I'm reading Romeo Dallaire's book on Rwanda, Shake Hands with the Devil. I'm not quite that far into it yet, but he has pled, to deaf ears, for just a few dozen more troops in order to head the whole thing off.

Kofi Anan was the one who directly refused his plea, but he doesn't blame Kofi. (Today, Anan is treated like some kind of elder sage hero, despite having been a model of corruption and acquiescence to brutality.)

Regarding Hillary: It's funny that it takes a further-left candidate for many old facts to suddenly surface. I've been seeing catalogs of the Clinton's sins which exceeded those I heard from the right during the 90s.

hospitals treat anyone, regardless of ability to pay -- but some believe that more government will both save us money, somehow AND deliver a higher quality of service.

Well, there are a lot of problems with the status quo. Not to advocate comprehensive single payer coverage through the government as some do, but in support of the notion that what we have shouldn't could be viewed as a valid type of universal coverage;

1. Using emergency equipment for routine doctor visits is a poor allocation of resources and creates tremendous insurance overhead while encouraging ineffective treatment.

2. Perhaps I'm deceived by the mainstream media here, but it seems like some hospitals have retaliated against people who used their services and were unable to pay. There's certainly incentive for such (illegal) retaliation. The Chicago Tribune, for instance, has reported hospitals dropping indigents in unsavory neighborhoods.

3. The current system of emergency treatment is still an unfunded mandate that we end up paying for, same as a gov't funded program.

You mentioned elsewhere support for a 'loser pays' legal system. I can understand the argument that people who are wealthy should have access to various superior material goods, but the fact that wealthy institutions can afford superior legal counsel (while admittedly also having greater ability to make amends for their mistakes, which is a bit of a counterbalance) makes me question the wisdom of this. We hear about exorbitant awards of various lawsuits. What we hear less about are the tremendous flood of harms which various medical practitioners have brought about which are never brought to trial. Until we do better at increasing the responsibility borne by physicians and hospitals for the results of their work and giving them some incentive to limit that harm, I'm hesitant to do anything to limit lawsuits.

Ryan! How pleasant, as always, to correspond with you!

I agree entirely that there are problems with the current medical system, including (but certainly not limited to) those you mention.

I'm not at all an expert in this area, but if I were going to try to think about the sources of some of these problems, I would start by investigating my hunches regarding:

1. Insurance. While I agree that in some senses we're underinsured, I also, paradoxically, suspect we're also overinsured. Insurance should be a hedge against catastrophe; when things appear to cost less to people (as with co-pays, and full coverage) actual prices tend to rise. This why socialized medicine is so expensive, and why politicians underestimate costs of such programs: they predict based on current need, but when (apparent) prices drop, demand explodes.

Let me give you an example: Just a week ago, I had a rather strange and deep pain in the shoulder and head. I wondered if this was one of those "warning signs you can't ignore", and took myself to a private clinic. It was nothing: just an unusual muscle spasm, apparently. The cost was supposed to have been $130, but when the doctor noticed I was self-paying (I carry high-deductible insurance, but with a high upper limit on services) he said: "Well, you didn't take that much of my time" and gave me a rebate -- as he probably would have in general, if most people didn't have "some big company" paying their bills and didn't feel the pinch personally.

Making people shop for their medical services lowers prices, just as it would with everything else. Instead, we generally see medical and insurance costs rising, contrary to every other area of technology.

2. Restriction on the market. Licensing is used to restrict services and protect the market from newcomers. You want better services for the poor? Lower your licensing requirements and allow less-trained people working for charities to help them.

Instead, even though you now pay doctor-type costs, in reality, actual patient care (and even some decisions) are often delegated to those who have as little training as a McDonald's employee, or less. (And may have a criminal history.)

3. The death of medical charity. Once hospitals were charities. Now they're businesses with government rules, and the ChiTrib runs the reports they do. Emergency rooms have incredibly long wait because they're the "doctor of last resort", and family GPs are getting scarce.

4. And the last is affected, a bit, by the current legal climate, addressed in a second.

The status quo certainly does have problems, but the question is always whether people's "fixes" will make it better or worse. If one is only focused on "change" (as some appear to be), one won't take the time to see whether the change is a good change or a bad one.

