Dear Science,
My conservative relations are pounding me over health-care reform. “Why should the government force me to pay for someone else’s medical care?” Moral arguments, like everyone deserves to be cared for when they’re ill, aren’t exactly getting me all that far. I claim that it’s cheaper to just take care of people rather than waiting for them to get really sick and show up in an ER. They deny this. I need proof, Science! Does kindness (in giving everyone health care for free) pay?
With Morals, Wanting Data
Science has the data for you, and it’s beautiful—a really lovely study first authored by Mary Larimer at the University of Washington Department of Psychology.
Consider the determined homeless alcoholic. Homeless Americans die at three times the rate of the general population. For someone both alcoholic and homeless (often with the former causing the latter), the expected life span is somewhere around 40 to 50 years; that’s what you’d expect for a citizen of the poorest and least developed countries on earth. Resources exist for the homeless—typically ladled out with a good amount of moralistic preaching. Alcoholism is a real disease—devouring some people whole. If you cannot be sober, most programs don’t want you. So, you stay outside. You beg for money. You commit petty crimes. Eventually, inevitably, you get sick. Then you present to the emergency room—either by choice, by police (often after “failing jail” for being too sick), or by medics after being “found down.” As you reach the end of your life span (entering late age in your 30s and the terminal stretch in your 40s), you find yourself at the ER more and more often. The costs pile up. Then you die. The median cost of this cycling—absorbed by society via cross-billing the insured or taxpayer-supported county hospitals—is about $4,000 per alcoholic per month.
Hearing this, we can imagine your relations spitting. The good authors of this study came up with a solution. It’s called Housing First and involves dispensing with moralistic preconditions for compassion.
A list of the region’s most expensive alcoholics (in medical costs, jail costs, and shelter costs for alcoholism) was compiled. Each was offered a free room in a dormlike building at 1811 Eastlake in Seattle; with the room came (cheap) preventative basic medical care and counseling. The first 95 selected for this program cost society over $8 million per year before being moved in. After the no-strings-attached housing, total annual costs (including for the rooms) for the 95 dropped to about $4 million—half. On average, those provided housing drank less; some stopped altogether.
Such a plan is ugly. It ignores questions of who deserves what. It worked. Sanctimony is objectively expensive. Ask your relations if they think we can afford it any longer.
Practically Yours,
Science
Ms. Larimer have had this discussion before, granted she may have a PhD, and I only had a MS, but I dealt with sustance abusers, and according to the APA and the AMA, alcoholism is not a disease.
Furthermore, 4 million going to 95 people is over 42 thousand a year, and without a management plan in place you are assisting them in killing themselves.
@2-
Be that as it may, it’s either save 4 million by housing/healthcaring for these folks, or continue to pay the 8 million. What’s so hard to grok with these numbers? Ethics have nothing to do with it- pure economics.
The only other alternative is to euthanize these folks, which some might argue is a good solution. Funny tho- it was the far-right, “I won’t pay for freeloaders!” bunch that was dreaming up the Death Panels in HCR. You’d think they could decide what they want.
HCR is all about staunching the hemoraging $Billions ($Trillions?) nationwide in our ER’s and hospitals to anyone who walks in for free medical care. We either figure an alternative, or let Grandma et al die outside the ER doors because they have no insurance.
I thought about the whole concept of “deserving” and ultimately decided I don’t believe in it. We give rewards for good behavior to encourage good behavior in the future, and punish bad behavior to discourage more bad behavior. When we find that rewards and punishments fail to have the desired effect on future behavior we should STOP DOING THEM, not excuse it as “they deserve it”. The whole notion of deserving rationalizes needless cruelty and prevents us from doing many things useful to reduce human suffering. The concept of “deserving” should therefore be disposed of.
@4 Agreed! “Deserving” causes a lot of policy problems.
Great column, Golob.
Interesting main idea, but there were a few points that seemed cloudy:
“Homeless Americans die at three times the rate of the general population.”
Doesn’t everyone die at a rate of 100%?
Also, 4 million for 95 comes to about $42,000/person per year. Better than 8 million, but still seems like quite a bit for a dorm room and some basic medical care. Then again, $84,000 seems astronomical. Care to provide a brief breakdown?
6: I drove all the way from home to work, so I drove at a rate of 100%?
Rates =/= percentages. Rates are ratios of two measurements, with units.
I drove at a rate of 40 *miles* per *hour*.
Homeless people die at 3x /
angle bracket fail 🙁
Homeless people die at 3x (number of normal people who died) / (time period)
@7/8, I figured there was something reasonable behind the statement, but I thought it needed to be expanded upon. Maybe my snide response was off-base. But that wasn’t my main question, so I’ll let it die.
