I've really enjoyed 'The Endgame.' Great writing, and interesting ideas, but...

I'd suggest staying in your lane. As a guy who has written about social policy for more than half a century, I am afraid that your ideas for 'saving' health care are old hat, have been discussed and tried and are wrong and/or impractical in both theory and practice.

First, you need to have a better understanding of health economics. Like some markets, health care is highly imperfect. Decisions on major expenditures are made by agents acting, supposedly, on behalf of the health care consumer, not by the consumer him or herself. You cannot walk into a hospital and decide to have a by-pass operation or a hip replacement. The decisions that are made by consumers are the least expensive parts of the system, such as whether to visit a primary physician, get a vaccine, go to an emergency room. All of these in themselves have negligible costs in the total system. Deterring these visits may even add to costs by delaying treatment.

One 'experiment' done in Canada when Ross Thatcher put user charges on patient-initiated services resulted in a decrease among person with low incomes and an increase among those with higher incomes for whom the charges meant nothing. I suppose the charges made people feel entitled. Also, doctors had to compensate for the income lost due to fewer visits by low income patients.

An actual experiment by the Rand Corp in the US found a deterrent effect among patients, but failed to look at the systemic effects overall (they only looked at the effects on the individuals paying a user fee).

As to deterring unhealthy behaviour, good luck with that! I suppose you can see how much lower obesity is in the US than Europe and Canada (NOT).

As to the idea of issuing a notice of the cost of services used, I recall that one province did try this (I'm too lazy to do any research and look it up). This added considerable costs to the overall system. Every doctor's office, lab, hospital, etc. had to hire people or extend hours and set up new systems. The verisimilitude of the accounts were proportional to the money spent on the system. How much should your account be for a one night in the general ward of the hospital? Should it be the marginal costs for the room (which would be very little) or the average costs (which would be a lot)? Should it be based retrospectively on last year's costs or prospectively on this years costs? More in the winter during flu season and less in the summer? Should it be a lot more for, say, the cardiac ICU?

In any case, as I recall, most people just throw out the invoice barely paying any attention to it since they did not have to do anything. But others had the bejesus scared out of them. Complaints and inquiries ensued. For what benefit? None, as far as anyone could assess.

Of course, if you are going to make the expenses taxable beyond a certain amount the bills had better be accurate, so get ready to expand spending on the health care system by a lot -- 10% or so like in the US perhaps? -- without adding any actual health care. What effect will these charges have? Tax the people who have been very sick? But people lucky enough not to have been sick pay nothing? Tell me this: if lack of revenue is the problem, why not just raise income tax rates on the wealthiest? This would entail no administrative costs at all, but presumably have the same economic costs as a health service related tax increase. Why is it fair to charge people in the time of the greatest need and not when they can better afford it? What exactly does this accomplish? Bottom line: if it is more tax revenue that is needed there are a lot simpler, fairer and less expensive ways to get it.

Anyway, I shall stop my rant here, encouraging you to continue the 'Endgame' to which I look forward each week.

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I agree that we falsely claim our health system is free and that a yearly breakdown of services provided and received would be useful. Do we over or under use the system? Have the services been effective in resolving our ailment, would be another question to ask. I believe, based on personal experience and preference, that including services such as acupuncture, massage, osteopathy, along with many other such services, can more effectively and less expensively address and resolve certain common health conditions and complaints. Our narrow view of what constitutes health care is problematic and, therefore, the approach to resolving ailments is narrow. I rarely visit a medical doctor, but I can't afford the non-medical treatments that are labelled 'alternatives.' It is these alternatives, a few mentioned above, that have brought me more relief from physical injuries as well as overall improved well-being.

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I like the idea of a statement outlining what it costs each year to see a doctor, specialists and other medical professionals covered by the health care system. I think healthy people who see the doctor for every sniffle and twitch, (my husband is a grand example, his motto is “it’s free, so use it!”), would make some people sit up and take notice. I, on the other hand am the complete opposite of my husband. I’m in my 60’s, obese but active, energetic and I feel good, but the last time I saw a doctor was 9 years when I had a chest infection, my last full medical checkup was 11 years ago. I HATE seeing doctors. I’m always scolded about my weight or get heavy eye rolls and talked down to when I come in with a health compliant. I once complained of a recurring sore throat but somehow my weight was the problem (turned out I had strep throat). When I had trouble getting pregnant 30 years ago I was simply told to lose weight. No referrals to a weight loss program or medication or other therapies, my family doctor just walked out. It’s also not helpful when our Alberta premier basically blamed the overburdened health system on smokers and people like me. I know the risk I’m taking but it bothers me when fingers are pointed at me saying I’m a burden, so I’ll take my chances. I’m sick, pun intended, of the discrimination and abuse. So to swing back to the idea of allowing people $10,000/year for medical procedures before being taxed, well aside from the doctor visit 9 years ago, I’ve saved Alberta healthcare $110,000, at least.

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Interesting analysis, both on Endgame itself and some of the commentators. I'm in Australia, where we have a partial Medicare system, where those who can afford it are rewarded with a tax cut for taking out medical insurance.

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Although I have no religious affiliation I suggest leaving it to St Peter at the Gate to compute our overuse of healthcare.

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Well it certainly was a somewhat nerdy journey.You make it as if we had options.

Being really sick doesn’t present to the patient options of his choosing.

I’m not quarrelling about standards of care,I’m questioning your assumption we have control of the process.Medicine is an art and accurate answers are not certain.

But as ever your comments are cherished.Julian

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