Hard News: John Key(nesian)
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Yes, I remembered that the biggest obstacle to an ACC like recovery system for non-accident healthcare is that Vote Health is already strained, and the demands of the health system are almost limitless - were we to have the best possible outcomes. Not to say it isn't possible, but Governments can only commit to one or two legacy projects like this in a term, and the current one is all out for the moment with Kiwisaver, WFF and other things.
As for rationing of healthcare on the basis of lifetime benefit to the patient, this already happens, people don't usually like to be to explicit about it. Pharmac and other government agencies use the concept of 'Quality Adjusted Life Years' to deal with it.
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But while the CCT is, in my view and not having followed it in great detail, a textbook example of how NOT to run a PPP, it doesn't immediately follow that PPPs are a bad idea.
Agreed, but the CCT fails on a number of simple tests and is only saved by the fact that it didn't create a public risk when it fell over.
Key's policy may fail all the tests and it's critical that we know before the election.
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Oh, and our concept of "retirement" needs to adjust. Older people will work longer, in a mixture of part time and voluntary work, rather than suddenly stopping full time work. They've always played a major role supporting the capacity of their whanau, and I'm not sure how that will change. However, their own health and support needs are undoubtedly higher as they get older.
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And Paul wrote:
1. All the contractual terms should be on public record - not the case with the Cross City Tunnel (CCT) in Sydney.
ITA. If you've got your hand out for public money, or are tendering for public contracts, then you accept a level of public disclosure and scrutiny that might be higher than you'd otherwise face. I know that it's not a perfect analogy, but as a citizen and a taxpayer, I think I've at least as much of a legitimate interest in the expenditure of public money as I'd have in the doings of a company I own shares in.
Don't like it, then who's holding a shotgun to your head and forcing you to be involved?
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I'm all for preventative medicine and better habits leading to longer, healthier lives, but let's not kid ourselves that it's going to save us money - we've never spent more in health services and yet we're the healthiest we've ever been.
Why do you think I've avoided talking about heart attacks and strokes and other seriously-life-threatening eventualities? Joint replacements and fractures are quality-of-life issues, rather than terminal ones (though death is not unheard of in patients who suffer hip fractures as the result of falls), so the costs associated with them are all about health rather than longevity.
As the population ages, and the size of the aged population increases, these non-terminal events become a greater drain on resources. Every joint replacement is tens-of-thousands of dollars in operative and post-operative care. Fractures can require months of treatment, as old bones don't heal as well as young ones. That's often in a hospital bed, requiring nursing care, catering, etc.Also, you talk about "retirement". It seems to be becoming an accepted position that for many people retirement won't be a complete cessation of employment. They'll work fewer hours, or play TradeMe as a way of generating income, but they won't be out of the productive sector. It's already happening, and the change will accelerate over coming years. If we can keep people capable of doing such things, the economic benefits are enormous. Keeping them fit and healthy and in a position to keep working is a saving, in that they're contributing economically instead of just consuming.
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As for rationing of healthcare on the basis of lifetime benefit to the patient, this already happens, people don't usually like to be to explicit about it. Pharmac and other government agencies use the concept of 'Quality Adjusted Life Years' to deal with it.
And then there's the nasty concept of DALYs, where disability is confused with being sick for a long time, and a disabled person's life is always worth less. Not particularly original, and appallingly poor policy in this day and age.
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What Matthew just said.
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Craig wrote:
I know that it's not a perfect analogy, but as a citizen and a taxpayer, I think I've at least as much of a legitimate interest in the expenditure of public money as I'd have in the doings of a company I own shares in.
Indeed Craig. And I'm pleased that at least we know in advance that Key's plan is to guarantee a specific rate of return. I don't agree with it at all, but at least this part of the policy is clear.
And, I hope you note that I've not addressed your rhetorical point about NSW btw, I've certainly tried hard not too because I'd (!)hate(!) to disagree.
