that tired, old, people are dying! trick

Perhaps it would help if we understood what we are buying with health insurance: health care. Not "death prevention". Health does not equal mortality improvements directly. If you have a mortal illness or injury, or one that if left untreated may become such, yes it does. But much of health care deals with improvements in health itself. If you ask a doctor, their primary mission is to improve the quality of life by doing things like alleviating suffering. The expansion of our life expectancy is, like GDP or unemployment, one important way to measure the success of that care that they provide. But it becomes absurd to suggest that out of the millions of people who go, even temporarily, without health insurance, that some thousands of them die as a result of that lack. There are some thousands of people WITH health insurance who die every year because of inadequate or inappropriate quality of care (from things as simple as washing your fucking hands). There are some thousands of Americans every year who die of treatable ailments who don't seek care soon enough or who have lifestyles which aggravate or help bring on ailments as well. Again, many of these people have access to health insurance. The problem that underlies all of this is twofold

Firstly, the mythology that doctors and health care providers generally are magicians capable of saving and extending our lives. There isn't, so far as I know, good evidence to suggest that this is the case. Doctors have done a great deal to help propel this mythology, mostly so that their services rendered may be regarded as expensive, but primarily what they do is not help us life longer.

Because, secondly, what they primarily do is help us life better or at least healthier. The ideal product they provide is something abstract like Quality Adjusted Life Years. That may mean, for example if you have cancer or some other potentially fatal illness or health condition, that they will try to give you years of additional life expectancy as a good patient/client outcome. That's good, and that's what people want when they go into a doctor when they get cancer (or think they have cancer). But that's not what they are selling. Even within modern medicine, a lot of it is things intended to help the quality of life, almost in a heuristic way. Pain management, notions of proper diet and exercise, mending non-fatal wounds and broken bones or ligaments, cleaning our teeth, adjusting prescriptions on glasses, helping clear our arteries or lower our blood pressure. Many of these things don't actually help us live any longer per se, but they most certainly are good outcomes when they succeed (and in many cases, they rely a great deal on patient collaboration more so than doctor skill). To my mind the appropriate idea when purchasing health care, even through the device of insurance paying for it, isn't to ask about how much longer I might live as a result of this procedure or drug, but how well I will live during that time. The medical community as whole I think has bought into the first question too much itself and has often failed to focus on what it is actually capable of delivering and promising in any statistically measurable way: better overall health outcomes for its patients/clients. One such outcome is that people can live longer. I don't object to that. But it's sort of silly to pretend that it's really the most important one.

So the ideal argument to be made about extending health insurance (what I refer to as health financing) to the sick (pre-existing conditions), the elderly, and to the poor more broadly than we have at present most commonly will have very little to do with helping them live longer or preventing needless death. Most commonly the problem is that most of these 20-40 somethings that go un-insured are not very likely to die in the first place from a health problem in any given year, and the 65+ crowd has coverage already through the government. The problem is that the 20-65 crowd that goes uninsured does not consume health care that might be beneficial for their health, the QALY adjustment goes down. They don't treat preventable illnesses because of the expense for example. Some of them, I think we might intuit, die as a result, or at least, might die sooner than they could otherwise. Some of them, based on the overall quality of health care or its inability to treat some illnesses with a consistent standard, might even die sooner. On balance it might make sense to claim that some amount of people die per year because they lack adequate insurance to pay for their health care, merely because mortal diseases are not very easy to treat in the absence of insurance. I can accept that with some logical analysis, but it's not the ultimate goal of health care providers to keep more people "alive" in the first place. We should be aware of what they are actually selling us.

Most of the reason for all these people putting off preventable treatments is less the device of insurance being unavailable itself and more what I refer to as a problem of health care financing. It's because we rely on a fee-for-service model too often rather than as a single function payment. That's not something that will be "fixed" by expanding health insurance either (ie, by increasing the amount of distance between client and provider in the transaction). In other words, to me the appropriate question is not how can we get more people covered with insurance, but rather, how can we get more health care transactions out into the open and still keep sick people with access to improve their health (and possibly live longer). Why aren't we asking what we are really paying for or why aren't we somehow equally angry that some thousands of people die needlessly IN the medical care of professionals (and not merely because they lack access to that care). Maybe because we don't see and pay for the bill?

I am not unsympathetic to the suffering of poverty, such the illnesses caused by poor diet or difficult and unhealthy living conditions (such as pollutants or drug/tobacco consumption rates), and despite my usual hostility toward the elderly and the infirmities of age, I think it is only natural that most people will wish to see their aging parents or grandparents attended to for as long as we can reasonably do so. But since those groups of people already have paid for health care at taxpayer expense, I'm not that worried (at least directly). What should be at question is how the rest of us will attend to our health care needs and what will we be getting in exchange for our money (and how will we pay). As with any question, one thing that needs to be asked is always what is unknown or unseen in the variables involved, in this case, things like the relative health habits and incentives of people with and without health insurance as examples. We cannot account for everything, so it can be assumed that people who don't have health insurance and the access it provides might have less healthy lives (and therefore be at some risk of premature deaths). There doesn't appear to be substantive evidence to back that intuition up though. So it's not the best argument to be used if you want to sell me on health care reform. Far more interesting would be an idea of how much each QALY costs us with or without insurance or through different methods of payment (and different kinds of insurance). If we can buy more "health" for less, wouldn't that be an ideal outcome which people might be interested in hearing about?

Unfortunately, our summer debate on health care managed to effectively kill off that discussion. By screaming about "death panels" and irate fears that our grandmothers would be killed off to have their organs harvested or some such nonsense, those people effectively stopped any sensible inquiry as to what health care dollars actually purchase and why. They may have succeeded, for now, in helping kill a bill putatively reforming health insurance as an industry (and not much else about the health care system), but I'm very worried that they managed to help kill off something more important: the way we talk about and approach health care itself in this country. It looks more like the ideas we have about death and mortality because of health care has become ever more entrenched instead because the response to it was to talk about people dying already under the current system. You don't have to sell me on the current system being broken and ineffectual. I'm not the average Joe, but I am the guy who you are going to have to sell on whether or not your proposed system would work better somehow, enough so to make it worth whatever price it will cost or tax it will enact. And using rather mythological beliefs about life and death being the pre-eminent concerns of health care is not the way to do it. Move on to something with more established statistics and economics behind it if you please.