December 12, 2010
Tyler Cowen: Medical Care Queues To Get Longer

Unless you have a great private health insurance plan or lots of money you face a future of rationing by queuing. Even if you have great private health insurance now you won't in your old age. My advice: plan accordingly. Start preparing for it by accumulating money.

UNEQUAL access to health care is hardly a new phenomenon in the United States, but the country is moving toward rationing on a scale that is unprecedented here. Wealthy people will always be able to buy most of what they want. But for everyone else, if we stay on the current course, the lines are likely to get longer and longer.

If you think this isn't going to affect you then unless you are wealthy think again. You need to start saving for your medical care in your old age. Sure, if you are in an industrialized country government will pay a substantial chunk of your old age medical costs. But you are far more likely to get better care and the most cutting edge care if you have the ability to spend substantial amounts of money out of your own pocket for your diagnoses and treatments.

Being unable to pony up some bucks for your medical treatment might not affect your longevity or how much you suffer. Could be you'll get lucky and get a killer disease that is cheap to treat and cure. Could be then you'll go some additional years and then get "lucky" in another way: You could get a killer diseases that is incurable and has no treatment. So being poor and unable to fund any of your own medical care in your old age might not matter.

But suppose you get a disease which has a cure that is in clinical trial where you have to travel somewhere (either in your home country or abroad) to get it before it becomes widely available. Well, being able to pay for this treatment yourself could become a matter of life or death. I think that especially likely for a lot of the great cell therapies and for methods to grow replacement organs. You might need to go to China to get these treatments or somewhere else offshore.

Large number of doctors who are most in demand have dropped seeing Medicaid patients and a growing number have dropped Medicare patients too.

A result is that physicians often make Medicaid patients wait or refuse to see them altogether. Medicare patients are also beginning to face lines, as doctors increasingly prefer patients with private insurance.

Suppose your doctors are stumped about what ails you and you need to see a great specialist. The best really are much better than the average or the below average. You might find yourself in the position of needing to spend your own money to travel to see the best specialist in a field. My advice: save for it.

Tyler says Obamacare is actually going to hasten the development of longer queues for waiting for diagnoses and treatment.

Access to health care will become problematic, and not only because the population is aging and demand is rising. Unfortunately, the new health care legislation is likely to speed this process. Under the new law, tens of millions of additional Americans will receive coverage, through Medicaid or private insurance. The new recipients of private insurance will gain the most, but people previously covered through Medicaid will lose.

You have been warned. What to do about it? Cut your spending and put aside more in retirement accounts. Also, when making career choices go for the money. The utility of money is going to rise with advances in biotechnology. Some extra tens or hundreds of thousands of dollars set aside for medical expenses might save your life.

Update: It is tempting to react to the health care debate by arguing for or against different reforms or by arguing that the other side is perfidious or your side can work miracles if only given a large ruling majority. But all this is besides the point when it comes to your own personal health care. Take the most probable range of health care policy changes in the next 20 year or so. Given any of those changes will you still be able to boost your chances of getting correct diagnoses and cutting edge treatments if you have more money in the bank (or in gold or stocks if you prefer)? I say yes and plan accordingly.

Share |      Randall Parker, 2010 December 12 11:20 AM  Aging Population Problems

Bruce said at December 12, 2010 12:01 PM:

"Paul Krugman, Nobel Prize winner in economics and an influential New York Times columnist, also has a blog, "The Conscience of a Liberal." On ABC's "This Week" (Nov. 14), during a discussion on balancing the federal budget against alarming deficits, he proclaimed the way to solve this problem is through deeply cost-effective health-care rationing.

"Some years down the pike," he said, "we're going to get the real solution, which is going to be a combination of death panels and sales taxes." That would mean the U.S. Debt Reduction Commission "should have endorsed the panel that was part of the (Obama) health-care reform."

Sarah Palin was one of the first, and the most resounding, to warn us of the coming of government panels to decide which of us especially, but not exclusively, toward the end of life would cost too much to survive.

She was mocked, scorned from sea to shining sea, including by the eminent Paul Krugman for being, he said, among those spreading "the death penalty lie" as part of "the lunatic fringe." (Summarized in "Krugman Wants 'Death Panels'" Catholic League for Religious and Civil Rights (Nov. 15).

Soon after he had left the ABC Studio, someone must have alerted Krugman that gee whiz he had publicly rooted for death panels!"

Jake said at December 12, 2010 12:20 PM:

I am on Medicare and cannot find a good primary care doctor that takes Medicare. So I am practicing Medicine 2.0.

Medicine 2.0 is you are in charge of your medical care and doctors are only your consultants. And you only use a doctor when you are unsure what to do or you need a prescription.

I order all my own blood tests through Direct Labs and because I am doing the ordering I can get more sophisticated tests than most doctors are willing or know to order.

