Tuesday, June 12, 2007

Healthcare. A long post.

Another healthcare post, partially inspired by the last comment over here. I'll start by introducing the principles I consider important in distribution of healthcare resources, then discuss how they might be realized in policy.

The essential healthcare problem is a matter of fairly deciding who loses. Healthcare resources (including not only money and physicians, but support from allied professions, physical resources (e.g., ORs, organs), and so on) are scarce -- sufficiently scarce that there isn't enough to go around. So, when deciding between various methods of distributing resources we have to view the decision as a matter of deciding who will not be treated, rather than who will; as who will continue to live in pain, rather than who won't; as who will die, rather than who will live.

Immediately, then, this rules out full-competition, private healthcare as exists (largely) in the United States. It is grossly unfair to decide that certain people will fail to be treated, will live in pain and will die because they lack the ability to purchase the services they need. The only argument to the contrary that is worth taking seriously is the libertarian argument. The libertarian position holds that resources can be disposed of as one wishes as long as the acquisition was just; so, if one has justly acquired the resources used to purchase healthcare resources, then the acquisition of the healthcare resources is also just.

A just acquisition, for most libertarians, is an acquisition via (at possibly some distance) resources that one received directly for one's labour. So, the chain would be: labour, receive pay, use pay to acquire goods ... use goods or pay to acquire medical resources. But, the problems with the libertarian argument are legion. In this context, the most important is the labour-pay connection. Sellers of labour are very often on unequal footing with purchasers: the latter have tremendous power and leisure in their negotiations, while the former simply do not. Sooner or later, the seller of labour will have to accept what he is offered or die; the purchaser has no such limitation, insofar as he has already purchased much of others' labour and is capable of sustaining himself on the resources he currently controls. (The latter is a not-unreasonable assumption in the contemporary labour market.) At this point, a libertarian might reply that no interference in negative liberty is ever justified, except to correct a prior violation. That this is false follows from enriching the concept of liberty in a way most libertarians refuse: with positive liberty, the expansion of one's powers and abilities, and thus of one's liberty in ways of living. The contrast is not sharp, admittedly, but it amounts to something like this: a proponent of negative liberty considers a person free if he is not in chains, while the proponent of positive liberty considers a person free if he can achieve his goals.

Seen from this perspective, the injustice of the libertarian position is clear. Sellers of labour are not free, on their construal, because their achievement of their goals is blocked by the actions of another; sellers of labour are not in chains, but their options are curtailed by the demands of a fully free market. So, the libertarian argument cannot justify a free-market free-for-all when it comes to healthcare resources, because the libertarian argument cannot justify the system of labour and pay that operates underneath the healthcare market.

If not ability to pay, though, then what should be the principles by which we decide how to allocate healthcare resources? At a minimum, I would suggest, we should look to both consequentialist and deontological considerations: that is, we should look to the outcome of a given use of resources, and we should look to the need for a given use of resources. The former matters because of concerns regarding waste; when resources are as scarce as they in the healthcare sector, we should be careful to use them as effectively as possible. The latter matters because of concerns regarding respect and dignity of persons; even though resources are scarce, that does not justify cavalierly or callously dismissing particular patients from consideration simply because their outcomes are less optimal than those of others. So, whatever system we adopt to allocate healthcare resources, it must somehow weigh outcome and need.

This may not seem to rule out ability to pay completely, though. One could suggest that ability to pay serve as a tie-breaker: when confronted with two patients who are equal in terms of outcome and need, ability to pay could serve as a morally-neutral way to resolve the tie between them. Of course, this just assumes that ability to pay is morally neutral; as argued above, though, given the problems with the current system of labour and pay, it is extremely doubtful that this is the case.

Moving down from the level of principle to the level of policy, there are two distinct questions. The first is how we distribute the pay for healthcare resources to those who provide the resources. After all, even given the labour market is unjust, as defended above, it doesn't follow that the healthcare-related labour market should also be unjust -- the opposite, in fact. The second is how to decide who gets to access these healthcare resources.