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If we can keep people capable of doing such things, the economic benefits are enormous. Keeping them fit and healthy and in a position to keep working is a saving, in that they're contributing economically instead of just consuming.
Christ. I want to retire *now*. You're telling me I have to keep working for *more* than another 32 years?
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Danielle, the idea is to up everyone's productivity so that you can put less hours in really soon, but keep going longer. More of that mythical work-life balance.
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Why do you think I've avoided talking about heart attacks and strokes and other seriously-life-threatening eventualities?
I know you didn't talk about heart attacks, I did. You talked about fighting obesity, and cardiovascular disease happens to be the main problem associated with it. Hip fractures are costly to treat, sure, and if they can be avoided early in life it's great (that'd be why car accidents are so expensive for society). But you can't delay the onset of such things forever, and there's going to be a bill at the end of the day. One of my aunts died at 101 and the thing that did, as is so often the case with the mega-old, was a broken femur.
Also, you talk about "retirement". It seems to be becoming an accepted position that for many people retirement won't be a complete cessation of employment. They'll work fewer hours, or play TradeMe as a way of generating income, but they won't be out of the productive sector.
Look, my father started working at 14 and died at 64. Can I tell you how much he was looking forward to retirement and no longer being a productive member of society?
You're still stuck on the basic premise, though: the longer we live, the more expensive we become. I'd like to buck a family trend and be as much of a burden in my old age as humanly possible.
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Danielle, the idea is to up everyone's productivity so that you can put less hours in really soon, but keep going longer. More of that mythical work-life balance.
But Sacha, I don't *want* 'work-life balance'! I want to sit at home eating bonbons and watching Judge Judy! :)
Seriously, I would argue that people who don't work outside the home are not actually 'burdens to society'. That gets perilously close to saying that people who do unpaid work (like looking after children, for example) aren't doing anything useful. It's a very... capitalist way of measuring value.
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Totally agree, Danielle - we need to encompass the wide range of ways that people contribute, and have always done so (not that you'd know from most economists). I'm sure that can be stretched to include the economic contribution of bon-bon consumption. :)
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Yin and Yang: Passive/active principle of the universe. Notice alot more elderly chinese out and about unaided around my area. Actually saw only one elderly westerner out today with the trusty ol' zimmerframe but elderly chinese all over the place and on bicycles too!
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Russell noted up thread that National's plan "offer a guaranteed return from the projects they fund", this means, under National's plan, that the public is. If there's one upside of the CCT project failure it's that at least the State government didn't inherit the risk.
Thanks Paul, that clarifies things.
My (UK) experience of PPP's and the Private Finance Initiative is that if the public carries the risk, they usually end up paying twice.
They pay the first time because the infrastructure in question which is PPP funded is generally considered essential (hospitals, transport, etc), so when the private firm responsible (seemingly inevitably) blows the budget, goes bust, etc etc, the government has to step in to pay the extra costs and generally bail them out and get the job finished.
They pay the second time because the company/shareholders then point out the 'guaranteed payment' clause in the contract, and the government has to stick its hands in the taxpayers pockets again to make sure the shareholders are paid off.
No sir, I'm agin 'em.
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Rich, I'm far from expert but have followed the CTT and other PPPs closely in Australia and particularly in NSW.
Macquarie Bank has been the big mover and 'innovator' here and has recently encountered serious expert and media criticism about the structure of the deals which rely on cheap credit and which are jepoardised by the subprime crisis. This quote (from an April SMH story) sums it up:
In the most detailed independent research of Macquarie Group and Babcock satellites to be published, Risk Metrics critiques the financially-engineered infrastructure model for its high debt levels, high fees, paying distributions out of capital rather than cashflow, overpaying for assets, related-party transactions, booking profits from revaluations, poor disclosure, myriad conflicts of interest, auditor conflicts and other poor corporate governance.
The full report is available here.
