by von
We all know that President Obama gives good speech, and I don't think that the fact that Obama gave a good speech last night is going to shift the health care debate in any meaningful way. But the substance of Obama's speech was ….. well, interesting, at least to this skeptic of the House Democrats' reform proposals. (As noted in prior posts, I prefer a different set of reforms.) Indeed, I found some things to like in the substance of Obama's speech:
1. Obama's proposed tax on "gold-plated" health insurance benefits is a better proposal than the House Democrats' tax on high earners. Taxing high benefits incentivizes folks to regard insurance coverage as income (which it is) and to make better decisions regarding the kind of coverage that they want. It may also result in cost savings to the extent that it causes folks to reduce their consumption of elective procedures (by eliminating the gold-plated plans that pay for those procedures, for instance).
1a. Be honest: Cost containment is simply another name for rationing (really, additional rationing, because rationing already occurs in the present system). Call a tax on "gold-plated" health insurance benefits "soft rationing."
2. On the other hand, I think it's unlikely that a tax on gold-plated benefits passes the House, largely because of Union pressure on the Democratic side. (Union workers tend to have better benefits than the average worker and thus will bear this proposed tax in disproprotionate numbers.) And it's still a new tax — and a complicated one at that – meaning zero Republican support.
3. I like that Obama made medical malpractice reform part of the discussion. Lots of folks overstate or understate the impact of defensive medicine on health care costs, but it is significant and kudos to President Obama for recognizing the fact. Like the Wall Street Journal's Law Blog, however, I have some real questions about what med-mal reform under Obama might involve.
4. It's great that Obama is focused on the cost side of the equation. Unlike Marc Ambinder, however, I don't think that limiting the cost of the bill to $900 billion is (perhaps) "conced[ing] too much." Cost is important, but the more important issues are the impact on the deficit and the sources of offsetting revenue. And $900 billion is not all that far from $1 trillion, so it's hard to call this a significant move.
5. It looks like the public option is dead. Public co-opts, anyone? (I'm fine with this but, again, what about House Democrats?) [Update: Whoops. co-ops, not co-opts.]
6. I also share Ambinder's other questions regarding implementation. As in: And how the heck is this going to be implemented?
President Obama has come a lot closer to enunciating a health care plan, and it's better than what the House Democrats are proposing. But he still hasn't told us his plan – i.e., what he'll go to the mat on – and some of his proposals seem unlikely to survive his own caucus. We're still hearing theory.
For this reason, I get the sense that Obama isn't shooting for an full reform. I think he's going for some kind of patchwork approach that might be used to set up future reforms … which will likely take decades to be fully resolved. Indeed, the falsest line in Obama's speech was "I am not the first president to take up this cause, but I am determined to be the last[.]" I'm pretty sure his claim will turn out to be untrue. And I'm pretty sure that Obama knows it.
What’s a public co-opt, and what does it have to do with health care legislation?
😉
5. It looks like the public option is dead. Public co-opts, anyone? (I’m fine with this but, again, what about House Democrats?)
This seems more like wishful thinking on your part than what was actually in the speech.
I haven’t heard of anything in any of the current plans that controls costs better than a public option.
And Obama stated that he would not compromise on that principle.
So if there is nothing more effective than a public option for cost control in the insurance exchange, then why would it be dead?
First sentence, the link says “gives good speech”. Typo?
It’s not clear to me that the “public option” is dead. However, the type of public option that Obama outlined last night could easily be implemented as either a straight forward, government administered health insurance plan, or a non-profit, government seeded co-op. It’s not clear it makes any difference at all. The major boundaries for either version are: 1) it’s non-profit, 2) it’s only available to people eligible to access the exchanges, 3) it’s entirely funded through premiums, and 4) it will not go into effect for 4 years. He definitely left questions of how this new company, regardless of how it is implemented, will negotiate rates (based on Medicare or based on private insurers?). That’s a significant question, but I’m guessing that Obama is working off of the philosophy that even if rates are based on the private market, it can still help control costs through economics of scale, enhanced competition in the insurance market, and low overhead. That’s not really what was on progressives’ wishlists, but it’s certainly better than what we currently have.
If anything, after last night’s speech, I think the public option is a shoo-in. Co-ops obviously will not achieve what the President is calling for.
+Regarding point number two, a study by the Congressional committes has found that the gold-plated plans are not union plans. A couple cities’ teachers’ and firemen’s and policemen’s plans come close, but aren’t there. Most of the gold-plated plans are corporate plans for the upper middle management and above.
I have no problem with malpractice reform, but only in terms of limiting lawyer’s fees, not capping actual settlements. What is interesting about malpractice insurance is that the rates have gone up and up and up while actual malpractice suits and settlements have stayed static or even dipped in some areas the past few years.
Yes, studies show some doctors practice defensive medicine, but the impact on actual health care costs is low. But even a 1% drop is significant.
First sentence, the link says “gives good speech”. Typo?
Nahh. I give good law, Obama gives good speech, you give good comment. It’s a continuation of the general Buffy-fi-cation of language.
Just want to push back on the idea that cost containment equals rationing.
Cost containment can be choosing less expensive among equally suitable treatment regimes. In other words, treatment selection based on value as well as outcome.
Cost containment can be emphasizing preventive care and general wellness.
Cost containment can be reducing waste and inefficiencies at a purely ops and/or paperwork level.
Conversely, rationing can be a means of allocating scarce resources, as opposed to managing cost, e.g. if there’s only one liver available for transplant, who gets it?
A nit perhaps but in context IMO it’s useful to observe the distinction.
It would be impossibly stupid to have a public option that people weren’t allowed to choose, which I gather is Obama’s plan at the moment. If a public option is available, no one should be banned from choosing it.
I just had a phonecall from someone who asked, curiously (aware I’d been following the debate more than he had) if I thought Obama was going to get healthcare reforms.
Not a chance, I said: too much pressure from the entrenched interests of the health insurance industry. Congress isn’t going to vote to save the lives of 22,000 Americans a year when it’s against the interests of their corporate donors: they’ll come up with any story – such as the one Von has just spun in this post – to justify letting thousands of Americans die rather than instigate the kind of wholesale reform that you need.
Not a chance, I said: too much pressure from the entrenched interests of the health insurance industry. Congress isn’t going to vote to save the lives of 22,000 Americans a year when it’s against the interests of their corporate donors: they’ll come up with any story – such as the one Von has just spun in this post – to justify letting thousands of Americans die rather than instigate the kind of wholesale reform that you need.
Jes, I always love it when folks who don’t live in the US and have no experience with US health care offer their caricatures of the US health care system. It’s almost as amusing as the caricatures of US cities, or crime, that I’ve been regaled with. (You mean that you actually walk around unarmed? And there aren’t Robocop-style gunbattles on a daily basis?) I wouldn’t purport to offer such a definitive opinion on UK health care, even though I have actually lived in the UK, experienced the UK system, and walked away favorably impressed.*
That said, what’s your support for your claim that 22,000 Americans die a year? You can start by explaining whether you’re asserting that the 22,000 Americans die because of lack of coverage, lack of treatment, bad doctors, swine flu, or untreated cases of the ricketts …. because it’s just not clear what you mean by the figure (or whether the figure has meaning).
*As an American, I likely swooned over the accent — making my judgment suspect.
The major boundaries for either version are: 1) it’s non-profit
There’s an old joke: “We’re a non-profit company. Not on purpose; it just worked out that way.”
“Non-profit” describes any number of major corporations whose C-level employees collect multi-million paychecks. It’s easy to make your profit zero: all you have to do is make your payroll big enough.
An actual government agency selling health insurance to citizens would presumably pay government salaries to its employees. If it happens to turn a profit, I don’t care.
So my criterion would not be “non-profit”. It would be “government agency”.
–TP
Non-profit private corporations also have a way of ending up being for-profit private corporations (demutualization etc).
As for the comments about Jes not knowing the US system – well, I do live in the US and have had extensive experience with the US healthcare system, and I think her characterization is accurate. By comparison to the UK system (which I have also had extensive experience with), the US system denies care to a significant number of people who need it, whether they’re people dumped through rescission, or people who make too much money for Medicaid but not enough to pay for private insurance, or people with pre-existing conditions that make it impossible for them to buy private insurance. It is a fair comparison and the US comes off badly.
@ Tony P.: You’re right – the important thing is to maintain low administrative costs. I’m assuming that for either a government run health insurance plan or a co-op could be chartered in such a way to mandate this. (though I admit that this might be naive)
I may be nitpicking language a bit too finely, but to me “rationing” of health care is stronger than “your health care provider refuses to pay for some procedures”.
For example, we do not currently ration gasoline. That doesn’t mean that I can have all the gas I want–it just means that I can buy as much gas as I can afford. Rationing would mean a cap on the amount of gas I am allowed to receive, regardless of how much money I have.
If we use the word consistently, rationing of health care would involve someone telling people that there are certain procedures that they may not have, no matter what insurance they carry or how much they are willing to pay.
Opponents of health care reform have deliberately taken advantage of ambiguity in the language to imply that limits on health care benefits (“rationing” in one sense) are actually limits on care (“rationing” in an entirely different sense).
Now, it’s true that for most people, this is a distinction without a practical difference. It doesn’t matter if I’m allowed to buy a supertanker of fuel if I can’t afford it. There is, however, still a powerful psychological difference between “the government won’t pay for this procedure” and “you are not allowed to have this procedure”.
As such, I must disagree with you von: It is not honest to say that “cost containment” is “rationing”, even when cost containment means not paying for some procedures.
I may be nitpicking language a bit too finely, but to me “rationing” of health care is stronger than “your health care provider refuses to pay for some procedures”.
For example, we do not currently ration gasoline. That doesn’t mean that I can have all the gas I want–it just means that I can buy as much gas as I can afford. Rationing would mean a cap on the amount of gas I am allowed to receive, regardless of how much money I have.
If we use the word consistently, rationing of health care would involve someone telling people that there are certain procedures that they may not have, no matter what insurance they carry or how much they are willing to pay.
I actually disagree with your first point: We absolutely do ration gasoline. We do so by price, which reflects not only the demand for gasoline but also the supply. It only seems that we’re not “rationing” gasoline at the micro level: to you, it seems that the supply of gasoline is infinite, and hence you’re restricted only by what you can afford. In fact, however, the supply of gasoline is finite and there are likely certain levels of gasoline that you simply cannot purchase for any price — the price becomes effectively infinite.
Now, that’s a difficult concept to grasp with respect to gasoline, but it’s a lot clearer when it comes to health care. Consider specialist health care, e.g., an orthopedic surgeon. There are a certain number of orthopedic surgeons in the world and, because of payment nuances, there are even a fewer number of orthopedic surgeons who will take Medicare patients and a fewer still number of hours in those Medicare-accepting surgeon’s work schedules. (That’s because the vast majority of orthopedic surgeons either cannot afford or are unwilling to afford an all-Medicare practice). The supply of surgery is finite. It’s plausible that a person on Medicare could run into a situation in which a noncritical treatment would not be available — or would not be available in an acceptable or reasonable schedule — because of this fact. The fact of the matter is such a situation will be more plausible in the future as the demand for healthcare grows.
Ultimately, we do ration healthcare today and we’ll do more rationing in the future.
The supply of everything is finite.
The construct:
[‘cost containment’ = ‘rationing’] as typically employed in the current discussion of health care reform =
http://en.wikipedia.org/wiki/Fallacy_of_equivocation
Aren’t doctors a renewable resource? I seriously doubt we are anywhere near a reasonable limit on doctor production. I understand that we have to ration organs for transplant – there are only so many of those, and their availability isn’t really something we control. However, the number of doctors is very different. We could easily have mroe primary care physicians – at some point, there was mention of having incentives to go into primary care in the reform bill.
why on earth would you want to cap fees in malpractice cases?they are the most costly and difficult cases to handle and statistically plaintiff’s lose 80% of the time.such a suggestion would insure that a person with a meritorious case would not be able to find a lawyer.i know something about tort reform.i handled the challenge in illinois.[best v.taylor]tort reform is about benifits to insurance companies and other chamber of commerce types.before you tout tort reform read the best case and see what the illinois supreme court had to say.warning:it is 98 pages
von, woukld like to make a guess as to what percentage of orthopedic surgeons do not take Medicare patients. I doubt if it is more than one percent. However, there may be a few more who do not accept Medicare assignment, which means they bill the patient for the difference between what Medicare pays and their regular charge.