With regard to the first, the options seem to be either free labour market or regulated. Clearly, a free labour market would just institute the problems with a free labour market demonstrated above: sellers of labour are under constant threat of violation of their positive liberty. So, what form should the regulation take? Free distribution of relevant information (e.g., complications records of physicians), of course; one of the causes of the above liberty problem is the labour-sellers lack of information regarding the purchaser. Minimum wages and other floors to the pay for providers of healthcare services also seems reasonable. The argument against price-fixing is that it leads either to surpluses (in the case of a price floor) or shortages (in the case of a price ceiling); however, there is already a shortage of trained healthcare service providers, thus a price floor, which would create a surplus, is actually a good thing. (FWIW, I have no ideas on how to solve the organ shortages, short of Max Headroom style murder-for-parts.) Whether or not there should be ceilings -- with the possibility that this sustains or worsens the current shortage -- relates to the second question, however: that is, how to decide who gets access to healthcare resources.

The pay for healthcare provision is, at least in part, borne by the consumers of healthcare resources. It follows from this that the prices for healthcare resources could serve as an access barrier; given the above claim that it is unfair to decide who loses healthcare resources on the basis of ability to pay (because ability to pay is determined by an unjust system), it would be unfair for prices to serve as a barrier to access. However, both the systems I will consider could adjust for pricing problems without putting a price ceiling in place.

Once the free-for-all of free-market healthcare is off the table, the remaining two options are public insurance and public health savings accounts (HSAs). Under a public insurance scheme, the public purse pays whatever the cost of the healthcare resources is. Under a public HSA scheme, the public purse contributes to a savings account, which is then drawn from in order to pay for healthcare resources. I envision the latter as a system whereby some fixed amount of money is reserved for every citizen under the government's jurisdiction, drawn from general tax revenues. This would prevent the wealthy from using their wealth to bulk up vast HSAs and consume far more than their share of healthcare resources, given that the middle-class and poor will run out their HSAs before the wealthy do. The amount should probably be determined based on the average cost of healthcare resources the average consumer needs (not uses, otherwise there's an incentive to overuse).

The former has good reasons to put a price ceiling in place: since healthcare consumers never have any real idea how much their use of the healthcare system costs, and since healthcare service providers won't be losing customers due to their prices, a price ceiling is the only way to prevent the system from being drained dry. The latter, however, has no good reason to do so: since consumers would control their own HSAs, they could shop around to the healthcare providers that they consider to offer reasonable prices for the service in question. One could also, if one chose, use non-HSA money to cover the difference between what the HSA money will cover and what one wants to purchase; since the HSA amount is determined by average cost of average need, this does not necessarily deprive anyone of healthcare resources without justification. The possibility of physicians rushing into elite practices and avoiding the middle-class and poor is a real one, I admit, but I suspect that tax disincentives could be used to steer physicians toward providing healthcare resources to the masses. (Something like: if you only performed six surgeries last year, but each cost $1 million, your tax rate increases by 50%. If you're already in a tax bracket of, say, 30%, that would increase the rate to 45%, which would constitute a big kick in the pocketbook.) Given that there is a price floor in place, the other concern -- that back-alley, disreputable physicians would undercut competitors' prices and offer incredibly bad service to the vulnerable -- is eliminated: if a consumer must pay the same amount to the back-alley doctor as a doctor providing better service, then why not go to the one with better service? (The incentive on the physician to provide better service would have to come from the profession; but that's an issue for another day.)Finally, HSAs have the advantage of encouraging rationing of routine medical procedures, as once the account is empty, it will remain empty until topped up again -- which, if the money comes from income taxes, will only happen once a year.