My understanding, limited though it is, is that Key's guaranteed return heightens the risk that they'll require paying "distributions out of capital" or the kind of "related-party transactions" that the CCT had (road closures etc) and why would a government borrow in the present market anyway?
In simple terms, what I think Key needs to do is firstly explain how precisely the debt-financed infrastructure will boost sustainable productivity and then explain how the approach will avoid the risks experience in Australia and abroad?
I don't want to sound cynical, but given the tendency for National's campaign to borrow policy from Australia, rely on strategy advice from Australia and the plans to sell ACC to Australian firms, it's hard not to wonder what next?
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All I'm saying is that it had better be a volunteer programme.
Yup. But one I'd want health professionals to push, assuming it was set up well.
The overwhelming issue with excessive weight is the increased risky of early death due to cardiovascular disease. The way it often pans out is you're fine, suddenly you have a heart attack, you die. That is very sad but not at all costly for the health system. If you live a longer, healhier life, on the other hand, things are still bound to catch up with you eventually, and caring for people in their eighties and nineties is really expensive regardless of their medical history.
I'm pretty skeptical of this. There's nothing about being 'old' that makes your medical costs higher than being young. It's not until your body gets sick or breaks down in some way that it gets to be more expensive. That often happens as you get older, but not necessarily. Lots of people in their 80s and 90s have no significant health issues. Lots of the issues that you associate with the elderly - arthritis, weak joints and bones etc - can also be improved through proactive work earlier (and later) in life in relation to exercise, nutrition, lifestyle etc.
And being 'obese' doesn't guarantee an early death, any more than smoking does. It does raise risk factors which don't guarantee death, but the treatment if they don't die is expensive. If you wanted to look at it from purely monetary terms we should at least try and keep everyone alive until about 65, at which point we've got the maximum tax take out of them </mercenary>
You did know that? Oh good. :)
Well Danielle, I'm not necessarily talking about weight, or BMI, which are only one indicator of health issues.
But I am talking about health professionals more actively (and proactively) engaging New Zealanders with serious health issues affecting them. If a doctor tells me I have a weight problem, or a cholesterol problem, or smoking is bad for me, that is a fairly good person to hear it from.
Oh, of course you are Kyle -- and what's wrong with the idea of good old fashioned public 'shame' as a mechanism of social control?
Well I'm not Craig. Like when you visit your GP, working with a community health nurse is a confidential visit.
I'm not at all opposed to using shame as a method in some public health issues. I'm a fairly fanatical anti-smoker, and I see it has some value there. I doubt very much that it's a tool for your GP or nurse however, they have an important relationship with their patient which needs to operate at a higher level than TV advertising.
And what Matthew Poole said about maintaining people in healthy, productive lifestyles so they can work and/or contribute to society, provide good role models etc etc.
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I'm pretty skeptical of this. There's nothing about being 'old' that makes your medical costs higher than being young. It's not until your body gets sick or breaks down in some way that it gets to be more expensive. That often happens as you get older, but not necessarily.
Have you been hanging out with Albert Hoffman? Watched Cocoon once too many times? Or are you seriously telling me that the average 80 year old needs as many meds and medical procedures as the average 50 year old?
If you wanted to look at it from purely monetary terms we should at least try and keep everyone alive until about 65, at which point we've got the maximum tax take out of them </mercenary>
I think you'll find that that particular goal is best achieved by letting people smoke and be obese. Worked a treat on my dad, to reiterate that rather painful point. He was an absolute boon to the state, barely used any public services in his life (including school).
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Well I'm not Craig. Like when you visit your GP, working with a community health nurse is a confidential visit.
Oh yes you are... and while I've been pretty candid (to a fault some would say) about my history of mental illness, many others aren't. And I sure as hell know people for whom having a psych nurse pulling up in front of their house in a marked car wouldn't be helpful at all, especially if there was "pushing" (however well-intentioned) going on.