Nonetheless, unless the orthopedic surgeon specializes in, say, sports medicine, and only treats sports related injuries, the likelihood is that that surgeon will not only take a Medicare patient, but also accept the Medicare level of reimbursement.
By the way, since I am in the healthcare field and work closely with contracting physician practices, I do have some knowledge of the situation.
And there are some physicians who do basically cater to an all Medicare patient base. However, there are few of any stripe who cater to an all-Medicare practice, simply by the nature of the business.
Medicare has nothing to do with noncritical services not being available. That happens now to any number of people, even those with “good” insurance coverage. There is an area in Kansas where, in a 200 mile radius there is exactly one oncologist. Needless to say, one can not just walk into that office and see the doctor for noncritical care.
The question here is more of a doctor shortage than anything else, but primarily in the area fo primary care, and the bills before Congress attempt to deal with that.
Aren’t doctors a renewable resource?
they’re even recyclable! after death they can be used to train other doctors.
Von: Jes, I always love it when folks who don’t live in the US and have no experience with US health care offer their caricatures of the US health care system.
Von, my worst experience with US health care was indeed at second hand: a few years ago, a close friend developed cancer. She had a job which gave her health insurance that covered her treatment, and she had a decent employer. But because she had cancer, she could not give up her job. She was in a developing relationship with a friend who lived far away – until she developed cancer, their plans were based on “which of us will move to be with the other?” but cancer took over: she had no choice but to stay with a decent employer and current health insurance. She died – and she might well have died anyway – but she died far from where she wanted to be and who she wanted to be with, because your sucky, Third World, second-rate, gimrack healthcare system gave her no other choice but to stick with her employer until death.
Let’s not forget the other American friends who have blown my mind at times by talking of how they have to “stretch” their medication, because they can’t afford to take the prescribed amount: or how they have felt a lump in a tender part of the body and are worried about it but can’t go see a doctor right now because they won’t be able to get time off work, and they can’t afford to pay for the examination, let alone any recommended tests or treatment. And I sit there reading their posts or their e-mail – but their posts are worse, followed by understanding, sympathetic comments from other Americans about how scary it is when something goes wrong and you don’t know if you can afford to get treated, while I just breathe deeply, trying to imagine what that must be like – having to worry, all the time, about the cost of healthcare.
Now, obviously, you have no friends who live in that kind of situation, or you just ignore them when they start to whining about how worried they are. But I do, and I can’t.
The only American friend I have who has never expressed any worry about healthcare in her own country is a dear friend whose parents both come from very wealthy families.
No, Von. Plainly, I couldn’t have any idea what your healthcare system is like.
That said, what’s your support for your claim that 22,000 Americans die a year?
Stan Dorn, “Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality,” Urban Institute, 2008 (PDF), via the National Coalition on Healthcare
Now, that’s a difficult concept to grasp with respect to gasoline, but it’s a lot clearer when it comes to health care.
And yet, so many conservatives are so foggy about the clear fact that a national health service is by far the most efficient and effective way of delivering healthcare to everyone who needs it. Because the larger the population you have to work with, the easier it is to predict healthcare needs and thus deliver them. Which is why the NHS is so greatly superior to the US system.
I actually disagree with your first point: We absolutely do ration gasoline.
If we want to begin considering limited supply due to purely market forces as a form of rationing, I have no objection. I think it would be a useful and interesting lens.
Pro-market folks might object because it doesn’t really reflect the normal meaning of rationing, which typically implies a deliberate and intentional allocation of resources for which there is more demand than supply.
The market model normally assumes those kinds of allocations happening through lots of individual decisions, taken in light of individual self-interest, rather than in a planned or deliberate manner.
The market model also assumes that demand will eventually drive up either supply or price (or both), which is also normally not part of what we mean by “rationing”.
But it might be an interest concept to introduce into a market analysis.
Either way, I think what we were originally talking about was whether rationing was synonymous with cost containment.
I don’t think that’s been demonstrated by your gasoline analogy.
Jesurgislac is correct.
Jesurgislac is correct. OBAMA IS LYING! The US corporate health system kills at least 50.000 people per year. Obama could save those peoples lives if he pushed for single payer. Their are 60 VOTES IN THE SENATE. If Obama wanted single payer he could get it, but HE WOULD RATHER LET THOSE PEOPLE DIE THAN DISAPPOINT HIS CORPORATE OVERLORDS. We need a real president who will fight for people, not profits.
Hooboy.
THIS IS THE VERY DEFINITION OF FASCISM! I don’t use the ‘f’ word lightly, but this is it. Fascism is not just about gas chambers and dictators with moustaches. FASCISM IS ABOUT USING STATE POWER TO PROTECT CORPORATE ECONOMIC INTERESTS AND COERCING CITIZENS INTO SUBMITTING TO CORPORATE RULE! This is exactly the economic system of Mussolini’s Italy. Obama will not have the government provide health care to needy people even though HEALTH CARE IS A RIGHT NOT A PRIVILEGE. Instead he will force people to give money to corrupt corporate interests just to enjoy a basic right. OBAMA IS FASCIST!
yay! FASCISM! FASCISM! FASCISM!
it’s even more true when you spell it in all-caps.
Hooboy, hooboy
no more red bulls for ricardo.
I can’t recall which of our former trolls this reminds me of.
What is your definition of fascism. And please remember that fascism is not the same as NATIONAL SOCIALISM. Fascism does not have to be a racist ideology. PEOPLE THINK THAT OBAMA CANT BE FASCIST JUST BECAUSE HES BLACK! But its not true. Last nite he said he’d include provisions AUTOMATICALLY CUTTING HEALTH CARE FOR POOR PEOPLE if the insurance companies dont ‘voluntarily’ come up with 900 billion in savings. DO YOU REALLY THINK THE COMPANIES WILL PAY THE MONEY? No, it will come out of the pocket of workers who are coerced into half their paychecks to corporate insurance rackets.
FASCISM IS ABOUT USING STATE POWER TO PROTECT CORPORATE ECONOMIC INTERESTS AND COERCING CITIZENS INTO SUBMITTING TO CORPORATE RULE!
In that case we’ve always had a fascist government.
Looks like I picked a bad day to quit methamphetamines.
Ricardo: (a) Please don’t CAPSLOCK. It’s yelling. It’s not nice to yell. (b) I strongly disagree with Obama’s position on many things, but I also disagree with your assertion that this is “exactly the economic system of Mussolini’s Italy”: it’s not. (c) Any comparison to fascism should not be lightly made. I feel that you are making this comparison without much thought and without sufficient justification. (d) Thank you for agreeing with me. Please try to justify your agreement without CAPSLOCK or inflammatory references to Mussolini and fascism.
“really, additional rationing”
No; *different* rationing. I, for one, would rather have to wait for non-life-saving measures while others go first (much like in the emergency room) rather than being able to get same-day appointments for a head cold while poor people with chronic diabetes can’t afford insulin, or get dropped by insurers.
ricardo has also been, er, gracing Matt Yglesias’ blog with his presence.
I do not make the fascist comparison lightly; as I already said. Hogan says that we’ve always had a fascist government. But that’s not true. LASIEZ FAIRE PROTECTS CORPORATE INTERESTS BY DEFAULT; BUT FASCISM GOES BEYOND LAISSEZ FAIRE. It actively uses COERCION to FORCE PEOPLE. That is what Obama is doing. Single payer supports human rights. AN INDIVIDUAL MANDATE TO BUT CORPORATE INSURANCE IS FASCIST!
If you want to understand what fascism really is please read this interview with Noam Chomsky.
i highly recommend that nobody click on ricardo’s link.
i’d also recommend banning him.
Seriously ricardo, definitions of fascism are a little bit squishy, but basically all of them include features that are not in evidence in the US at this point.
Not to say we could never tilt toward fascism, or come with something equally horrendous that had our own special aroma, but the political, social, and economic environment of the US is not fascist by any definition that respects the historical meaning of the word.
If you’d like to pursue the question maybe we can discuss what some of those features are, or you might want to do some homework on your own.
But dude you have to turn the caps off. They hurt our eyes.
“i’d also recommend banning him.”
Well, we do agree on something.
ricardo,
good lord, I hope you get some help.
but basically all of them include features that are not in evidence in the US at this point.
The militarization of the manufacturing sector since 2000 is another interesting feature.
Concentration and cartelization of sectors of the economy;shift of power to the executive
Dave & Sara may focus a little too heavily on the street-level social manifestations and not enough on the governing structures, but that is how the history and analysis was usually written.
Oh, ricardo is our teenage troll who thinks it’s funny to link to the goats ex image. Maybe someday he’ll grow up.
I’m with russell on the response to this statement, for the most part. I think it might be useful to explore market forces as a form of rationing, in that they act as a mechanism to determine who can and cannot have something of which there is a limited supply. If nothing else, it would help puncture some of the conservative shibboleths that come pretty close to deifying the free market as an absolute good.
The problem is that doing so renders the word “rationing” essentially meaningless as a descriptive term, particularly in the current context. It turns the word into a catch-all that basically means “any process that results in some people getting a thing and others not”. Using this logic, every market and financial transaction in the world would qualify as a form of rationing, and frankly that’s absurd. There is a nontrivial distinction to be made between having the right or permission to buy something but being unable to afford the price, and having the money to afford the price of a thing but lacking the right or permission to buy it.
While I appreciate the usefulness of refuting the idiotic FUD arguments that health care reform will result in “rationing” by pointing out that our current system has a similar effect–particularly where the purveyors of said FUD cannot usefully define “rationing”–I’m concerned that doing so is contributing in its own way to the corruption of the term.
The way the insurance companies currently approve or deny care does not amount to rationing of health care in any meaningful way–there is no actual shortage of the care itself. What they “ration”, if you can call it that, is their own profits: every time they approve a claim and provide the service for which they are paid, that hurts their bottom line. We’ve gone over this to death.
The term for what they’re doing isn’t rationing, though–it’s fraud.
I should correct my last line because I’m sure that the industrial history of 20s Italy & 30’s Germany has been studied extensively.
The usual precursor is called “corporatism”
(Here was a sentence about the National Recovery Administration, but the suspension of the Anti-Trust laws was only a small part of an incredibly complicated series of initiatives.)
“I’m with russell on the response to this statement, for the most part. I think it might be useful to explore market forces as a form of rationing, in that they act as a mechanism to determine who can and cannot have something of which there is a limited supply. If nothing else…….”
In many waays I am with Catsy(and Russell) on this point. The argument around rationing is circular and not meaningful as “rationing”.
More or less services will be denied by various solutions. I would also add that while I know of as many insurance denials as anyone else there are two things I don’t think have been mentioned.
For those on Medicare the service levels are very well defined. In any ongoing care situation the provider usually checks with Medicare to see what will be covered and only provides that care. There are advocates who actually help justify additional care under the rules, but care is regularly changed, more often than denied, to be within guidelines.
Second, I have been lucky enough to have reasonable to excellent coverage for years. Several years ago my doctor recommended a relatively ne drug for my pain management and the insurance company refused to pay for it. I was not in a position to pay for it myself so the doctor gave me the older version of treatment. Thus, I never took Vioxx three times daily for multiple years right up until they took it off the market.
My initial reaction to being denied was much tempered by the risk I never took.
All insurance denials are not fraud. Some are based on coverage levels, some on non-approved experimental treatments or new drugs. The things I have fought for over the years, getting waivers so treatments will get paid for, have given me an appreciation of the vast array of products that insurance companies have to review, along with your doctor. Luckily for me in many senses, I have had employer sponsored health insurance so recission was never a possibility.
Not to defend those cases where they set automatic denials so those who don’t challenge it don’t get it paid for, I’ve had to fight those battles also.
It is just more of a mixed bag and even a public option would struggle with some of the challenges.
The militarization of the manufacturing sector since 2000 is another interesting feature.
Concentration and cartelization of sectors of the economy;shift of power to the executive
See, *now* we’re talking.
The integration of the industrial and business sectors with the state was definitely a feature of fascism. However, in classical fascism, if we can use that term, the goal of the integration was to bring industry under the control of the state.
No more capitalist entrepreneur seeking his or her personal highest self interest.
The transcendent good in Italian, Japanese, and German fascisms was the state, both in its operational apparatus and its role as embodiment of a superior people, where “people” is used in a collective rather than an individual sense.