Overall, public HSAs seem to do a good job of balancing outcome and need, as long as the profession is doing its job, and the tax system works to push healthcare providers to work for other than the good of the rich. Where HSAs clearly fail, though, is in catastrophic cases and in expensive, routine procedures. The amount saved in an HSA may not be equal to the costs of a significant healthcare problem, and it seems unjust to punish those who are greatly in need. Similarly, it seems unjust to punish those who need expensive, but routine, procedures by forcing them to pay for the care out of pocket. The latter is fairly easy to solve: on a case-by-case basis, a given person could petition to have their HSA amount increased; if the problem is across a particular group (for example, women), then the distinction could be built into the HSA system from the beginning. The former is also fairly easy to solve: catastrophic cases are where an insurance scheme really shines, after all. So, the public insurance scheme would still exist, but as a back-up system to, on a case-by-case basis, fund necessary treatment that exceeded the amount contained in the HSA.

I think that covers most of the basic principled and policy ground. Any thoughts, omissions or critical remarks are welcome.

10 comments:

Dan said...

It's an interesting solution. The thing that stands out to me, at least as a practical problem, is that by layering two systems like that there would be a substantial increase in state bureaucracy (at least when I imagine this system).

Additionally, we'd need to find a really efficient way for deciding when to kick in the insurance back-up thing in many cases.

From a practical standpoint, those are the concerns that jump out at me. Otherwise it seems like a good, workable system.

Psychols said...

ADHR,

There are numerous concerns with HSAs. Indeed, the biggest shortcoming is that there are so many obvious shortcomings that a complex regulatory system is required.

One problem with HSAs is that they will allow the diversion of funds from proven health care methodologies to unproven and potentially harmful processes. I'm speaking about alternative medicines that are not subject to the same type of scientific study as more conventional medicine. They are also not subject to the same marketing constraints. Do we regulate these processes or do we exclude them from the system?

ADHR said...

Dan,

I'm not sure the bureaucracy would increase necessarily. A lot of the funds administration is dropped onto the consumers. That is, instead of a battalion or two of adjusters approving or disapproving of every billing, the consumer controls his or her own portion of the healthcare dollars. Also, keep in mind that the actual insurance side would be significantly reduced, which would free up civil servants to administer the HSA side.

You're right about a way to decide when the insurance scheme kicks in. Certain procedures could be immediately covered, as they wouldn't be performed unless they were needed -- coronary bypasses, for example. As for other, less obvious cases, I think there'd need to be some analogue to the current disability support programs: a physician applies for coverage on a patient's behalf.

Psychols,

That's a pretty minimal problem. If that's the worst about HSAs, then they're obviously superior to an insurance scheme!

The easiest way to deal with these pseudomedical procedures is, as you say, to exclude them. Anyone who wants them can pay out of pocket or fall back on private insurance. (Frankly, as far as I'm concerned, "health" insurance that pays for homeopathy is equivalent to insurance against alien invasion.) The easiest way to pull off the exclusion is to exclude practitioners of these various non-medical arts: so, chiros, acupuncturists, homeopaths, etc. simply won't be able to accept whatever means consumers can use to pay for healthcare. Optometrists, psychologists, physicians and dentists (and others), on the other hand, could.

Psychols said...

Fair response. I suppose certain medical practices will be excluded as they are in the current system. My misunderstanding of your proposal stemmed from the fact that I have seen the HSA proposal put forward by the practitioners of alternative medicines so often that I incorrectly (and foolishly) assumed that you endorsed their position.

Of course, an HSA is not going to add services such as optometrists, psychologists, physicians, dentists, dietitians and drugs. That requires more money.

Your proposal permits consumers to top up the HSA. More competent practitioners and those with better facilities will charge more. Consumers with the means will utilize the better practitioners. It may become a multi-tiered health care system.

Conversely, the insurance model generally imposes a flat fee per visit (at least it does in Alberta). That discourages efficient health care by rewarding quantity of patient visits over quality. The "one issue per visit" rule imposed by some (many?) family physicians in Alberta is particularly irksome and indicative of a system gone awry.

The HSA system would have to be adjusted for gender, age and race - a thorny legal problem.

