a sensible thing for society in general to pay for when we are in a funding constrained situation. Socialised medicine already makes funding decisions regarding who gets healthcare, for example in the mental health example, that is really poorly funded relative to the amount of benefit it provides compared to cancer care for the elderly. We actually already do incorporate the concept of "quality adjusted life years" into calculating whether to fund a medication, it's just that decision is only made once, at approval time, using the average impacted patient's age/health. However, that has the even worse side effect of causing very effective treatments for diseases that mostly only affect the extremely elderly to not be approved, meaning the odd 35 year old who gets that disease can't get treated without the paperwork of an individual funding request. That is to say, this choice is already in the hands of other forces - and actually in the UK, it's up to the medical team, not the individual or their family to decide whether to withdraw care, but typically (though not always) they do what the family requests.