If and when the US finally goes to the dogs, IMO it’ll be other way around. The government and all of its institutions will not be master of capital enterprises, but rather their slave and instrument.
I’m not sure what the proper name for that will be but it won’t be fascism, precisely.
Maybe something more along the lines of British / East India Company imperialism. Only shinier, with a better public face.
Like Disneyland, only with tanks.
All insurance denials are not fraud.
That’s true, and all of your points here are good ones, Marty.
But I think we can all agree that recission, by which I mean taking someone’s money in the form of premiums for X years, then aggressively reviewing their medical history to find reasons to deny them coverage when it looks like they will present a net negative to the bottom line, is fraudulent.
If someone is an unacceptable risk, the time to decide that is before you take their money. Once you take their money, you own the risk.
Cases of insureds deliberately concealing information is another story, but I don’t think that’s what we’re discussing here.
My suggestion would be corporatocracy.
Not all, but I would venture to say a significant majority are, in the sense that the actual reasons for denial of coverage are merely a pretext–they literally start with the objective of denying coverage, and look for any reason to do so. Your anecdote about Vioxx is fortunate for you and forms an interesting counterpoint, but I don’t think it really bears on the point I was making.
The practice of rescission, now–I have no qualms in making an absolute statement to the effect that any case of rescission that does not involve deliberate fraud–not mistakes, but actual provable fraud–on the part of the patient amounts to fraud on the part of the insurance company.
Here’s a link to a CNBC article on Una Merkel’s policy Kurzarbeit in Germany, and it’s surprising success. I read a litte more detailed article in the econosphere, but can’t find it. Merkel was much more reticent about bailing out banks, and got a lot of heat for it. There is a lot of attention now being paid to Germany from the world economic community.
Just to point toward a different recovery policy than Bush/Obama’s tax cuts and financial bailouts, and to, ya know, ask the question as to why.
Don’t worry, russell and bob: Before long, the activist conservative justice on the Supreme Court will make it simpler for corporations to simply buy the government. Then we can see exactly what results.
If and when the US finally goes to the dogs, IMO it’ll be other way around. The government and all of its institutions will not be master of capital enterprises, but rather their slave and instrument.
I’m not sure what the proper name for that will be but it won’t be fascism, precisely.
no, it won’t be fascism. but it will be exactly what is predicted by hundreds of near-future sci-fi books, movies and video games. the all-seeing Corporation, with hooks into everything we do, controls the government.
we could call it “AllMart”.
“The practice of rescission, now–I have no qualms in making an absolute statement to the effect that any case of rescission that does not involve deliberate fraud–not mistakes, but actual provable fraud–on the part of the patient amounts to fraud on the part of the insurance company.”
This I could not agree with more. It is number two on my HCR priorities (after insuring the 47M).
Jes, your friend’s experience is precisely why I want to separate health care from employment — something that neither President Obama nor the House Democrats want to do. Which is why, despite Obama’s modifications, I still oppose this particular “reform” effort.
The data that you rely upon, however, is for crap because it fails to account for other salient factors that probably have a much greater impact on health than the presence (or lack) of insurance, including: income, diet, education, and location. It also fails to distinguish the reasons why and the character of the purported lack of insurance.
The practice of rescission, now–I have no qualms in making an absolute statement to the effect that any case of rescission that does not involve deliberate fraud–not mistakes, but actual provable fraud–on the part of the patient amounts to fraud on the part of the insurance company.
Wait a minute … these rescissions are about pre-existing conditions. Why should a patient be charged more, or have to interact with an insurance company more, or be penalized at all, because that patient was sick before? What kind of disclosures are they asking for that would inspire someone to lie (defraud)? The fact is, medical history should have absolutely nothing to do with the cost of future care. Explain why it should.
No; *different* rationing. I, for one, would rather have to wait for non-life-saving measures while others go first (much like in the emergency room) rather than being able to get same-day appointments for a head cold while poor people with chronic diabetes can’t afford insulin, or get dropped by insurers.
And additional rationing, BitchPhD. That is what it means to bend the cost curve: it doesn’t all come out of efficiencies.
Now, we hope that this additional rationing will come from procedures with low cost-benefit (e.g., not ordering a CT when the indication is headache caused by head cold and the likelihood of brain tumor is remote).
As for the debate over “rationing”: I’m using the term as economists do, which is appropriate because there’s a market for health care as much as there is a market for gasoline. I recognize that some folks don’t get it — or, worse, might maliciously misuse the term for political benefit — but I’d rather keep on using the appropriate term.
(Third paragraph of my 6:45 comment was to Russell [and others], not B-PhD.)
Marty: Second, I have been lucky enough to have reasonable to excellent coverage for years. Several years ago my doctor recommended a relatively new drug for my pain management and the insurance company refused to pay for it. I was not in a position to pay for it myself so the doctor gave me the older version of treatment. Thus, I never took Vioxx three times daily for multiple years right up until they took it off the market.
My initial reaction to being denied was much tempered by the risk I never took.
And whenever you hear conservatives trumpeting about NHS “death panels” deciding who will or will not receive expensive new medical miracles: consider that the NHS puts all its figuring right up front on NICE or on NHS Choices – and if you’re not happy about that, you can ask your MP to take it up in the House of Commons. None of which public information and discussion was apparently available to you, Marty, under the US system.
This I could not agree with more. It is number two on my HCR priorities (after insuring the 47M).
Number three, then. Since number two is getting 47M uninsured, and number one is apparently “protecting the profits and wellbeing of the health insurance companies”.
The fact is, medical history should have absolutely nothing to do with the cost of future care. Explain why it should.
but a person’s medical history does affect the cost of future care. many illnesses have a good chance of recurring. many illnesses are chronic. having one of those illnesses in the past raises the probable cost of care in the future.
von: Jes, your friend’s experience is precisely why I want to separate health care from employment
But so long as you’re glommed on to the idea that healthcare has got to be profitable to a corporation, you’re going to be stuck with a system that is worse than that of any other developed country.
Worse things could have happened to my friend than being stuck in a job she no longer wanted when she was dying of cancer. She could have had no health insurance at all.
The data that you rely upon, however, is for crap because it fails to account for other salient factors that probably have a much greater impact on health than the presence (or lack) of insurance, including: income, diet, education, and location. It also fails to distinguish the reasons why and the character of the purported lack of insurance.
*claps claps* Thanks for demonstrating that you didn’t bother to read the study I linked to before you dismissed it as “crap”. As you would know if you had read it, the studies demonstrating that 22,000 people die in the US each year because they do not have health insurance, do in fact control for
socioeconomic status and other factors.
Your preference for ignorant rejection of data that proves you wrong is noted.
Now, deal with it: the conservative preference for protecting the profits of healthcare insurance companies over the welfare of Americans kills 22,000 people each year. You defend that preference. Didn’t you use to call yourself “pro-life”, once upon a time?
“but a person’s medical history does affect the cost of future care. many illnesses have a good chance of recurring. many illnesses are chronic. having one of those illnesses in the past raises the probable cost of care in the future.”
Sure. Agreed. So, if I’m an expensive case, I should have to pay more for my right to be covered for a broken arm? Give me a break – the fact that I am predisposed to sickness has nothing to do (in a civilized world) with my right to be treated. How is it my fault if I have a genetic predisposition to heart disease? Or porphyria? Or osteoporosis? Sure, it’s predictable that I’ll cost more, but why is it my fault – should I have to be an investment banker instead of a social worker in order to excuse myself?
cleek, in other words, you’re buying into insurance risk schedules as a model for societal healthcare. Is that what we, as a society want, that people who have chronic medical conditions should pay a premium for health care because of it? It’s a lottery then, based on genes. That’s the model we want? Good model for eugenics.
, I should have to pay more for my right to be covered for a broken arm?
oh no. i’m absolutely not arguing the rates should be any different. but it’s inescapable that the insurance company can expect to pay more for some people based on their prior medical history. but the only way for a system to be just, IMO, is for all to pay the same amount. the healthy subsidize the sick.
This is a bit of mind reading, but I have always thought that the rescission issue was the insurance companies looking into a future where genetic markers might inform them who would suffer from expensive chronic illnesses. If they can get to a point where DNA tests are routinely done, a marker appears that the patient didn’t follow up on, and when the chronic illness appears, they rescind the coverage.
cleek, thanks – sorry to be so outraged – I totally agree.
I agree with comment upstream about “rationing” — i think it’s wrong to equate them. Rationing is a subset of cost containment, but not the only type. It’s like all squares are rectangles, but not vice-versa. All rationing is cost containment, but not all cost containment is rationing.
So I disagree with the use of it. There are other ways to save.
Also, “rationing” refers to a finite resource. We have 100 widgets, so everyone gets only 1 and no more. That’s not the case here at all. Anyone can buy any additional supplemental they want.
So in addition to being politically loaded, I just don’t it accurately describes what the Dems want to do
“Taxing high benefits incentivizes folks…to make better decisions regarding the kind of coverage that they want.”
For most people, high benefits come into play only in the case of disastrous non-elective medical conditions. Few people have significant choice about the kind of coverage they get anyway.
Expansion of coverage will be paid for with taxes no matter what kind of gimmicks are put into the bill, and the best way to do this is to provide a minimum amount of coverage with general tax income and let people choose what they want above that.
I think one can use rationing to mean either (a) any means of allocating a finite resource whose supply is not adequate to the number of people who would want it if it were free, or (b) some means of allocation that caps the amount you can get even if you are willing to pay.
But I think that if one chooses (a), it shows good faith if one objects every single time someone yells: OMG, rationing!!!, and points out that any market system rations, according to definition (a). So long as health care is not available for free to all comers, the dreaded rationing is taking place. If one chooses (b), on the other hand, neither the Obama plan nor any other plan I know of that’s under consideration now involves rationing.
Indeed, the falsest line in Obama’s speech was “I am not the first president to take up this cause, but I am determined to be the last[.]” I’m pretty sure his claim will turn out to be untrue.
He was making a claim about what he wants, not making a prediction about what will actually happen. The statement’s truth value is not proven by events- he is either accurately reporting his internal state or he is not.
I actually disagree with your first point: We absolutely do ration gasoline. We do so by price
“Rationed” already has a definition. Perhaps you’d like to make up a new word for “resource that is not infinite”. This would be easier to understand than trying to guess when you’re redefining pejorative words so you can use them on Obama’s proposals.
Cos let’s face it, this is all about getting to say “admit it Obama, you want to ration care.” Even if all it means under the new definition is “Obama, your proposal does not provide infinite healthcare at reasonable prices.”
Jes, you write:
claps claps* Thanks for demonstrating that you didn’t bother to read the study I linked to before you dismissed it as “crap”. As you would know if you had read it, the studies demonstrating that 22,000 people die in the US each year because they do not have health insurance, do in fact control for
socioeconomic status and other factors.
You then go on to say some nasty things about me.
The fact of the matter is that I read your link. The IOM study was very clear about how it reached its calculation. It used the following formula:
This is a direct quote from page two of the document that you linked.
As you’ll see, my statement is correct: The IOM study controls for age but not for the factors that I listed.
Now, it’s absolutely true that your linked paper lists alternative studies that provide different numbers on page 4, some of which the paper claims do correct for (e.g.) socioeconomic status. I’m thinking specifically about the study by McWilliams et al. (2004). Of course, the methodology of these studies is unknown and they do not provide the numbers that you’ve cited. So I have to assume that you’re not relying upon those alternate studies.
I don’t expect you to acknowledge the above; I expect that you’ll accuse me again of lying. But understand that this tactic of yours makes discussion with you a waste of time. You’re trolling. Please stop.
von, although I also would want insurance delinked from employers, that has less chance of p[assing than any proposal than single payer, and actually single payer would be the best way to manage the delinking.
However, it is hardly the only way to solve the dilemma Jes’ friend faced. No pre-existing conditions would be another. In fact, by law, a person can move from one group policy to another (i.e. by changing employers), and there should not be any pre-existing condition riders. The problem is that it would have been difficult for her to be employed if the company knew of her condition because they would have been socked for higher premiums by the insurance company.
I wanted, also, to elaborate on a couple other comments. The first is about Medicare reimbursement. As I mentioned above, there are very few providers (take away the glamour professions like cosmetic plastic surgeon) that do not accept Medicare assignment. There are reasons for this. Medicare payments are lower than insurance payments in most cases (mental health treatment is the exception where the reverse is true). However, Medicare reimburses in about half the time or less than most insurance companies which increases cash flow substantially.