I also worry that an HSA may limit access for individuals who need more than the average amount of health care but lack a compelling diagnosis to prove their need for those extra pseudo dollars.

I'm also thinking that there is more merit to the idea than I first thought. Steps have to be taken to prevent it from becoming a private pay health care system (even if we are paying the first thousand dollars with monopoly money).

ADHR said...

In principle, there's no reason not to cover those services (opto, psych, dentists, pharma) under the current insurance scheme. The money thing is a bit of a blind, as people already buy these services privately -- so the money already exists, it's just distributed through market mechanisms rather than centrally. Given that, there's no reason not to cover them under an HSA-style scheme.

As for topping up, let me quote myself:I envision the latter as a system whereby some fixed amount of money is reserved for every citizen under the government's jurisdiction, drawn from general tax revenues. This would prevent the wealthy from using their wealth to bulk up vast HSAs and consume far more than their share of healthcare resources, given that the middle-class and poor will run out their HSAs before the wealthy do.

That is, I'm actually saying we shouldn't allow the wealthy to spend their own dollars to purchase healthcare resources. As I opened the post, it's questionable whether the wealthy deserve what they have (and the non-wealthy deserve what they don't); so, it would be an offense against justice to allow scarce resources like healthcare to be distributed to those with more money. So, the scheme proposed would still block private purchase of healthcare services.

What wouldn't be blocked is private purchase of non-covered services (like homeopathy), which is the case under the current system, anyway.

The "one issue per visit" rule is, I'd think, a side-effect of price-fixing. If physicians don't feel they're making enough per visit, they have an (economic) incentive to force patients to attend on multiple occasions for multiple problems. If they could simply charge what they felt was a fair price, the market would sort out whether the service they provided was acceptable.

I agree that the HSA system would have to be adjusted for certain predictable healthcare outcomes. For example, women require more frequent and costly interventions than men, statistically speaking. Insofar as we know about these sorts of predictable consequences, they can be built into the system from the get-go. Unpredictable consequences -- such as the development of some sort of chronic condition -- would have to be dealt with case-by-case, through some sort of arbitration system.

An HSA system might limit access for those who need more healthcare, but lack a diagnosis to justify it. But, then again, I have a hard time conceiving of someone who needs more healthcare but doesn't have some diagnosis to explain why.

undergroundman said...

Of course I wholeheartedly agree with the philosophy of the HSA program (and I applaud you for thinking this through with an open mind!). There are a couple nitpicks:

Immediately, then, this rules out full-competition, private healthcare as exists (largely) in the United States. It is grossly unfair to decide that certain people will fail to be treated, will live in pain and will die because they lack the ability to purchase the services they need.

This is a widespread misconception of the United States. The system is private, but it is not competitive. The only competition is between insurance agencies, who have conflicting incentives to cover lots of healthcare quickly and easily but also to minimize the amount of healthcare they cover. Thus they do a lot of micromanagement and bartering, but not very effectively. In recent years there's been a lot more competition because so many people are uninsured, but most of the uninsured are young people. Small clinics will charge more than hospitals and specialists charge more than general practitioners (the cost is different even in Canada - of course, in a socialized system people may not realize that they can save the system money by avoiding the hospital/emergency room), but to say that it's fully competitive (nonexistent in any industry) is greatly exaggerating. Also, and this is the big one - millions of Americans are covered under Medicaid and Medicare. Those who aren't are treated in emergency rooms. One of the stronger arguments in favor socialized healthcare (subsidized HSAs essentially fall under this umbrella) is that it would save the system money by reducing the emergency system costs. In America we don't exactly have the uninsured dying on the street in front of hospitals - foreigners just like to think we are that brutal. ;)

A just acquisition, for most libertarians, is an acquisition via (at possibly some distance) resources that one received directly for one's labour.