The tests show what the normal ranges are for each item tested. If something is out of range, I change my diet or supplements and then retest later to see if it works. If I need a prescription, I visit a cash only doctor and bring my test results

The net result is that I now have the best blood values I have ever had in my entire life. The internet has made it very possible for many people to eliminate their primary care physician. And because you are on top of your medical condition, you can take preventative steps so that you need not see a specialist either.

Randall Parker said at December 12, 2010 2:27 PM:


The political battle between partisans is really besides the point. Do you think health care will become more or less rationed? If you think more then save more and try to make job changes that'll increase your ability to save.


Good for you. Medicine 2.0 is definitely the way to go for anyone smart enough to do it.

More sophisticated tests: can you provide some examples? Also, what dietary changes seem to give you the most benefit?

Also, do you pay the cost of the blood tests? If so, how much do they cost?

Everyone else,

Look at Jake. Too few physicians in his area take Medicare. Your ability to just pay for office visits in your retirement could make a big difference.

el chief said at December 12, 2010 3:26 PM:

I went to the hospital up here in Canada and had to wait FIFTEEN ENTIRE MINUTES!!! before seeing a doctor. It was awful.

It was funny, I went to lunch after, and waited even longer in line.

Quit your facile scare tactics.

Randall Parker said at December 12, 2010 4:04 PM:

el chief,

A friend who grew up in southern Ontario as an adult had to wait years to find a general practitioner who would take him as a patient. He used to have to go to the emergency room if he needed to see a doctor. He waited hours at his local emergency room. From what he's told me availability of physicians in Canada varies greatly by where you live. He said if he'd lived closer to Toronto then it wouldn't have been a problem.

Do not assume your experiences are the same as everyone else. Also, if you haven't needed expensive procedures then you might not have run up against rationing of expensive procedures which is done in Canada.

On the bright side Canadian dogs can buy their way to the front of the queue.

Bruce said at December 12, 2010 6:33 PM:

"The political battle between partisans is really besides the point"

Not if one side is lying, and one side is telling the truth and the lying side lies about the non-lying side telling the truth.

Death Panels exist in the UK. Its called the Liverpool Pathway. Death Panels will occu in the USA under Obamacare. Get ready for long lineups and early deaths that would not occur pre-Obamacare.

el chief ... 6 months for cataract surgery, years for other surgeries. 9 months to see an eye specialist. My Canadian friedns tell the truth ... its a disaster.

Jake said at December 12, 2010 6:43 PM:


A year ago, I ordered the Food Allergy IgG & IgE-Genova $296 a food allergy test that determines your adverse reaction to 88 foods.

It showed I have a major reaction to red grapes which explains why two glasses of red wine would give me a terrible hangover. I only drink white wine now and I get no wine hangovers. The test showed that I have a moderate reaction to dairy so I eliminated diary from my diet except for special occasions.

Recently, I ordered a NMR lipo profile, $99. A CardioPlus Advantage w/ VAP $219 and Fasting Insulin $29. (Most doctors will not order any of these tests.) This breaks your HDL and LDL into particle size and count. There is no correlation between LDL and heart attacks but there is a correlation between small LDL size particle count and heart attacks.

Because I dropped dairy, my small LDL count dropped by 66% and that put in into a safe zone for heart disease.

From my cholesterol particle count and mix plus fasting insulin, the lab determined that I have zero insulin resistance which explains why I could lose 34 lbs in the past two years and keep it off.

Also my C-reactive protein test dropped by 61% and so I have eliminated almost all inflammation in my body.

Finally, the lab took all the values in these tests and gave me an estimated heart disease risk of .5. High risk is 23, average is 6. This is great news as my father died of heart disease.

These tests show that my Paleo lifestyle will keep me lean, diabetes and heart disease free as long as I stay with the lifestyle. I plan to do no diet related testing for the next 3 or 4 years unless I change my diet

Mercer said at December 12, 2010 7:21 PM:


Where do you live? Is it a rural area? I don't think all doctors could give up Medicare because there is not enough business from people under 65 for our huge medical system.


Do you think there should be no restrictions on what Medicare pays for? Do you think taxpayers are morally obligated to pay for any procedure that a doctor recommends for Medicare patients? If you think seniors should have a blank check from taxpayers what taxes do you propose to raise to avoid having "death panels"? If you think there should be restrictions on what Medicare pays how is that different then having "death panels"?

Randall Parker said at December 12, 2010 7:44 PM:


How do you draw blood and send it in? Is this place you are using on the web or do you send to somewhere local?

I wonder if one took 100 people and did food allergy tests on them what the results would look like.

I'm counting about $700 worth of tests above. But some must have been done before and after.


With or without Obamacare the cost of medical care is rising a lot faster than inflation. There are a few reasons for that including:

- Aging population.
- New treatments that are more expensive.
- Regulations at the state level that force more conditions to be covered in a basic policy.
- More people covered by government (i.e. taxpayer) funding. So more buying power.