Most insurance companiers contract with providers on the basis of a percentage of Medicare. For orthopaedic surgeons (your example von) the general range is 110% to 160% of Medicare. This may sound like a significant difference, but in actuality it isn’t that much.
The adminstrative costs related to working with insurance companies, including the cost of hiring someone to confirm eligibility and benefits, then to get authorization for surgery (which can take several days, phone calls and the cost of transmitting x-rays, etc to the insurance company), then the cost of administrating the claim processing and auditing of reimbursement are high and eat up a lot of the difference.
Additionally, it is not uncommon, when benefit checking and authorization may take place weeks before a procedure, that when the claim hits, to find out that the coverage no longer exists for some reason or another.
None of those problems exist with Medicare.
Concerning insurance denials. There are 3 major reasons. The first, and most controversial falls into the no longered covered category. There are a lot of reasons for this and recission is one.
However, this is really not the largest category. In fact, it is probably the smallest.
Second is for the experimental, unproven treatment category. This is frequent and is sometimes justified, particularly when normal proven courses of treatment have not been tried. The problem is that the insurance company gets to decide when a treatment no longer falls into that category. Not surprisingly, the more costly a treatment is the longer it stays classified as experimental. When I was a mental health case manager, actually in a position to approve and deny coverage (different than treatment)I was frequently looking at people requesting approval of a costly treatment for autism. Because I could override the carriers position in some cases, I would approve it under certain circumstances (I won’t go into the criteria). The point I want to amke though, is that many insurance companies would deny this treatment even though it had been in existance for 20 years and been shown to be highly effective.
Finally, the last and most common reason for denial is non-medically necessary. Again this is a legitimate reason to deny coverage, but it also serves as a screen behind which many things can be denied. Sure the denials can be appealed, sometimes through several appeals, but many people never did. And believe me, the pressure was on those who did the initial review to send a certain percentage of cases to the medical directors to approve or deny, and pressure was on them to deny a certain percentage of cases. If they didn’t, they may not have their jobs long.
Main point, not all denials are fraud or illegitimate, but even the “legitimate” reasons are used to cover some marginal, if that, reasons for denial.
Maybe more later.
“First sentence, the link says “gives good speech”. Typo?”
Nahh. I give good law, Obama gives good speech, you give good comment. It’s a continuation of the general Buffy-fi-cation of language.
Posted by: von
Buffififcation? Maint’Non! When in the newsroom, some 35 years ago, long antedating the sallow Buff, colleagues regularaly brought me problematic stories to read and slug because, it was alleged, I gave good headline…
Von, I still say by using the word “additional” you are question-begging. If a plan is passed which forbids caps on benefits or post-hoc cancellations of policies by insurance companies, then some of the current rationing will be no longer. “Additional” implies that not only will current forms of rationing continue, but there will be *more* (additional) rationing on top of it.
As for the debate over “rationing”: I’m using the term as economists do, which is appropriate because there’s a market for health care as much as there is a market for gasoline.
Being a general economics bonehead, I wasn’t aware of the way rationing is used as a term of art in that discipline.
von is correct, here is what an economist means when they say “rationing”:
In economics, it is often common to use the word “rationing” to refer to one of the roles that prices play in markets, while rationing (as the word is usually used) is called “non-price rationing”. Using prices to ration means that those with the most money (or other assets) and who want a product the most are first to receive it.
So, my bad.
By this definition, it’s true that rationing already happens in the current system. If you have a lot of money, you can have whatever health care you damned well please. If you don’t have a lot of money, you’ll get whatever your insurer will cover, assuming you have an insurer. You might get none at all.
Also by this definition, the relationship between cost containment and rationing is as follows: if you don’t have the dough, you don’t get the service.
So, the way we’ll contain costs is simply by making sure fewer people can pay for the service.
Cost contained, QED.
Splendid.
Carleton’s 8:32 is spot-on. i’d been trying to think of what was bothering me about this and he nailed it.
one can’t use words that have become inflammatory and be surprised or pedantic when they inflame.
By this definition, it’s true that rationing already happens in the current system.
It’s not just that- using this definition, rationing is happening under any conceivable system. If this is the definition von was relying upon originally, then why make the statement?
Of course, by some amazing coincidence, this is a meme pushed by right-wingers- ObamaCare is rationed care!
Carleton, that is, of course, the whole point, to scare people. There is no conceivable system that can avoid rationing. However, von seems to think that Obama’s plan would actually increase rationing by creating an increased demand on the system.
Again, any system that increases the number of people who have access to healthcare also increases demand, thereby creating additional rationing, one can only assume that von, if he is using the word “rationing” as a criticism of Obama’s plan, does not really want to see increased access to health care.
However, I really don’t believe that of von. Therefore he must not be using it as a criticism. But then, the question must be asked, why use the word at all, as you ask above.
If von, you are using it to point out that people are wrong defending Obama’s plan by saying it doesn’t ration care, I don’t know anybody that does, not in the sense you are using it. So do inform us, please, why you even bring the word up?
However, von seems to think that Obama’s plan would actually increase rationing by creating an increased demand on the system.
Im not an economist, but using the economics definition from wikipedia definition- could one speak of “increasing rationing”? It seems more like a process- ie rationing is the market using price/demand info to determine allocation of a limited resource.
Whereas “increasing rationing” makes perfect sense when one is discussing the nontechnical definition- but it also seems to be inaccurate in this case.
Equivocation.
It’s not just that- using this definition, rationing is happening under any conceivable system.
Actually, not that we are ever going to see a single-payer system in this country, but under a single-payer system rationing does not occur through the mechanism of price.
In other words, the cost of a medical service or product is not the means by which all of the folks who need it are sorted into who will get it and who will not.
There may be other rationing mechanisms, but “who has the most money” is not one of them.
Figuring out if that is more fair, or less fair, depends on whether you think medical care should be treated as a commodity or as a public good.
We don’t ration access to mail delivery, highways, tap water, police and fire department services, or trash pickup on the basis of who has the most money. We may ration those things, but not on that basis.
“I think he’s going for some kind of patchwork approach that might be used to set up future reforms … which will likely take decades to be fully resolved.” – von
Well that’s depressing as hell considering it already taken “decades” to get to where we are now. Good grief…
Any non-economist, talking to an audience that is not 100% economists, who says “rationing” the way Republicans say it in the current debate, is a Frank Luntz wannabe.
I accuse no one here. Anyone who feels accused must think that the shoe fits.
–TP
I have to agree with the people who find the usage of the term rationing to be a poor choice. Yes, there is a technical term “price rationing” that economists use, but if you are writing for a non-technical audience, and want to make things as clear as possible, you should tell them that you are using a technical term and why. Otherwise it looks like you are trying to deceive your audience or use a word with a negative connotation for propaganda value, and honestly that’s the way the use of the term here reads to me.
“Price rationing” as economists use it is not necessarily a bad thing, they would claim it is often the most efficient means of rationing scarce resources, so if you really meant rationing as price rationing, why would that be a criticism?
Perhaps you could describe the decrease in the death rate that would result from increased access to health care as “death rationing” in order to make it sound extra-scary. That would work two typical conservative scare words into one rant.
Most non-economists may think it is possible to avoid rationing, but most non-economists are wrong. Rationing, like death (and unlike taxes) is a necessary part of the human condition.
I don’t hear anyone claiming we can avoid rationing.
The question is not whether there will be any rationing or not, the question is the basis of the rationing.
We have rationing now. If you have the money, you can get whatever you want. If have insurance, you can get what they’ll pay for. If you have no insurance and/or not a lot of money, you get nothing.
The question is whether that’s the way we want to live.
However, von seems to think that Obama’s plan would actually increase rationing by creating an increased demand on the system.
I wouldn’t say that there would be an increase in rationing. (I don’t know why I wouldn’t say that, but it just doesn’t sound right to my ears.) I would say that there would be additional rationing, because there will be either the same — or, possibly, fewer (more on this I hope later …. it has to do with medicare reimbursements*) — medical resources for more people. And to an extent that’s a good thing: Americans by and large overconsume health care. Some of its self-sightedness (get my kid antibiotics now); some of it is defensive on the part of doctor and/or patient (a 1% chance of a brain tumor? better order that CT); some of it is greed (I get paid more for every CT I do); and some of it is inefficient habit (we always do CTs when a patient presents with X).
Most non-economists may think it is possible to avoid rationing, but most non-economists are wrong. Rationing, like death (and unlike taxes) is a necessary part of the human condition.
You earn your name with this comment, Pithlord.
You earn your name with this comment, Pithlord.
Yeah, it’s pithy, but it’s not to the point.
Who is claiming that rationing — meaning the allocation of finite resources — is avoidable?
Pithlord’s pithy comment boils down to “many people think the sky is not blue”, or “many people think the sun rises in the West”.
No, they don’t think those things.
There are two questions that folks are discussing.
1. Whether rationing by price is equitable.
2. Whether you, von, are being disingenuous in raising the issue of rationing in the context of Obama’s speech on health care.
I look forward to your, or Pithlord’s, or anyone’s, pithy replies.
“Rationing, like death (and unlike taxes) is a necessary part of the human condition.”
‘Necessary’??
I don’t think so.
‘Inescapable’ or ‘inevitable’ — maybe.
And what else is going to be inescapable and inevitable are the longer wait times we’re going to see when 40 million uninsured become eligible for medical care –in comparison it will make Canada’s historically slow system look like the Roadrunner on steroids…
I’d like to see Hilzoy’s point address more directly too.
“Rationing” can be meant in two different ways. The first way (we allocate scarce things) is so obvious that it’s not even noteworthy. Under this view, we already ration — and in a highly inefficient and immoral way.
Under the second sense (we impose caps), it doesn’t apply at all to Obama’s health care plan
Most non-economists may think it is possible to avoid rationing, but most non-economists are wrong. Rationing, like death (and unlike taxes) is a necessary part of the human condition.
Do most non-economists think that all resources are infinite? I think not.
However, if they think that it is possible to avoid having some entity set limits on purchase or distribution of some products, then those non-economists are correct.
This is like saying: Many sports fans think that the Lakers victory last year was significant. But statisticians know that a single event can never be significant.
Am I the only person who tends to find von’s healthcare posts mystifying or even impenetrable at times? He just seems to flip logic on its head often.
Von: This is a direct quote from page two of the document that you linked.
Actually, what I’m accusing you of is ideological convictions that make you indifferent to the human cost of denying people healthcare to make a profit.
But hey. Continue to accuse me of trolling, if it means you can avoid discussing the lives lost because people can’t get the healthcare they need in your preferred system.
In the US, where healthcare is rationed by how much money you have and where motherhood is a strong indicator of poverty, 6.26 infants die for every 1000 live births. In the UK, is the worst country in Europe, 4.85 infants die for every 1000 live births. To you – to most conservative Americans – the babies who die can be blamed on the mothers, not on a system that denies them healthcare because they are insufficiently profitable: in the UK, we just figure that every woman who wants to have a baby should be cared for according to her needs, and every baby born should be cared for according to its needs. You think that prenatal care, childbirth, and pediatrics should be a profitable business and the extra cost of babies dying is just a side-effect that can be blamed away on someone else: I think that – like any other kind of healthcare – everyone deserves to get what they need, and we should all collectively pay what we can. And in your preferred system, more babies die as a result. Didn’t you call yourself pro-life, once upon a time?
At the other end of life, it’s estimated that sixty thousand people die each year as a result of bedsores in the US. cite In England, about a thousand people die each year as a result of bedsores. cite. The US has just about 6 times the population of England… and 60 times as many deaths as a result of poor nursing care.
By the way, the first cite has pictures of what bedsores look like. Your ugly cost of denying people healthcare when it’s not profitable.
As Russell says: We have rationing now. If you have the money, you can get whatever you want. If have insurance, you can get what they’ll pay for. If you have no insurance and/or not a lot of money, you get nothing.
That’s the way you want other people to live and die: but at least, don’t be hypocritical about it.
In the UK, is the worst country in Europe, 4.85 infants die for every 1000 live births.
Nitpick. The UK is not the worst country in Europe. We were second worst round the turn of the millenium, admittedly. (At around 5.8). Off the top of my head, Ireland’s at 5.05. Greece and Italy also have higher rates, and Cyprus has the distinction of having a higher infant mortality rate than the US.