I once did a similar breakdown of the cost to a statistically typical american community of housing someone in a statistically average hospital bed versus jail cell versus a room in “regular” housing. The hospital bed was most expensive, jail cell second most expensive and a room was least expensive. Since homeless people end up in jail and/or a hospital bed (and hospitals cannot release someone with no place to go)… the obvious practical solution to homelessness is exactly what this article suggests – house the homeless to save money.
As the first reply to the article suggests, it is not really practicality or even their wallets that people, who are against practical social structures, really care about. The real desire is to punish people they believe are somehow “other” and “non-normative” and “immoral” in order to get everyone to shape up and be just like them.
I once did a similar breakdown of the cost to a statistically typical american community of housing someone in a statistically average hospital bed versus jail cell versus a room in “regular” housing. The hospital bed was most expensive, jail cell second most expensive and a room was least expensive. Since homeless people end up in jail and/or a hospital bed (and hospitals cannot release someone with no place to go)… the obvious practical solution to homelessness is exactly what this article suggests – house the homeless to save money.
As the first reply to the article suggests, it is not really practicality or even their wallets that people, who are against practical social structures, really care about. The real desire is to punish people they believe are somehow “other” and “non-normative” and “immoral” in order to get everyone to shape up and be just like them.
oops double post sorry 🙁
The questioner writes: “I claim that it’s cheaper to just take care of people rather than waiting for them to get really sick and show up in an ER.”
This is not such a good claim when you speak with your relatives, as the Massachusetts health plan (implemented Jan 08) has resulted in 10% to 15% increases in ER visits over the last year. Granted these people are not as sick as the folks who wait until they need full emergency attention – most of them are patients who have no primary doc and just need to be plugged into the system. But this data shows, at least in the short run, that universal coverage increases ER visits. Now whether ER visits are to blame for increased health spending – that’s a whole ‘nother issue – some calculations suggest that visits to the emergency account for 1-2% of all healthcare costs – and that includes folks with broken bones and heart attacks.
Great article Dr. Golob. I read every one from afar!
@ heartfelt who claims:
“…and hospitals cannot release someone with no place to go”
I disagree on point of fact, my dear friend. The opposite is indeed the case, and it happens every single day and night. Call Harborview to confirm, or tell the rest of us on what planet you presently reside. It sounds like a wonderful, civilized place. [Is it Cananda?]
@4 That’s exactly what’s wrong with a retributive system of justice.
Stop RomneyCare!
What hospitals are not legally allowed to do is turn away a homeless person who is clearly a threat to themselves. Homeless people in need of shelter now know that all they have to do is show up at the emergency room claiming they are going to kill themselves (plus they have a specific plan) to get a night’s lodging billed to the rest of us. Really, we have to do one thing or the other. Either refuse to provide ER treatment for people who cannot pay or provide free housing for the homeless. This schizophrenic system we have now is just irrational.
Part of the problem is that when people don’t have to pay for their own health care, in their minds it becomes something unvalued. As a physician in the urgent care clinic of the local children’s hospital, I see people bring their children in for un-urgent, un-emergent, unnecessary visits which could have waited until the next day or even the next week to be seen in a primary care setting. However, they don’t have to pay for any of this so immediate gratification is the most frequently chosen option.
The fact that an urgent care visit costs (someone) $200, emergency room visit costs (someone) $500, and a primary care physician appointment costs (someone) $75 is irrelevant to these people.
We could save a ton of money by having this care cost them *something*. Like, $10 for ED, $5 for urgent care, and $0.50 for a PCP visit. By demonstrating that these services COST something, you’d be able to better serve the overall community by keeping people out of emergency departments who don’t need to be there.
And all those older Americans complaining about socialized healthcare? Give up your fucking Medicare and then you can talk to me.
@1 are you aware of the fact that for many people the reason they can’t get a job is because they are sick. even if you have money, say enough to live on for 6 months while out of work due to a serious problem, you can’t get insurance if you have a pre-existing condition that you, you know, actually need treatment for. then you have to spend the remaining dollars you do have for out of pocket healthcare (which you probably won’t get if you can’t pay for the majority up front)…which is insanely and needlessly expensive in this country.people inevitably get sicker if they can’t get the proper treatment, and are then out of work much longer. i’ve talked to a lot of doctors about this and it really pisses them off that their patients can’t get the care they need. while yelling at people to gets jobs might make you feel awesome, it does nothing to actually help…
@1: O rly? The GOP would need 67 votes in the Senate to overturn a veto. Even if they were to win all 36 Senate races this year, they’d only have 59.
Sorry if reality spoils your wishful thinking.