From my POV, the basic, subtle, underlying "liberal" assumption is that things are terrible here, so almost anything called "change" will end up making things much, much better. In contrast, the basic "conservative" assumption is that though we have some problems, we're doing unbelievably well, comparatively, and have so much for which to be grateful -- and thus we should be cautious about "change", since most changes will generally point downhill, not uphill.

Loser pays...

... the fact that wealthy institutions can afford superior legal counsel (while admittedly also having greater ability to make amends for their mistakes, which is a bit of a counterbalance) makes me question the wisdom of this...

But you also have to consider that they have superior funds. Your argument above, if I can paraphrase liberally, is basically that if you have approximately equal merits on each side, each party should have a 50/50 chance of winning. But by having superior legal talent, that can be increased, in the same exact circumstances, to 60/40 or even 90/10.

Fair enough. BUT the problem is that currently, such corporations can "win" even in cases which where the odds are 1 in 1,000,000,000 against them. (I'll take the previous percentages, thanks!) All they have to do is sue you, and force you pay legal bills until you're bankrupt, as the years drag on. (Long "discovery" periods also need to go. That was a bad, recent change.) They don't have to actually win, or even have a ghost of a case.

In loser pays, the big, evil corporation would end up paying their legal bills; other than time (and I suppose even that could be compensated for) it would ultimately cost the victim nothing.

Scientology is an example: in the 80s and 90s, they had lots of lawyers working pro-bono as their "tithe", and would sue any critics into silence. If they lost one suit, they'd just move on with another; merit didn't matter, just the draining effect. Under loser pays, Scientology would have effectively ended up suing itself in the vast majority of those cases.

It's akin to high-stakes poker with someone who doesn't have sufficient cash. If they can't meet your bet, even if they have four aces, they have to fold. You win not because you have the better cards but because you have the superior cash. Loser pays changes all that.

Europe has loser pays, and they have a lot fewer lawsuits. I don't generally emulate Europe but I agree with their approach in this area.

I understand: your argument is that the little guy with the 30/70 (in favor of the little guy) legal case might be sued by the big corporation would could use enough lawyers to turn it into 90/10, and then he'd end up paying for all those lawyers arrayed against him.

But us little people only have a certain amount you can take from us. It's usually enough to run us under with ONE lawyer. The point by the company is to get you to give in, and settle out of court, not to actually win.

Further, if your case had merit, you could also attract your own lawyers, who might be willing to take a risk and work for you for the fees they'd expect to see later.

Finally, you could cap "loser pays" legal fees to an amount an individual could afford: say, standard legal fees for one lawyer for a trial of that length.

What we hear less about are the tremendous flood of harms which various medical practitioners have brought about which are never brought to trial.

Agreed: They've done studies and found that consumers don't look into medical quality databases, etc. It's kind of mind-boggling: I go on a three-day trip to somewhere, and I and others read lots of sites like "tripadvisor.com" with revues of hotels, etc. Put yourself under a knife with some guy you don't know, and there's nothing similar.

Again, this is because people currently don't have a mentality of shopping for medical care, as they would for everything else. Until we get used to asking about prices, and shopping around in this area, like others, this will continue as usual.

Also, the AMA, I believe, has convinced the government to let it self-police, and generally, when it can, covers up evidence. So we're back to problems caused by licensing and a government-created monopoly.

And of course, many people don't find out about wrongdoing because most claims are settled out of court. Why? Because the legal bill are crazy high, and because nobody, even the "winner", can afford to go there, unless you're a big company with a lot at stake. I suspect "loser pays" might help here too, but I need to ponder it more before deciding.

Thanks for the response. Could you recommend a good medical quality database?

I suppose 'loser pays' might make sense in regards to libel suits, say. But I'm not convinced it would be helpful without some other, finer corrective mechanism (like good consumer ratings of doctors, say)

Thanks for the response. Could you recommend a good medical quality database?

Sadly, not offhand. I was hearing one of Bush's appointees on CSPAN talk about how they'd done one, or were working one, but I don't know the status of that.

Best to you!