It’s worth noting that Ireland has a lot of private involvement in healthcare, and that the other named countries are … not economic powerhouses.
What a not insane, not anti-social discussion of health care cost management looks like.
h/t tristero at digby’s place.
Any chance of anything like this happening?
As always, cherchez l’argent.
Von:
As you’ll see, my statement is correct: The IOM study controls for age but not for the factors that I listed.
Actually, this doesn’t appear to be correct. The IOM study used estimates of mortality differential from other studies, which apparently did control for some confounding factors. I quote (my bold):
The formula you quoted certainly isn’t support for your statement, as the formula is just a way to derive an estimate of the number of deaths based on an estimate of mortality differential derived from some other means: in this case, 25%, which is where the factor of 1.25 comes from in the formula.
So quoting the formula was either deliberately misleading, or a mis-analysis on your part. Second,
Now, it’s absolutely true that your linked paper lists alternative studies that provide different numbers on page 4, some of which the paper claims do correct for (e.g.) socioeconomic status. I’m thinking specifically about the study by McWilliams et al. (2004). Of course, the methodology of these studies is unknown and they do not provide the numbers that you’ve cited. So I have to assume that you’re not relying upon those alternate studies.
After reading the paper, this statement seems excessively weasely. In fact, the paper points to a large body of research, and “claims” that it all broadly confirms the finding of an approximately 25 percent differential in mortality rate (i.e., something on the order of 20,000 excess deaths a year). In some cases much worse.
The citations are all there, and you’re welcome to go through and analyze each paper, but this looks to me like a pretty robust result.
—-
The McWilliams paper does indeed appear particularly interesting–again, my bold:
I don’t write this to object to health-care reform in the US, but because I think it’s true and needs to be considered if we’re going to discuss national statistics on infant mortality. It’s a dicey business.
Not all countries draw the line between infant mortality and still birth in the same way when counting such occurrances. Further, not all countries health systems have the same resources generally to extract and sustain distressed fetuses/infants. If you’re better at getting the fetus/infant out and keeping it/him/her alive for some period of time, you’re going to accumulate, depending on how you count such things, more infant mortalities that would have otherwise been still births.
I don’t know how this, if taken into account, would affect the specific numerical rankings of various countries with regard to infant mortality, but I’m pretty sure it would.
Stats are funny things.
hairshirthedonist, I got challenged about this a while back by someone who claimed that in specific countries (I think the meme was “France and Sweden”) there were specific, very large differences in recording infant mortality.
I looked the facts and the stats for both countries up online, and found that no – there really wasn’t much difference. Pro-lifers in the US like to make big claims for how the reason infant mortality stats in the US are higher than those in other developed countries is because in the US what would be called a miscarriage elsewhere is called a live birth, but this has not been true for at least 20 years – the US, like most developed countries including all the EU countries (at least, all of those that were EU countries twenty years ago…) started to use the WHO definition of a live birth between 20 and 30 years ago.
So while all the countries round the world don’t necessarily record live births the same way, and if you look at stats over the past 50 years you won’t necessarily be comparing like with like, any comparison between European countries, or Australia or New Zealand or the US or Canada, all of which use WHO definitions of live birth and still birth, are comparing like with like: the US just really is that bad at keeping babies alive after they’re born. Universal healthcare is good for mothers and babies, it turns out: who’d have thought it?
When I still went to school (2 decades ago)some countries counted only children that survived their first year while others counted all live births in their statistics for life expectancy. The differences could be significant.
The problem with using the word “rationing” in this discussion–particularly in the way in which it’s being used–is that it confuses the issue rather than adding clarity.
The way economists use the term is completely beside the point. Every industry has terms of art they use, and most of them have hijacked perfectly ordinary words and given them a specific meaning. Law and economics are replete with examples like this, but IT does it too–for example, where I work we refer daily to “bouncing” services or servers, which means to restart or reboot them, respectively. If I walk into a discussion about car problems, and I suggest that someone “bounce” their car (i.e. restart it)–that may be an accurate way to use the word in my industry, but it’s just going to confuse everyone else.
So while economists may well use “rationing” in a way that makes it germane, that’s not what everyone else in the country hears when you use it. To most people, rationing specifically involves a deliberate system for distributing a commodity that is in short supply, limited by either who can have it, how much each person can have, or both. To most people, it carries a decidedly undesirable connotation, as it’s typically associated with wars or hard economic times where it was a necessary evil–which is why the Republican Party started using it to describe HCR in the first place.
You’re doing their job for them. Just stop.
In all honesty, I think the UK figure of 4.85 deaths per 1000 births is shameful, and we should absolutely be striving to do better – but US defenses of their infant mortality rate based on claims that it’s just the US counts live births / still births differently from other places, are straightforwardly false*.
*And apparently (according to wikipedia) can be sourced directly to an article in U.S. News & World Report published in 2006 – and the section quoted on wikipedia does contain some awfully familiar claims which researching the data country by country, can be shown to be false.
Maternal morbidity, another area where the US does badly and the UK does – not quite as badly – is a much more grey area, but still demonstrates that, even given an unhealthy group of people who eat badly and take little exercise – which applies to Brits as much as to Americans – providing universal healthcare is going to save lives and keep people generally healthier.
A friend whose body reacts badly to the hormones of pregnancy, making her mentally unstable, swears she would have done something appalling to herself if not for the free psychiatric care provided on demand by the NHS Trust’s pre-natal service: she said that, quite aside from the helpful advice, it was just damn helpful to know that there were so many other women who reacted the same way that the local NHS Trust had a service ready set up for them: feeling uniquely crazy had been worse than anything.
But that kind of provision of care – you don’t know who among the thousands of women a year will need it, but you know a certain percentage of them will – is exactly the kind of thing that a national health care service does better than any other kind of healthcare service – even if the NHS is still catching up on funding needs after nearly 20 Thatcherite years of steady starvation.
but IT does it too
Even with numbers: 1K = 1024 (10 to the 10th power) rather than 1000 in IT.
Dietary “calories” are really kilocalories to a chemist or physicist.
So let’s not use the word rationing. Let’s just say that no one is going to put a numerical limit on, say, the number of MRIs or open-heart surgeries that can be paid for in a year for a given number of people under government-provided health insurance. Okay?
The economist version of the word has nothing to do with what people are afraid of, considering that it’s utterly unavoidable and going on right now. They’re afraid of “Sorry, we’re all out appendectomies for the year as of last week. Your plan’s allotment has been used all up. Try again next period. Otherwise, your appendix is just going to have to burst inside you.”
Jes, you may be right regarding countries using WHO standards. (Luckily for me, I have no ideological resistance to such facts.)
I think our health-care system is missing basic humanity.
During my first visit to St. Petersburg, Russia, in 2003, I developed terrible blisters on both feet, really bad. One of the friends I made there took me to a clinic, I was seen within 10 minutes, and the doctor, an ex-pat from England, took her time treating the blisters and bandaging my feet.
Money was never discussed or exchanged.
I wonder if an international traveler would receive the same courtesy here.
As we all know, a job with health insurance is considered a great perk these days.
This year, my employer changed our Blue Cross/Blue Shield plan, announcing the change as being new and popular.
My employer pays the first $1,200 of doctor visits — which my wife, son and I used up by June — and the employee is responsible for the next $1,200. (After that, the employer picks up everything.)
On the surface, this sounds like a decent plan. But coming up with that next $1,200 during a recession is a problem.
I suffered a stress fracture in my right foot in February and wore one of those walking casts into April.
Now I’ve reaggravated the foot, same spot. At least that’s my diagnosis.
I owe the doctor $150 from follow-up visits and can’t afford to run up my tab any further.
_
Can an admin delete the 1:06 post by _ that appears to have been made for no reason but to add open italics and bold tags?
lemme take a whack at it.
Could you remind me of the proper tag structure to kill those? I’m pretty sure I’m half-remembering it, but I’ve had no luck the last few times I tried.
(There’s paragraph tags involved, aren’t there?)
i used:
[/p][/b][/p][/b]
[/p][/i][/p][/i]
close paragraphs, multiple times.
First, I’m in favor of universal heath care (if some of the flaws in the present offering are fixed). Every American Citizen should have it!!
Second, the Infant Mortality Rate in the US has little to do with the presence or absence of universal coverage. And if you’re arguing it does, you’re a (fill in the blank).
To start, here in the US almost any woman who wants it can get free or very low cost prenatal care, have their baby in a hospital, and receive free or very low cost post-term care.
Doubt it? Ask the millions of Hispanic and other Immigrant women who have come here in the last three or four decades for verification. There’s multitudes of programs available, from S-CHIP to Medicaid to thousands of prenatal and birth clinics, dotting the American landscape with more offices than Wal-Mart and CostCo combined. And those programs provide care through the first year of birth.
So if we already have widespread (really, they’re universal) pre-birth-post-natal programs available, how is a universal health care system going to improve the infant mortality rate, when mothers and babies are already receiving the same care?
Another reason the institution of universal health care isn’t going to significantly lower infant mortality rate is that (a) more than half of infant deaths occur in premature births, before 32 weeks gestation, and (b)those born after 32 weeks gestation are three times more likely to die early, and (c) the other leading causes of infant death — low birth weight and birth defects — are mostly the result of poor diet, heroine use, and smoking and drinking — and a universal national health plan won’t address those deleterious behaviors any better then the present system does — not unless, that is, we include a Stupid Watch for pregnant women, comprised of nurses who smack them alongside the head when they engage in those behaviors (I’d be in favor of that if it could be done on the cheap). Also, SIDS is another main cause of infant death. Again, a national health care program won’t do much to prevent that.
btfb:
You must be mistaken about the doctor’s visit in St. Petersburg, Russia.
That was a death panel. You were a victim of bureaucrats.
Sarah Palin could see your feet in St. Petersburg from her house in Alaska and she said they cut them off by accident and you died of an infection.
How is heaven, anyway, back here in the United States?
Gotta find a job in six weeks or my health insurance is kaputkin.
Tell me again who won the Cold War?
Speaking of death, it’s odd and unspeakable that death itself is not rationed. Each one of us gets an equal supply of it for free and without even asking. What’s with that?
So if we already have widespread (really, they’re universal) pre-birth-post-natal programs available, how is a universal health care system going to improve the infant mortality rate, when mothers and babies are already receiving the same care?
This CDC pdf suggests even if it is ‘available’, 30-50% of Hispanic women do not utilize it. (p 183)
This also discusses some problems with US prenatal care
The proportion of women who began prenatal care late (after 15 weeks) is highest in the United States (21.2%) and lowest in France (4.0%). This contrasts with the median number of visits, which is greater in the United States (11) than in Denmark (10) or in France (7). Across all maternal ages, parities, and educational levels, late initiation of prenatal care is more frequent in the United States, and median number of visits in the United States is equal to or higher than that in the other countries. CONCLUSIONS. In countries that offer nearly universal access to prenatal care, women begin care earlier during pregnancy and have fewer visits than women in the United States
link
First, I’m in favor of universal heath care (if they fix the flaws). Every American citizen should have it.
Second, the Infant Mortality Rate in the US has little to do with the presence or absence of universal coverage. And if you’re arguing it does, you’re a ( fill in the blank ).
To start, here in the US almost any woman who wants it can get free or very low cost prenatal care, have their baby in a hospital, and receive free or very low cost post-term care.
Doubt it? Ask the millions of Hispanic and other Immigrant women who have come here in the last three or four decades for verification. There’s multitudes of programs available, from S-CHIP to Medicade to thousands of prenatal and birth clinics, dotting the American landscape with more offices than Wal-Mart and CostCo combined. And those programs provide care through the first year of birth.
So if we already have those programs available, how is a universal health care system going to improve the infant mortality rate, when mothers and babies are already receiving the same care?
Another reason the institution of universal health care won’t significantly lower infant mortality rate is that (a) more than half of infant deaths occur in premature births, before 32 weeks gestation, b)those born after 32 weeks gestation are three times more liky to die early, and (c) the other leading causes of infant death — low birth weight and birth defects — are mostly the result of poor diet, heroine use, and smoking and drinking — and a universal national health plan won’t address those deleterious behaviors any better then the present system does — not unless, that is, we include a Stupid Watch for pregnant women, comprised of nurses who smack them alongside the head when they engage in those behaviors (I’d be in favor of that if it could be done on the cheap). Also, SIDS is another main cause of infant death. Again, a national health care program won’t do much to prevent that.
sorry, that should be page 167. It is a bit complicated because not all states used the same reporting standards.