It seems more accurate to say that libertarians believe that healthcare should be paid for with resources acquired fairly or through a free consensual exchange of resources (Nozick). Those who haven't acquired resources fairly don't deserve healthcare because they have no resources. People who have no resources to pay for healthcare because they are incapable of acquiring (perhaps lazy, perhaps disabled, perhaps incapable) are a more tricky area - but basically, yeah, libertarians say people who haven't put something in don't deserve to take something out. Is that unfair? In the case of the disabled, likely yes (libertarians might say that relatives should support them). There are obvious practical problems in deciding who's acquired resources fairly and when we're allowed to take it away. Also, often the richest people are the not the people who have created the most of value in the world.

Sellers of labour are very often on unequal footing with purchasers: the latter have tremendous power and leisure in their negotiations, while the former simply do not. Sooner or later, the seller of labour will have to accept what he is offered or die; the purchaser has no such limitation, insofar as he has already purchased much of others' labour and is capable of sustaining himself on the resources he currently controls.

Been studying the monopsony theory of labor supply, eh? :p

Most mainstream economists don't believe in it because the studies refute it. But you're right - wage-earners are on a very unequal footing with capitalists. People earn the market value of their skills (similarly, capital earns a market wage for itself). If a skill is rare, the worker charges a high premium. Unskilled labor is a dime a dozen, and even skilled laborers are becoming superflous with the advent of better technology and the number which are being churned out. That doesn't mean that we should get rid of the technology - but we have to find a way to adjust the system (I think a wealth tax would do nicely).

By the way, most of the income in the United States accrues to workers (or at least it did) and I have read people say that if the poor and middle-class spent judiciously, this country would be much more equitable in ten to twenty years. I have my doubts about this, but it's obvious to me that the poor and lower middle-class aren't financially savvy.

Sellers of labour are not free, on their construal, because their achievement of their goals is blocked by the actions of another; sellers of labour are not in chains, but their options are curtailed by the demands of a fully free market.

You're losing me here...nobody is absolutely free. I can't fly. Libertarians probably believe that all people should have freedom of opportunity, and many maintain that freedom of opportunity can exist without extra help from the government. I suppose your argument is that this is untrue?

So, what form should the regulation take? Free distribution of relevant information (e.g., complications records of physicians), of course; one of the causes of the above liberty problem is the labour-sellers lack of information regarding the purchaser.

You mean labor-buyer? Who are you referring to - doctors or consumers? In this case doctors are the laborers (also, incidentally, the labor-purchasers when they own practices) and consumers are the purchasers of labor. But of course I agree that more information to potential buyers and sellers is always nice - obviously it helps people make good decisions (and avoid being killed by bad doctors).

Minimum wages and other floors to the pay for providers of healthcare services also seems reasonable. The argument against price-fixing is that it leads either to surpluses (in the case of a price floor) or shortages (in the case of a price ceiling); however, there is already a shortage of trained healthcare service providers, thus a price floor, which would create a surplus, is actually a good thing. (FWIW, I have no ideas on how to solve the organ shortages, short of Max Headroom style murder-for-parts.

Free market for organs. ;) (Hey, there is a black market right now - do poor people really need their kidneys? :p)

I'm typically biased against price floors like that, but I suppose it could work. One potential method for alleviating the shortage is increased education grants for students studying medical sciences.

This would prevent the wealthy from using their wealth to bulk up vast HSAs and consume far more than their share of healthcare resources, given that the middle-class and poor will run out their HSAs before the wealthy do.

How would the wealthy use their wealth to bulk up vast HSAs? Lost me here. Potentially, one could means-test the entire system; that is, the wealthy don't get an HSA account - they can choose to pay out of pocket or buy standard insurance.

The possibility of physicians rushing into elite practices and avoiding the middle-class and poor is a real one, I admit, but I suspect that tax disincentives could be used to steer physicians toward providing healthcare resources to the masses.

The rich will have better care, just like the rich have better legal advisors, financial advisors, food, and entertainment. There's a reason for this: most of the rich have worked very hard to build up their wealth through producing valuable resources or services. People consent to pay them for what they've built. One should be careful not to confuse equality and fairness; is it fair to treat everyone the same regardless of differences? Should I get an A when I deserve a B in a class? The analogy is sound. We do what we can to reward excellence and hard work.