What's that old proverb about the paving stones on the road to hell? -
I'm a fairly fanatical anti-smoker, and I see it has some value there.
It has value for *you*. It makes *you* feel better. It doesn't help the smokers themselves. You can't hate people for their own good, to quote someone very clever whose name i can't remember.
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I'm a fairly fanatical anti-smoker, and I see it has some value there.
It has value for *you*. It makes *you* feel better. It doesn't help the smokers themselves. You can't hate people for their own good, to quote someone very clever whose name i can't remember.Yeah, what Danielle said
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You can't hate people for their own good, to quote someone very clever whose name i can't remember.
Yes, but on the other hand hating people for one's own good has never been especially hard. And who among us does not see the slippery slope from what is being proposed here and the refusal to cure people who make bad personal choices?
When this story broke a few months ago, I was outraged enough by the proposition that
smokers, heavy drinkers, the obese and the elderly should be barred from receiving some operations, according to doctors, with most saying the health service cannot afford to provide free care to everyone.
But then it transpired that many UK hospitals are already doing just that, in the case of smokers and the overweight.
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Totally. When the whole All Black front row would be classed as obese, you know there's something wrong with the system being used.
However, there's also something wrong when school uniform stockists routinely carry (instead of specially ordering in) pants in sizes that could fit two of me. I'm not exactly rake-like, either.Trying not to pick on you Matthew, but the same bunk gets trotted out every time BMI is discussed, and it simply doesn't hold any water.
BMI is a population statistic and as such is not intended to be applied to individuals. It is a good indicator on a individual basis though (as long as all of the other considerations are used).
It was also developed for a largely sedentary population and as such athletes and other people who are very physical are not good examples by the BMI scale. But on that matter, if you got the All Blacks worked out their BMI's, then compared them with someone else with the same height and BMI, the non athlete would be quite visibly obese.
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Have you been hanging out with Albert Hoffman? Watched Cocoon once too many times? Or are you seriously telling me that the average 80 year old needs as many meds and medical procedures as the average 50 year old?
No, I'm saying it's not 'being old' that costs a lot of money, it's being sick or having injuries.
If we improve health throughout life, in many areas, people will be less likely to be sick or injured when they are older because their health will be better. They will have stronger hearts, lungs, bones etc etc.
Oh yes you are... and while I've been pretty candid (to a fault some would say) about my history of mental illness, many others aren't. And I sure as hell know people for whom having a psych nurse pulling up in front of their house in a marked car wouldn't be helpful at all, especially if there was "pushing" (however well-intentioned) going on.
Well, people are under no obligation to engage the service, which is already run to some extent in various DHBs across NZ. And if you go see a GP now they already will 'push' you to do something about any health issues you have - smoking, weight, cholesterol, depression, etc etc. It's otherwise known as their job. And there's no requirement for it to be a marked car. People only end up in these programmes when they sign up to them, standard informed consent applies.
It has value for *you*. It makes *you* feel better. It doesn't help the smokers themselves. You can't hate people for their own good, to quote someone very clever whose name i can't remember.
Well OK if you think so. Take your complaint to the smoking advert brigade though, I'm not the one putting them on.
Personally I know smokers, and ex-smokers, who think the adverts are good, but I didn't say anything about spending *my* billion on that, Craig raised the shame issue. I think *my* billion would be spent on putting health professionals closer to people with health issues with long term impacts.
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If we improve health throughout life, in many areas, people will be less likely to be sick or injured when they are older because their health will be better. They will have stronger hearts, lungs, bones etc etc.
We're going around in circles here. So let me ask you again: and then what happens? Are you planning to emulate the divine Maude and take a pill on your eightieth birthday? Things are going to start to go wrong eventually, and your demise won't be any less expensive for the public health system than anyone else's - likely more so, in fact, since people who live longer are statistically more likely to get Alzheimer's which is just about the most heart-breaking and expensive way to go.
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