To start, here in the US almost any woman who wants it can get free or very low cost prenatal care, have their baby in a hospital, and receive free or very low cost post-term care.
Hmm.
1. “Almost” is not all.
2. It’s important not to confuse technical availability with actual availability and utilization (i.e., what you get when you factor in all the nitty gritty informational, transaction cost, and accessibility details.)
I’m not accusing you, but there’s a real tendency among conservatives who adopt a very moralistic view of things to dismiss these factors as unimportant to public policy (or, indeed, important NOT to factor in, as that would be coddling laziness).
I mean, clearly every pregnant woman could, theoretically, somehow find out about the unpublicized free assistance program, fill out 12 pages of forms in triplicate, finally get interviewed and approved by a case worker after a mere 3 or 4 weeks of delays and missed connections, then make an appointment and walk to the clinic three miles away on her single day off each week. It’s totally her fault if she doesn’t and then something goes wrong, right? I mean, we did everything we could…
Back in reality, this is a really, really big, genuine advantage to universality. In the UK, I imagine everybody knows that they can get care, where and how to get it, and there’s no administrative cost from all the excess paperwork, foot dragging and means testing.
“It’s totally her fault if she doesn’t and then something goes wrong, right? I mean, we did everything we could…”
remind you of Hitchhiker’s Guide to the Galaxy, chapters 1 and 3?
remind you of Hitchhiker’s Guide to the Galaxy, chapters 1 and 3?
Maybe we could get the Republicans on board with socialized medicine if we agree to print “Beware of Tiger” on everything.
jack lecou: Back in reality, this is a really, really big, genuine advantage to universality. In the UK, I imagine everybody knows that they can get care, where and how to get it, and there’s no administrative cost from all the excess paperwork, foot dragging and means testing.
Indeed. One of the most amusing reactions I get from Americans about the NHS is that it must be terribly bureaucratic.
It isn’t. It doesn’t need to be. If everyone resident in the UK is entitled to whatever healthcare they need free at point of access, that just wipes out a whole stack of bureaucracy. Not needed. Not there.
Jay Jerome’s unsubstantial certainty that in principle any woman in the US (if she can prove she’s poor enough) can get free/cheap pre- and post-natal care and delivery, reminds me strongly of the conservative woman who assured me angrily that Deamonte Driver had in fact died because his mother had not bothered to find the free dentist that this conservative was sure was available in the area where the boy and his mother lived: not that she lived there herself, or had any recent experience trying to find a free dentist there, but she was sure there was one because it did not fit with her ideology that a 12-year-old boy had died because he did not have health insurance.
Doesn’t fit with Von’s ideology, either. But Deamonte Driver is still dead, conservative ideology can’t bring him back to life, and it wouldn’t have cost nearly as much to save his life by giving him free dental care biannually as was spent, in a Washington DC ER, in a frantic attempt to save his life after the infection from a tooth absess had spread to his brain.
To save a child’s life by providing all children with free biannual checkups and free toothcare, is expensive: but it’s a lot cheaper than providing last-ditch help when teeth have decayed out of a child’s mouth, plus, you get the imponderable and unprofitable benefit of a host of children with healthy sound teeth.
And while you can argue that all parents have to do is fill in all the paperwork, it’s a hell of a lot simpler just to declare all children eligible to fill in their teeth.
Jes, i hugely appreciate your comments and insights here. I agree with you on all of them.
Von, you are still a terrible writer. You start off with a an allusion to fellatio (“gives good speech” is a variant on “gives good head”) , don’t bother to read the report Jes linked to, approve of Lord Pith’s comment about death being inevitable… I actually think you are the most inarticulate blogger I have ever read on a halfway mainstream site, because your points are all over the map. You’re against health care reform, bore us with talk of gasoline rationing as if that was the same as human lives. I honestly find every time I come here, what you have to say is drivel. And I don’t know why I bother with this site, you drag it down to some vague blend of libercontrarian word-exercises that I don’t know why anyone bothers reading it much less arguing with it. Reading this entire thread, and the way you keep blathering about irrelevant asides, seem pleased at the idea that death is inevitable when the subject is health care, ignore and talk over the very good points commenters make.. Just blather, poorly written and just there to hear yourself talk. I tried, you just seem to come from some attitudinal place, with nothing solid behind it and zero charisma that’s a chore to read. Buy yourself a real name when you get a chance, or at least a capital letter.
• The leading causes of infant mortality were congenital anomalies, disorders related to immaturity (short gestation and unspecified low birthweight), SIDS, and maternal complications. (2002)
• Mortality rate for infants of non-Hispanic white mothers — 5.8 (2002)
• Mortality rate for infants of non-Hispanic black mothers — 13.9 (2002) [The cause for the high rate among black mothers, even those with good health care, is unknown. Some argue that being a black woman in the U.S. is more stressful, regardless of social/economic status, than for women in general.]
• Mortality rate for infants of Hispanic mothers — 5.6 (2002)
• Mortality rate for infants of American Indians and Alaska Native mothers — 8.6 (2002)
• Mortality rate for infants of Asian/ Pacific Islander mothers — 4.8 (2002)
• 83.9 percent of mothers began prenatal care within the first trimester of pregnancy (non-Hispanic black mothers — 76.5, Hispanic mothers — 77.4, non-Hispanic white mothers — 88.9, mothers 15 to 19 years of age — 71.0) (2004)
• Low birthweight babies (less than 5 pounds, 8 ounces) — 8.1 percent ) (2004)
• Smoking during pregnancy — 10.2 percent (2004)
• Low birthweight births to smokers — 12.4 percent, nonsmokers — 7.7 (2003)
• Conditions and behavior that can result in low birthweight babies: smoking, drug and alcohol abuse, inadequate weight gain during pregnancy and repeat pregnancy in six months or less.
• Babies born to mothers who received no prenatal care are three times more likely to be born at low birth weight, and five times more likely to die, than those whose mothers received prenatal care.
• Infants born to teenage mothers are at higher risk of being born low birthweight babies and have a higher mortality rate.
Preventing Infant Mortality
Doctors left a premature baby to die because he was born two days too early, his devastated mother claimed yesterday.
Sarah Capewell begged them to save her tiny son, who was born just 21 weeks and five days into her pregnancy – almost four months early.
They ignored her pleas and allegedly told her they were following national guidelines that babies born before 22 weeks should not be given medical treatment.
[…]
‘Doctors told me it was against the rules to save my premature baby’
Rosemary Munkenbeck says her father Eric Troake, who entered hospital after suffering a stroke, had fluid and drugs withdrawn and she claims doctors wanted to put him on morphine until he passed away under a scheme for dying patients called the Liverpool Care Pathway (LCP).
Mrs Munkenbeck, 56, from Bracknell, said her father, who previously said he wanted to live until he was 100, has now said he wants to die after being deprived of fluids for five days.
[…]
Daughter claims father wrongly placed on controversial NHS end of life scheme
PARENTS are being threatened with having their children taken into care after questioning doctors’ diagnoses or objecting to their medical care.
John Hemming, a Liberal Democrat MP, who campaigns to stop injustices in the family court, said: “Very often care proceedings are used as retaliation by local authorities against ‘uppity’ people who question the system.”
[…]
Question a doctor and lose your child
CharlesWT, though I’ve noticed Americans accustomed to Fox News standards of reporting seem not to notice or care, the Daily Mail is not a reliable source. For anything.
You can set the first story aside: there may be some frail thread of reality somewhere in it, but only enough to keep them from being successfully sued. If you check, you can find that the third story, about a 12-year-old girl hospitalised, is also primarily a Daily Mail story about the evils of the HPV vaccine and bad mean social workers taking children away from loving parents.
Ironically, everyone’s always ready to accuse social workers of acting too fast to take children away from their loving parents, until a child dies, at which point the social workers suddenly become neglectful for not taking children away from their abusive parents sooner. Local councils, the employers of social workers, are bound by strict rules of confidentiality not to talk about their clients: their clients have no such restriction in badmouthing the social work department.
No doubt social work departments make mistakes. In general, however, the spectre of the evil social worker taking a child from their parents because the parents have failed to wash the child’s hair or “talked back” to a doctor, is usually the result of an angry parent talking to the media and slightly failing to mention the multitude of other issues that the social worker also had: the really bad decisions social workers make hit the headlines when they failed to take action in time.
The middle story, the one you sourced to the Telegraph, is actually worth discussing. It’s still part of the conservative media’s anti-NHS series, but the Telegraph is actually a reputable paper with standards, albeit a clear political bias.
You should note, however, that the NHS sees one million patients every three days: it puts the claims by conservative media sources that there are one million people in the UK dissatisfied with the treatment they have received from the NHS in the past year, into some perspective.
Still, while the Daily Mail and The Times dig up smear/scare stories, the Telegraph is a proper news source: I don’t doubt that the daughter interviewed is convinced that her father isn’t dying.
And she may be right: doctors are not infalliable. But then neither are daughters. I don’t know: I know I wouldn’t want to believe my dad was dying no matter how many doctors told me he was.
But insofar as the story is part of the conservative campaign to present the Liverpool Care Pathway for the Dying Patient as “NHS death panel” care: this is nonsense.
Jesurgislac, thanks for the perspective.
You all should really read this: http://www.regressiveantidote.net/Articles/Obama_Tries_On_The_Uniform.html
Charles, I think it is genuinely worth warning foreigners that the Daily Mail, though it undoubtedly serves right-wing Americans up with the brew they want to drink, is really not a reliable source for news. Of course there will sometimes be stories on its site that are actually factual – but if so, they’ll be carried by some other paper as well. In essence, the Daily Mail exists to provide white right-wing Brits with a good solid dish of hate and rancour every day.
If you want to try and bolster your ideological convictions that the NHS is bad news, it’s much safer to stick to the Telegraph. The stories there may be less flashy, but they’re unlikely to serve you up with outright nonsense.
But the spectacle of Americans trying to convince themselves that the grapes are sour by feeding on negative stories about the NHS from British conservative newspapers, is not a pretty one.
Jes, I don’t have any ideological stake in whether the NHS is bad news or not. It would be OK with me to learn that the NHS worked just fine and Brits were quite happy with it.
I just don’t think an endeavor can magically overcome the shortcomings of any human endeavor just because it is administered by government instead of private enterprise, free or otherwise. My own preference is for a much as possible to be left to private enterprise and the marketplace while government acts as referee and takes care of those who fall through the cracks. I don’t want the government trying to spackle all the cracks with a million laws, rules and regulations. And I especially don’t want the government being a player in the game. After all, would you want to sit in on a poker game where one of the players made all the rules, was the sole judge of whether the other players were following the rules and had the only gun?
Charles, you begin by claiming you don’t have any ideological stake in whether or not the NHS works better than the private enterprise system – presumably, then, you cited those news stories just randomly and pointlessly.
But in paragraph 2, you go on to outline your ideology that healthcare ought to be profitable and that people ought not to be allowed to run national healthcare services as a collective act of goodwill mutually paid for*, because your ideology prohibits your seeing that as a good thing.
So why claim you don’t have an ideological stake in believing the NHS is bad news, and then go on to explain your ideology in such detail? I mean, I could believe you had just been surfing randomly and decided to troll the discussion with a bunch of pointless links – but not when you explain that you did, in fact, have an ideological purpose for linking to those stories, and an ideological stake in believing that the NHS doesn’t work.
*Nye Bevan’s description of the NHS in 1952 (In Place of Fear). He goes on to say “‘The old system pays me better, so don’t interfere.’ Who would dare to put it so crudely?” and the answer is – any right-wing American dares to put it so crudely, confident that Americans hold profit sacred above human life.
Jes, you sure are able to read a great deal into what people say and don’t say. No doubt, if I could read between the lines so well, I would get a great deal more out of my web surfing.
You have been vehemently persistent in you condemnations of American health care while, on occasion, touting NHS. I threw in the links to indicate that at least a few Brits are not entirely happy with NHS. Though it’s no skin off my nose whether NHS works or not, it wouldn’t make me happy to see it not work since that is what you have and I don’t wish ill on any of you.
I think I indicated a preference more than an ideology. And said nothing about profit or being profitable. After all, private non-profits can do well while doing good while not have the need to make a profit hanging over their heads.