Finally, HSAs have the advantage of encouraging rationing of routine medical procedures, as once the account is empty, it will remain empty until topped up again -- which, if the money comes from income taxes, will only happen once a year.

You mean they encourage people to spend carefully? HSA money should rollover as well. And I would say that preventative procedures should be covered for free by the state every so often.

The amount saved in an HSA may not be equal to the costs of a significant healthcare problem, and it seems unjust to punish those who are greatly in need. Similarly, it seems unjust to punish those who need expensive, but routine, procedures by forcing them to pay for the care out of pocket. The latter is fairly easy to solve: on a case-by-case basis, a given person could petition to have their HSA amount increased; if the problem is across a particular group (for example, women), then the distinction could be built into the HSA system from the beginning. The former is also fairly easy to solve: catastrophic cases are where an insurance scheme really shines, after all. So, the public insurance scheme would still exist, but as a back-up system to, on a case-by-case basis, fund necessary treatment that exceeded the amount contained in the HSA.

Indeed. There could easily be a program for people with chronic disabilities. High-deductible health insurance covers huge expenses after a certain point.

The thing that stands out to me, at least as a practical problem, is that by layering two systems like that there would be a substantial increase in state bureaucracy (at least when I imagine this system).

I don't see this as a problem. Every citizen (or every citizen below a certain income level) is put into the system linked to Social Security (in the US). Everyone is given a debit card. Electronic deposits are made into these accounts monthly (or yearly, in one lump-sum). The account earns an interest (could do a money-market sweep program). The catastrophric coverage kicks in at a definite level - say, after you've spent $4000-$5000 (perhaps what you get every year - this is a lot less than what good health insurance costs anyway, so instead of paying for a risk, you save up to cover the risk out of pocket. For example, Peter Rost in his book says his health insurance cost $15000/year. Mine currently costs around $900/month or $11000/year. You are deluding yourself if you think these costs completely disappear under a socialized system).

But, then again, I have a hard time conceiving of someone who needs more healthcare but doesn't have some diagnosis to explain why.

Oh? You haven't heard of Chronic Fatigue Syndrome/Fibromyalgia then. I've done some research because I was worried that I had it. One doctor who used to have it claims to be able to treat it using largely alternative means. I read the book.

Psychois, do you work in the pharmaceutical industry? :p

ADHR said...

UGM,

We're agreeing on what libertarianism amounts to, really. Fair acquisitions usually get boiled down to labour. Nozick is the classic example, as he purloins Locke's theory of property acquisition to account for how private property can be originally justified, then adds on top a theory of just transfers. The usual -- and correct -- objection to libertarianism is that it emanates from a position of very distinct, and very historically-loaded, "privilege" [I hate that word in this context]: the usual sort of invisible-because-it's-so-pervasive white-guy "privilege". Libertarianism only really works as a fair system if everyone started out having a fair short at acquiring resources. In the actual world, that never happened. So, either libertarians advocate a massive redistribution to get the libertarian system off and running -- and, off-hand, I don't know of one who does -- or they ignore the problem.

The freedom issue has nothing to do with being "absolutely" free. It's the distinction between positive and negative freedom. I'm suggesting that negative freedom is too thin -- almost too trivial -- to be morally worthy; certainly too much so to be the only moral value, as libertarians hold it is. Positive freedom is what matters: the development of capacities and the inculcation of powers to succeed. The limitations imposed by the current labour market are, I'm claiming, an unjustified restriction of positive freedom.

Strictly, libertarians don't believe everyone should have freedom of opportunity, because freedom of opportunity is a positive freeom. What libertarians believe is that everyone should have freedom from restrictions in opportunity, in the sense that no one should be actively prevented from taking any opportunity that presents itself. If the selection of available opportunities is limited, though -- such as through historical accident -- libertarians, officially, don't care.