My take is that the cost of medical care is getting so high (headed for 20% of GDP having already blown past 17%) that rationing by various means is in the offing. So without taking sides on what should get cut or funded I am arguing (getting back to the thread topic) that you should prepare to fund more of your own health care.

Jake said at December 13, 2010 8:33 AM:

I live in a city of 100,00. There is huge shortage of primary care doctors so they can pick and choose their patients and it is only going to get worse. Only 5% of medical school grads become primary care doctors. I have no problem seeing a specialist as there appears to be a surplus of them.

Direct Labs sends you to a Labcorp location to get your blood drawn and tested. Labcorp is also used by most doctors and hospitals for testing although they might do the blood draw themselves. Labcorp is in most cities with hospitals.

Increasingly, tests can be done in the home by doing a finger stick and putting the blood spot on a test paper. Then you send in the test paper and you get the results by email. In home testing is a hot new area in medical technology.

Remember that you need a food allergy test only once in your lifetime unless you incur an unexplainable illness. Many tests are once only. Now that I have my diet set, I plan on spending less than $200 a year in testing.

What is self testing worth if you can prevent getting heart disease, diabetes, cancer, dementia and autoimmune disease. According to biochemistry as it exists today, I will not get any of these diseases as long as I stick to my paleo diet which I have custom fit to my body through testing.

I think the a partial solution to the permanent shortage of primary care doctors is to establish walking in store front testing centers. People would get their blood tested at these centers for their annual checkup or continuing checkup for chronic diseases. If the results come back within range, you are not sent to a doctor.

Sgt. Joe Friday said at December 13, 2010 8:37 AM:

For some reason I am reminded of the last time we tried wage and price controls, under Nixon in 1971. I don't think that worked out.

People are always going to find a way to get what they want. If the government starts to ration medical care, I think you'll see high-end clinics opening up in places like Tijuana and Mexicali, with modern equipment and English speaking physicians, catering to a cash-paying American clientele. Medical tourism is already a burgeoning industry in places like Costa Rica, India, and Thailand. Would it be inconvenient to go to Costa Rica for cataract or hip replacement surgery? Sure, but if Uncle Sam says you can't have it, or have to wait 2 years for it, what choice do you have?

The ruling class' likely reaction to this will be to make it a crime to seek "unauthorized" or "out of network" medical care. They will probably try to criminalize all the things that lead to medical problems as well. Maybe they'll try to make getting old a crime...after all, part of the reason health costs are skyroceting is because accidents, heart attacks, and cancer aren't killing us off in late middle age the way they used to.

Bruce said at December 13, 2010 8:43 AM:

Mercer: "Do you think there should be no restrictions on what Medicare pays for?"

I think there should be no restrictions on how much money you personally wish to spend on private health care plans. The purpose of Obamacare is to destroy private plans.

Randall, many problems could be solved by just getting fraud out of the medicare system.

" Medicare fraud - estimated now to total about $60 billion a year - has become one of, if not the most profitable, crimes in America."

Thieves love big, badly run government programs that can be looted quite easily.

Imagine if Obama chose to return 60 billion each year back into medicare by fighting fraud instead of creating Obamacare and death panels.

Kirk Farrar said at December 13, 2010 12:20 PM:


Could you possibly take a moment and tell us a little more about your paleo diet? Like where to find good info. on it, for one thing. I'm considering some major dietary changes to improve my overall level of health. The info. I've found so far has either been overly strict, or lackadasical to the point of confusion.

bob said at December 13, 2010 12:44 PM:


For good physicians, 85% of ideas for a dx come from what someone tells them, 10% from physical exam and only 5% of ideas come from lab tests. Usually, studies only confirm or do not confirm a diagnosis. Or else may help in management.
In days past, when someone died with normal labs it was called a Harvard death". Good luck, as your perception of availability and ability is right on the money.

joe bloggs said at December 13, 2010 12:51 PM:

60 billion in fraud. Good lord.

If it costs say 50k on average to treat someone in a year (random ass guess), that's an extra million people that medicare could cover without any increase of monetary allocation. Crazy.

RetiredE9 said at December 13, 2010 12:55 PM:

Here in Dallas my old physician joined a group of other physicians and now has a cash only practice. Surprisingly their charges are quite reasonable since they no longer have to jump through federal hoops to get paid. They refuse to accept Medicare or any other form of insurance. Cash/credit card is due at the time of service or on approved payment schedules. I suspect a lot more physicians are going to go that route, as the full horrors of Obamacare become known.

eLocke said at December 13, 2010 1:03 PM:


Good luck with your self treatment. One minor point of which I think you should be aware. White wine is made from red grapes (at least chardonnay that I am aware of). What makes the wine red is the length of time the skins are allowed to sit in the juice, not the types of grapes used.