I didn’t say whether anyone should be allowed to do something or not. If that’s what the voters want, so be it. It’s just my opinion that it’s not going to work as well as so many people seem to think it will.
Like a lot of huge, unwieldy enterprises, NHS probably works well for most of the people most of the time with the rest being vary degrees of not so good. Are there other approaches that would work better? Probably. Even if they were known doesn’t mean you can get from here to there politically.
My ideology, such as it is, is that people should be given the greatest amount of freedom possible within the rule of law.
If the majority of the players in the game collectively nominated one player to set and enforce the rules (and hold the gun), with the caveat that they’d periodically get to renew or recall that mandate… why should said players object overmuch?
More to the point, this is a truly awful analogy, albeit to my eye a telling one. The only thing this illuminates is the outlook of insurance companies vis à vis a government “player”. It is utterly useless to elucidate the relationship between government-run health insurance (or care) with citizens. The care or insurance providers do not have the same goals as the consumers, nor do they “win” in the same way. If you truly must have a poker analogy, I would argue it make more sense to cast the providers as dealers operating a number of tables in a casino where consumers could chose to play. At that point the question becomes whether it’s preferable to have private parties dealing for a cut of the pot, or a house dealer whose wage is paid by the host casino (which, admittedly, may be charging an entrance fee to set foot on the floor) in a manner not perforce tied to the pot. The analogy isn’t all that compelling or illuminating though. Better to abandon it.
And its principle flaw is its dogged unwillingness to admit that freedom can be restricted by non-governmental entities, either singly or acting in collusion. But that’s hardly a novel observation.
Charles: I threw in the links to indicate that at least a few Brits are not entirely happy with NHS.
But, so what? About 2% annually of NHS patients have some serious complaints to make about NHS care. We have high standards: we complain if our healthcare system doesn’t meet them.
The US system is so appalling that it’s not merely a matter of 2% of the patients complaining about the care they received: it’s a significant majority declaring that the system should be abolished and replaced with something new. You’re trying to compare rotting, squishy apples with ripe oranges: some of the oranges may be less good to eat than others, but the only thing to do with that box of stinking apples is to throw it out.
After all, private non-profits can do well while doing good while not have the need to make a profit hanging over their heads.
But you can’t run a national healthcare service on private non-profits. It’s not possible.
I didn’t say whether anyone should be allowed to do something or not. If that’s what the voters want, so be it. It’s just my opinion that it’s not going to work as well as so many people seem to think it will.
But you are basing that opinion on ideological belief, not evidence. The evidence is in that any developed country with a government-supported national healthcare service – which is every single one, aside from the US – runs a cheaper, more effective healthcare service, and gets better results. Your ideological convictions are not evidence.
The NHS isn’t the world’s greatest healthcare system: not least because it was systemically starved of resources by a conservative government for nearly 20 years. It’s just much better than yours.
My ideology, such as it is, is that people should be given the greatest amount of freedom possible within the rule of law.
Except that you appear to be committed to the idea that it’s OK for private enterprise to restrict people’s freedom by making their access to healthcare a matter of profit. The NHS supports freedom – freedom to act, as well as freedom from fear. An entrepreneur in the UK needn’t worry about the market costs of healthcare as their opposite number in the US must.
Or, from another perspective: A clear part of Obama’s election platform was consistently been to promote reform of the US healthcare system away from your current model of unrestricted private enterprise.
Obama won by a clear majority.
A British politician who ran on a platform that promoted “reform” of the UK healthcare system away from the NHS to anything like the US model of private enterprise would lose. Even Margaret Thatcher, no fan of the NHS, accepted that.
That’s the difference. That’s why citing stories from people dissatisfied with NHS services is a silly way to argue, when in your own country what you have is not people complaining that they were dissatisfied with the standard of healthcare they got, but people dying because they couldn’t get access to healthcare.
Fun with blinders.
I’m sorry I’ve been gone for the weekend, and haven’t had a chance to read or respond to the various points. The highlights:
Jes and Jack (from way, way upthread): That ION study still does not support Jes’ figure, no matter how much invective you use.
Jack, you cite this passage from the IOM study for proof that the IOM numbers controlled for the concerns that I identified:
This obviously doesn’t mention any of the factors that I identified. Indeed, it only admits that the studies differed in some unknown respects and controlled for (unidentified, and probably different) “potentially confounding characteristics.” Moreover, the IOM does not explain how the admitted differences in the studies were reconciled. This does not answer my criticism of Jes’ number.
You next accuse me of being misleading because I pointed out that the IOM study in fact does mention a different study that does appear to control for my concerns, but the number isn’t what Jes claim. Ummm, ok. I don’t know how my acknowledging that Jes may be correct in general (even thought her numbers appear to be bunk) is being misleading, but so it goes.
And Jes continues her crusade to attempt to establish that I’m somehow in favor of killing children by keeping the current system, even though I’ve actually agreed with her that the current system is not working and needs to be changed.
Hilzoy makes the following comment, which Publius seconds:
Hilzoy and Publius: I thought I was pretty clear that I’m using definition (a), which is the definition of rationing that economists use. As I wrote (in point 1a of my original post): “1a. Be honest: Cost containment is simply another name for rationing (really, additional rationing, because rationing already occurs in the present system).”
But it doesn’t follow from this that all forms of rationing are equal and identical.
p.s. to Marc: I don’t post all that frequently, and you’re free to ignore me when I do.
Am I the only one who finds it somewhat disingenuous that you’re simultaneously throwing up your hands and declaring the details and methodologies of these studies unknowable while at the same time declaring that they don’t address any of the “concerns” you raise (spoiler: they do)?
Von: And Jes continues her crusade to attempt to establish that I’m somehow in favor of killing children by keeping the current system, even though I’ve actually agreed with her that the current system is not working and needs to be changed.
In favor of letting babies die – and of course, letting older people die of bedsores. At least get my invective right. I note that your present system has unpleasantly high death rate: you favor continuing the system. Which, given your claims long ago to be “pro-life”, is more than slightly ironic.
Whenever you’ve posted recently about US healthcare, Von, far from agreeing with me that what you need is a socialist national health service such as US veterans or the entire population of the UK enjoy, you’ve asserted that what the system needs is more and different profit-seeking private enterprise.
N.V.: Am I the only one who finds it somewhat disingenuous that you’re simultaneously throwing up your hands and declaring the details and methodologies of these studies unknowable while at the same time declaring that they don’t address any of the “concerns” you raise
But Von will never acknowledge that, because… well, he probably still likes to think of himself as a pro-lifer. And acknowledging the death rate inherent in following his ideology is exactly what pro-lifers won’t do.
Am I the only one who finds it somewhat disingenuous that you’re simultaneously throwing up your hands and declaring the details and methodologies of these studies unknowable while at the same time declaring that they don’t address any of the “concerns” you raise (spoiler: they do)?
NV, this is ridiculous. The Franks study (thanks for the link) does appear to adjust for some of the issues that I raise; the Sorlie study largely does not. Unsuprisingly, they come to different conclusions regarding the multiplier that accompanies a lack of health care. There’s also no indication how the IOM blended these studies, given their significant difference in methodology, or arrived at a 1.25 multiplier. And, in any event, the IOM study itself only purports to be an extrapoliations from these earlier studies, which in turn are derived from data from 1971-87 and 1982-1986 (respectively).
I realize that nuance is deadly to the committed partisan. I realize that any exploration of the nuance of these sorts of things is going to result in a passive aggressive “Am I the only one who finds it somewhat disingenuous …..”? But I stand by my point: The IOM study does not support the claim that 22,000 people are currenty perishing each year for lack of insurance.
Now, we could move on to what some would say is the more important point: That I agree with you and Jes that lack of insurance is correlated with (indeed, causes) additional deaths. And that I agree with you that the system needs to be changed. But that’d be boring, and would deprive your of your carefully cultivated sense of outrage.
Von, my point remains – not that I expect you to respond to that either: You do not agree with me that the system needs to be changed, because you are not proposing a change in the system of market forces ruling healthcare provision. You are in fact proposing that the current system should continue. Under any profit-driven system, some people will be denied healthcare because it is not profitable that they should receive it. And some of those people will die.
That you prefer to close your eyes and assert that you’re sure it’s not that many people who die, reminds me somewhat of the persistent claims by war supporters that they were sure that Iraqi casualties couldn’t be that high. It rests on a similiar nothingness – you’re sure, that’s all, and that’s enough for you to presume that academic studies must be wrong.
The House Democrats and Obama also agree that health care (and health insurance) remain privatized.
Crimes also committed by the Democrats and President Obama, apparently, since they, too, disagree with your view that health care should be government-run.
And it’s almost beside the point that I didn’t presume “that academic studies must be wrong”.* I pointed out that the study that you relied upon for your 22k figure was not very good. I didn’t challenge the underlying assumption: Indeed, looking at the IOM paper, I identified a study that supported your general proposition. And, indeed, I agree with your general proposition: lack of insurance kills.
One final note: I stated above that you were trolling, and asked you to please stop. It’s the above kind of fact-free claims (accompanied by considerable personal invective) that are a problem. We all choose to be here for the discussion …. there are other places to rant.
*By the way, the IOM study was not an “academic study.” It was a projection by an advocacy group based primarily on a very simplistic set of assumptions. True, for the complex part of the analysis (the multiplier), the IOM study relied upon two old academic studies, which it scarcely describe except to say that they had different methodologies. Based on the links NV has provided, it’s clear that those two older studies relied on very different assumptions — and it’s not clear how they were reconciled or if such a thing was even possible.
NV, this is ridiculous.
Indeed, it is.
I realize that nuance is deadly to the committed partisan.
…which is why my eyebrow hit my hairline upon reading your blanket claim that neither study cited by the IOM report adjusted for any of the factors you felt they should. Unsurprisingly, after 5 minutes of hunting down the studies, and perhaps another 5 to read the methodology summaries, I saw that both adjust for income at a minimum (Franks and Gold adjusts for a good deal more, including education). Which is fascinating, since you’d blithely asserted that they do no such thing – without reading them, you made the blanket assertion that they did not adjust for four factors that, per you, “probably have a much greater impact on health than [insurance]”.
Please deflate yourself slightly and cease lecturing me on my inability to grasp your careful “nuance”. It is, to use your formulation, ridiculous.
The Franks study (thanks for the link) does appear to adjust for some of the issues that I raise; the Sorlie study largely does not.
Franks and Gold directly addresses two of the four “issues” you raise, as well as 11 other OTA-identified factors affecting health. Sorlie et al adjusted for one of the four. But… why, exactly, should we accept your from-the-hip assertion based on no visible support that these four factors are crucial to any study and call results into question if not present?
Seriously, I’m disinclined to accept your rejection of these studies as being woefully inconclusive on the basis of your “they’re omitting factors that are probably even more significant than insurance status”… especially when I’ve no reason to suspect the omitted factors are independent of factors that are adjusted for.
Unsuprisingly, they come to different conclusions regarding the multiplier that accompanies a lack of health care.
Yes… my reading puts one at 1.25, and the other at a range of 1.2-1.3. Woefully disparate.
There’s also no indication how the IOM blended these studies, given their significant difference in methodology, or arrived at a 1.25 multiplier.
Gosh, yes, I’ve no idea how one could arrive at a single figure of 1.25 given two studies purporting to show either 1.25 or 1.2-1.3. The mind boggles.
And, in any event, the IOM study itself only purports to be an extrapoliations from these earlier studies, which in turn are derived from data from 1971-87 and 1982-1986 (respectively).
Actually… you seem to have missed a key point here, though you take it as a bludgeon to thrash Jes with in your next comment. The IOM paper is not a study – it’s a report. It’s derived from an earlier report (I think you might find appendix D particularly interesting), the background research for which is summarized in the Haas and Adler paper I linked upthread. The report is attempting to collate multiple studies and produce an accessible, non-brutally-technical summation thereof.
Now, we could move on to what some would say is the more important point: That I agree with you and Jes that lack of insurance is correlated with (indeed, causes) additional deaths. And that I agree with you that the system needs to be changed. But that’d be boring, and would deprive your of your carefully cultivated sense of outrage.
Ah, but therein lies the rub. I’m not personally overmuch invested in a figure of 18k or 22k excess deaths from lack of insurance. I have no sense of outrage in this regard to cultivate, carefully or otherwise. I do, however, have a hammered-in respect for adhering to proper citation and research methodologies. Your dismissal of these studies have utterly lacked rigor, which is painful to watch given that your objection to their conclusions is that they lacked rigor.