So, on the whole, the section about libertarianism was intended as a sustained attack on the idea that the wealthy (or even reasonably well-off) have any prima facie entitlement to their wealth. That wealth was not gained through a fair distribution, because (1) the mechanism of distribution (through the labour market) is not fair and (2) the initial acquisitions (through various historical injustices) were not fair. So, we'd have to decide whether the wealthy are entitled to their wealth case-by-case; the burden of proof is on the wealthy person (or, as said, the reasonably well-off person) to prove that he deserves his wealth. If we have the rare wealthy person who has gained his wealth through hard work and natural talent -- as Wilt Chamberlain in Nozick's example, say -- may be entitled to it, but only insofar as his entitlement isn't outweighed by others' entitlement.

This means both that you can't assume wealth is deserved and that you can't assume it creates an all-things-considered entitlement, rather than an entitlement prima facie or pro tanto.

I have heard of CFS and FMS. The diagnoses are controversial. Considered opinion at this point seems to be that there's something to them, but they're probably not diseases in their own right; rather, they're patterns of symptomatology that map onto several different pathologies (some physical, some psychological). But, in relation to this discussion: if CFS and FMS are accepted as diagnoses by the medical community, then they count as diagnoses that could underwrite an increased need to access healthcare resources. However, if they are not so accepted, then they don't; it'd be like saying you had Magical Goblin Syndrome. If they do count as legitimate diagnoses, however, it's worth noting that there may not be any benefit to be had from giving greater access to healthcare resources, which is the other part of the equation: in order to qualify for further monies, there has to be demonstrable benefit to the extra expenditure. Think of the Crohn's sufferer who needs bloodwork performed much more frequently than the average person; without the regular testing, the disease could progress and become fatal.

Claims that alternative "medicine" actually has positive treatment outcomes don't, in the vast majority of cases, stand up to testing. (Acupuncture being one notable exception. Insofar as it works, it should be covered.)

Psychols said...

Psychois, do you work in the pharmaceutical industry? :p

I have never worked in that particular industry. I do believe that prescription medicines are proven using appropriate (double blind) scientific analysis so I trust them more than I trust unproven alternative medicines. There are no guarantees because we are all different but I would rather go with the scientifically tested solution than self experiment.

"Natural" health products are particularly troublesome. They may simply be unregulated chemicals. I'll take an 81 mg aspirin tablet daily but I'll refrain from consuming willow bark :).

undergroundman said...

Claims that alternative "medicine" actually has positive treatment outcomes don't, in the vast majority of cases, stand up to testing. (Acupuncture being one notable exception. Insofar as it works, it should be covered.)

Vitamins, minerals, amino acids, and other preventative supplements have certainly demonstrated positive effects and are grouped as "alternative" therapies (they are expensive). And we know why they work. I've read numerous studies for every supplement I take (CoQ10 - increases energy, ALA - powerful antioxidant, Acetyl L-Carnite - increases energy/activity, multivitamin/mineral). There are hundreds of scientific studies on these biological compounds. Herbs have been shown to have pharmacologic effects (in fact, aspirin is derived from willow bark, an ancient herb known for alleviating pain - personally I know that Kava Kava is one of the most powerful drugs I've encountered and has been used very successfully in treatment for Social Anxiety Disorder). So you're plain wrong in that area. Research into hypnosis has shown it to effective.

Even homeopathy, which is the most far-out alternative therapy out there, used to have a buzz (and to some degree still does) over the fact that it has been shown to be effective when tested against a placebo control in a fair amount of studies. (The vast majority, even - 81 effective vrs 24 ineffective!)

So we've got nutrition, hypnosis, acupuncture (by your admission), and even homeopathy showing positive results. What's left? Chiropractic has certainly been shown to be effective for lower-back pain. So what's left, and where is this research that you refer to?

Most of the information that I refer to I've gathered over the years, but it's clearly available on Wikipedia (mostly through references to print journals).