Rev. Herman Richard Matern, MD,FACS said at December 13, 2010 1:06 PM:

No, no,no! SAVE money and improve your health. Most health shortcomings are self inducesd and most medical problems now in USA can best be improved by taking less drugs (including alcohol and tobacco), eating less, climbing the hill behind your house, or just walking (or better running), get yourself a dog and take good care of him - race him around the block, climb those hills with him --you wanna sleep well every night? A brisk walk with him every night just before bed). Shovel your own walk, do your own gardening. I could go on and on, but you get the idea. Hey, I'm 83, 6ft and 170 lbs, still active in 2 professions, and NEVER go see a doctor. Yeah I have a huge prostate and I empty my bladder manually, by pressure and motion on the bladder just above the pubis and need to go no more often than anybody else and keep my BUN and creatinine within normal limits with these small measures.

dbr1 said at December 13, 2010 1:07 PM:

"I order all my own blood tests through Direct Labs and because I am doing the ordering I can get more sophisticated tests than most doctors are willing or know to order.

The tests show what the normal ranges are for each item tested. If something is out of range, I change my diet or supplements and then retest later to see if it works. If I need a prescription, I visit a cash only doctor and bring my test results. "

I am a doctor and you are most certainly deluding yourself about how much you think you know about these blood tests and how useful or more to the point, typically not useful that they are.

Michael Kennedy said at December 13, 2010 3:50 PM:

RetiredE9, that is the future for us oldsters. I am a retired surgeon and feel apologetic when I go to one of the doctors I see. I know how little they get for my visit so I mostly manage my own health. Eventually, we will all have to find doctors who take cash or we will be rationed to death. The solution for Medicare would be to use the French model and allow balance billing. In France, the health plan pays a flat fee to the patient. The patient pays the doctor first, unless it is a huge procedure, in which case it pays 2/3 in advance to the doctor and hospital, and the doctor and patient are free to negotiate a price. If you want to go to the best cardiologist in town, you will pay a lot more than the health plan fee. If a doctor is willing to accept the health plan payment as the full amount, the system pays into a pension system for him or her and also pays for vacation.

The incomes of doctors in France are lower than here but they have no debt because medical school is free. France has its problems but the medical system is not one of them.

flicka47 said at December 13, 2010 7:08 PM:

Re: Blood tests
If you have a major medical plan like I do that means routine blood tests come out of your pocket. It helps to call around to the different labs to see what their prices are, and they can vary a lot. I live in a town of only 36,000 and there are 3 blood labs. One is consistently 50% cheaper than the other two. All three have cash prices that are at least 25% cheaper than the charge for the insurance price. Some of the tests are expensive no matter where you get them done,but check to see who has the best price.

gnolls dot org said at December 14, 2010 12:34 AM:


I'm not Jake, but paleo 'dieting' is simple.
Eat what people ate for millions of years: meat (including fat and organ meats), fish, eggs, vegetables, and some root starches.
Don't eat things that we've only eaten since 10,000 years ago...5,000 years or less for most of us (all grains and grain products, including corn, soy, and wheat).
Really, really don't eat things that didn't exist until this century (refined 'vegetable oils', actually grain oils...see and anything in the 'snack' aisle)

Here's a good overview of the various variants of 'paleo':
And the entire site will give you a better summary of the issues than I can.

dbr1: "I am a doctor and you are most certainly deluding yourself about how much you think you know about these blood tests and how useful or more to the point, typically not useful that they are."

I am a patient, and you are most certainly deluding yourself that some of your patients don't know how to use Google Scholar and aren't frustrated that their knowledge is more comprehensive and up to date than yours in the fields of their specific interest.

MF said at December 14, 2010 7:05 AM:

For a cash-based compensation model based on paying for the time and expertise of the physician, visit

Dr. Cherewatenko makes a compelling case for restricting the middleman role of health plans, reducing medical practice overhead and consequently reducing costs. A dollar-based design, rather than procedure-based reimbursement, allows consumers to better understand and participate in something close to a market for health care services.

Edgar said at December 14, 2010 1:43 PM:

Health care is just another industry that we in the United States through our hopeless political apparatus have collectively sentenced to outsourcing. Regulation has rendered nearly all labor intensive activities non-viable in the US. Like the Brits we will be getting our dental care while on holiday and searching overseas for best values in by-pass operations.

ManekiNeko said at January 12, 2011 1:42 PM:

Apropos medical tourism and clinics with English speaking doctors and modern equipment being set up in Tijuana and Mexicali, I would not be surprised to see some enterprising entrepreneur situating hospital ships outside the 12 mile limit for major procedures with air or water taxi service to and from. It would be a lot cheaper for the patient than having to travel to India or other medical tourism hot spots.

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