I have heard of CFS and FMS. The diagnoses are controversial. Considered opinion at this point seems to be that there's something to them, but they're probably not diseases in their own right; rather, they're patterns of symptomatology that map onto several different pathologies (some physical, some psychological). But, in relation to this discussion: if CFS and FMS are accepted as diagnoses by the medical community, then they count as diagnoses that could underwrite an increased need to access healthcare resources.


They are accepted by the medical community - the CDC says that "after more than 3,000 research studies, there is now abundant scientific evidence that CFS is a real physiological illness." They are symptoms of something, yeah most of these people likely have nutritional deficiencies (possibly caused by celiac sprue), high levels of toxins (and a high sensitivity to toxins - toxins effect people differently on a normal distribution), and thyroid/hormonal disorders.

It looks like you've suffered from the "common knowledge" fallacy - you assume that since something id dismissed by the mainstream, it must be wrong.

The most uncommon and suspect alternative medicine is homeopathy, but if you're going to attack homeopathy, say that. Because otherwise you're painting yourself uninformed.

ADHR said...

I note with interest that you refer to "hundreds" of scientific studies, but cite two Wikipedia articles, neither of which proves your point. With regards to CoQ10, Wikipedia claims that it can be prescribed for certain conditions (which would make it a prescription medication, by definition) but also that its effects as any other form of treatment are unproven; with regards to ALA, not only is there very little in the article to support it actually having some sort of beneficial effect on some particular condition (there's more than a little hand-waving). With regard to herbs, as Psychols said, you really should take aspirin rather than willow bark -- the former has everything that works in the latter, concentrated into a useful form. With regards to Kava, our good friends at Wikipedia give us very little in terms of proof that it does anything, and also suggest it can cause liver toxicity.

Hypnosis is used both by physicians and psychologists who specialize in pain management, in particular. So, I'm not sure why you're bringing it up. A lot of highly-trained people seem to think it works in some cases, for certain conditions. No one thinks it should replace "conventional" treatments, and it seems to be used to conjunction with same. So, what's the issue?

As for homeopathy, again, let's look at the article you cite:

The meta-analysis on homeopathy concluded, "At the moment the evidence of clinical trials is positive but not sufficient to draw definitive conclusions because most trials are of low methodological quality and because of the unknown role of publication bias. This indicates that there is a legitimate case for further evaluation of homoeopathy, but only by means of well performed trials."

"Systematic reviews have not found homeopathy to be a definitively proven treatment for any medical condition."

A number of its key concepts defy chemistry, physics, and other sciences.

It is uncertain how a remedy with so little, "perhaps not even one molecule" of its active ingredient could have any biological effect.

Around 200 randomised controlled trials evaluating homeopathy have been conducted, and there are also several reviews of these trials. Despite the available research, no clinical evidence has shown that homeopathy works. Many studies suggest that any effectiveness that homeopathy may have is due to the placebo effect, where the act of receiving treatment is more effective than the treatment itself.


Etc. Etc. Etc.

FWIW, the studies I've seen on chiro show it to be minimally effective for about three months, and no more effective than physiotherapy or massage. So much for chiropractors: glorified massage therapists. (Not that I have a problem with the latter; but if the benefit is the same, why pay more for the chiro?)

As far as CFS, you don't understand how either science or medicine work. If it's dismissed by the mainstream, it is by definition wrong. It's up to those with fringe views to convince the mainstream they are right by performing the appropriate tests to the accepted standards; then the fringe becomes the mainstream. You like Wikipedia articles, don't you? From the one on CFS: Despite promising avenues of research, there remains no objective assay or pathological finding which is widely accepted to be diagnostic of CFS, and it remains a diagnosis of exclusion, made on the basis of patient history and symptomatic criteria. In other words, it's exactly what I said it was: a symptom pattern which may be indicative of a group of underlying pathological processes.

In any event, as I also said, if physicians accept it as a real diagnosis, then it is one. But, even so, it doesn't follow that sufferers deserve more healthcare resources, as said resources may not be effective for treating them.