So. If you want to set these figures aside lightly, please give a reasonable justification for your assertion that they ignore independent factors with greater significance than those they do cite. Citations to academic studies to this effect would be nice. Avoiding vague appeals to ignorance in the face of freely available source material would also be nice. As would be over-broad unnuanced blanket claims (see, e.g., the last sentence of your 13:03 comment).
If absolutely nothing else, please read source material before lecturing others about what it does or does not say. Failure to do so does rather bad things to your credibility.
von: “The House Democrats and Obama also agree that health care (and health insurance) remain privatized.”
Well, only about 15 or 16 house dems ‘agree’ — Obama and the rest ‘reluctently’ are backing away from it (except, possibly, as a cosmetic face-saving ‘failure fallback’)which is exactly what I predicted was going to happen when all the blah blah discussions about the universal govt option was being touted here as an absolute necessity that O’Blah would not give up…
From Associated Press:
WASHINGTON – The White House and members of Congress on Sunday played down an immediate role for a government health insurance option and turned attention to regulating insurers, with the goal of lowering costs and ensuring coverage regardless of medical condition.
Hilzoy and Publius: I thought I was pretty clear that I’m using definition (a), which is the definition of rationing that economists use.
That definition is ‘price rationing’- the process whereby prices allocate finite resources in a market.
If that’s the definition that you were using, can you explain what you mean by additional rationing? Can you explain how cost containment is simply another name for rationing when “rationing” is the case for every market that uses prices to allocate goods?
I don’t think this makes any sense, but perhaps you can explain.
Ah, but therein lies the rub. I’m not personally overmuch invested in a figure of 18k or 22k excess deaths from lack of insurance. I have no sense of outrage in this regard to cultivate, carefully or otherwise. I do, however, have a hammered-in respect for adhering to proper citation and research methodologies. Your dismissal of these studies have utterly lacked rigor, which is painful to watch given that your objection to their conclusions is that they lacked rigor.
….
If absolutely nothing else, please read source material before lecturing others about what it does or does not say. Failure to do so does rather bad things to your credibility.
This criticism is very odd, NV. I read the “source material” — the IOM paper — and noted that it didn’t account for several issues. You then dug up two of the studies that were the basis for one of the IOM paper’s assumptions (the ratio). In addition to confirming that these studies indeed use different methodologies, as the IOM paper admitted, your review confirmed that neither study accounted for all of the issues that I raised, and that one study accounted for only one of the issues that I raised. This validates my skepticism of the figures offered by IOM.
Any time an advocacy group provides a projection and doesn’t show their work, I think that skepticism is in order. When later review confirms that the skeptics have a point, the credibility of the projection — not the skeptic — takes a hit. That’s how it works when we haven’t already landed on our preferred outcomes, at least.
Incidentally, I think that you may be misreading the 1.2-1.3 figure of the second paper. (I’ll not touch on the other issues you raise.)
Jay Jerome, I understood Jes to be arguing for a solely public system, with no role for private insurance. The vast majority of Dems oppose that view.
That definition is ‘price rationing’- the process whereby prices allocate finite resources in a market.
If that’s the definition that you were using, can you explain what you mean by additional rationing? Can you explain how cost containment is simply another name for rationing when “rationing” is the case for every market that uses prices to allocate goods?
Carleton, price rationing is rationing. We allocate goods and services (who gets what) based on their price. If you don’t have the money, you don’t get the good or service. Period.
I may have been unintentionally misleading when I said that I’m using “rationing” as economists do, because rationing by price is just another form of rationing. Price rationing and nonprice rationing are not different in kind, in the sense that, under both, someone who wants a good still doesn’t get the good. There are different, however, in how the rationing occurs.
I may have been unintentionally misleading when I said that I’m using “rationing” as economists do, because rationing by price is just another form of rationing. Price rationing and nonprice rationing are not different in kind, in the sense that, under both, someone who wants a good still doesn’t get the good. There are different, however, in how the rationing occurs.
You are still not explaining how there can be “more” price rationing or how it’s noteworthy that cost containment equates to more of it- price rationing happens, some people get goods, others dont. “More” rationing sounds like the normal definition- smaller externally-enforced rations. I don’t see how there is “more” price rationing, since there is no entity ‘enforcing’ quotas or other measures that might be quantitatively increased.
Nor do I see why you’d bring this up in the first place- is it news to *anyone* that the healthcare supply is not infinite, and that it uses prices to distribute goods? How have current proposals changed this in a noteworthy way?
So while I can easily make sense of your statements using the normal definition of rationing, I can’t with the definition from economics that you’re using. Please, try again for me, in smaller words- what is “more” price rationing? Why did you point out the seemingly obvious fact that cost containment will be a part of a price rationing system, allocating scare goods via price signals?
This criticism is very odd, NV.
Actually, it’s not. I will try once more to outline why your comments merited criticism.
Jes linked the 2008 IOM report. The report included an excess mortality figure derived from two prior studies, both of which were clearly cited and included in its list of references.
You responded that the report’s conclusions were “for crap” because it “fails to account for […] income, diet, education, and location”, which you asserted without offering the least justification as “probably [having] a much greater impact on health than the presence (or lack) of insurance”.
You then strengthened your stance by stating “As you’ll see, my statement is correct: The IOM study controls for age but not for the factors that I listed.”
A bit latter you re-emphasize your position: “[A passage from the 2008 IOM report] obviously doesn’t mention any of the factors that I identified. Indeed, it only admits that the studies differed in some unknown respects and controlled for (unidentified, and probably different) ‘potentially confounding characteristics.'”
Here’s the problem: you very boldly claimed that the studies the IOM report based its figure on did not control for income, diet, education, and location. This is beyond dispute. You further asserted that the studies “differed in some unknown respects and controlled for (unidentified, and probably different)” factors. This is beyond dispute.
To sum, you made an unequivocal claim regarding the studies’ contents while simultaneously suggesting there was no way of knowing what those contents were.
That alone, devoid of context, would be appalling. However, as I laid hands on the clearly-cited source studies in all of five minutes of looking and confirmed that your unequivocal claim was false, it goes beyond merely appalling.
To re-sum, you made a false claim about papers you did not read, though you easily could have. Even reading the abstracts of the papers would have shown your claim to be in error. However, you chose not to do so, and instead asserted without basis that the studies controlled for none of the four factors you arbitrarily identified, while implying there was no way of knowing what they did control for.
Let me repeat that for a third time to beat the intellectual dishonesty of what you did well and good into the ground: you claimed to definitively know what the studies did not control for while simultaneously suggesting we could not know what they did control for. That both parts of your claim were wrong was merely a lagniappe; even had they been spot-on, you would have been disingenuous to make such a statement.
Does that make my criticism seem less odd? Or am I merely a determined partisan who can’t help but fail to grasp the nuance inherent in making false claims regarding the content of source materials that one hasn’t read (but easily could have) while simultaneously cautioning one’s interlocutors against making any assumptions about what said source materials contain?
Any time an advocacy group provides a projection and doesn’t show their work, I think that skepticism is in order.
This doesn’t apply, Von. They did show their work. They meticulously cited the studies upon which their calculations were based, and said studies are readily available online. Your skepticism cannot claim refuge in this.
When later review confirms that the skeptics have a point, the credibility of the projection — not the skeptic — takes a hit.
Three points: if the skeptic chose to make claims regarding the projection’s nature that could have been easily confirmed or denied by reading the clearly-cited source studies, and those claims turn out to be false, it’s not the projection that loses credibility. The skeptic has (to be charitable) jumped to conclusions in order to land on their preferred outcome. This does nothing to enhance their credibility. To the contrary, it shows them to be willing to present as fact assertions they have not made the least effort to confirm – behavior I would hesitate to describe as “credible”.
Second, your formulation seems to imply that the projection crafters hid their sources, you called them out on something they were hiding, and my five minutes on Google confirmed that they were indeed hiding what you claimed they were. In that case, your little story would indeed hurt the credibility of the authors, not the skeptic. But… this doesn’t even begin to apply here. The report isn’t making any claims regarding your concerns, so there is no hidden nefarious truth for your skeptic’s intuition to ferret out. I could assert that the studies fail to control for exposure to asbestos in considering excess mortality; the act of confirming that, indeed, they did not would do nothing to hurt their credibility unless they had claimed they had. The damage their credibility could take in that hypothetical exchange would rise or fall strictly on the validity of assertion that they had failed to control for a significant factor.
Which leads us to the third and final point – and if you address anything in this excessively verbose comment, please make it this. That some of the skeptic’s concerns have not been addressed does not in and of itself confirm they have a point, if the skeptic has done nothing to demonstrate the validity of their concerns. It is your responsibility to show that failing to address your concerns is significant. To do so, it falls upon you to offer more justification than a weaselly assertion (for what purpose beyond weaseling could the modifier “probably” serve in that context?) that these four factors are more important in considering excess mortality than insurance status. If you shirk this task, we have no reason to accept your arbitrary standard for rejecting the studies’ findings… and our doing so in no way marks us as determined partisans trying fervently to land on our preferred outcome in order to maintain our carefully cultivated sense of outrage.
You’ve established little in the way of basis for rejecting the study beyond your stubborn (and as-yet unfounded) assertion that the source studies ignore “confounding factors” more significant to projecting excess mortality than the factors they did control for. Oh, and your vague, unexplained assertions that the methodologies must be so different that the (not-horribly-disparate) conclusions of the two studies are irreconcilable. Your behavior prior to actually reading the studies suggests that you’ll do what it takes to land on your preferred outcome regarding them, but you’ve not given us more than vague, unexplained and uncorroborated hand waving as to why we should join you in making that jump. That we refuse to make what amounts to a leap of faith hardly gives you justification to slyly cast aspersions on our intellectual honesty.
And once again, von manages to obfuscate his was off the field.
I mean, I don’t expect people to sit around and argue with me forever, but von, you manage to never address a single substantive point over and over.
And you do this serially: post something indefensible, go a couple of rounds of posting non-responsive replies, and then front page some more nonsense.
Quick recap:
von-Obama’s plan will increase rationing
chorus-there is no rationing now or in Obama’s plan
von-I meant, using this technical definition
me-but, how can there be “more” price rationing? And why bother posting to tell us that Obama’s plan distributes scare goods via price signals?
von-let me explain- I am using a technical definition
me-yes, but how does that technical definition make sense in this context?
von-I apologize for perhaps confusing people with my use of a technical definition
me-Yes, but the technical definition doesn’t make sense in that sentence, does it?
von exits stage right
So I have to say it- you were never using the technical definition. There is no way to make that fit with statements such as Call a tax on “gold-plated” health insurance benefits “soft rationing.” You are not talking about prices allocating scare goods- you are clearly using “soft” to distinguish from the “hard” rationing where the government sets allocations. That is, the common definition that you disavowed earlier.
Either that, or you have invented your own definition of “rationing”- something that involves prices, but also something that there is more of in Obama’s plan. Something, perhaps, like the novel “soft rationing” you describe. Anyway, anything to get the word “rationing” into the conversation.
What Carleton Wu and Nombrilisme Vide said.
*grins*
Of course, there’s a reason why Von’s posts on healthcare are so intellectually incoherent, and why he never responds on substantive points.
He is ideologically opposed, as a conservative, to any kind of major reform away from profit-driven healthcare. The notion of providing healthcare to all, more cheaply and more effectively, by switching over to tax-funded healthcare – either the all-in socialism of VA or NHS, or something more like the French program – isn’t something a right-winger can ideologically accept, so Von rejects it.
But he’s smart enough to know that the reform his ideology requires him to oppose would save lives: would make millions of Americans healthier, wealthier, and happier. He can’t defend his ideology except by intellectual incoherency and insults. We will not see anything better from Von than we’ve seen already, because he can’t.
(I admit insulting me is fair game: I’m insulting him. Carleton Wu and Nombrilisme Vide have been much politer, and neither one of them has got a responsive answer.)
Sept. 17, 2009 — In a new study, researchers estimate that 45,000 deaths per year in the U.S. are associated with not having health insurance.
That estimate appears in the advance online edition of the American Journal of Public Health.
Data came from about 9,000 people aged 17 to 64 who took part in a government health survey between 1988 and 1994. They were followed through 2000.
During those years, about 3% of the participants died. People without any health insurance were 40% more likely than people with health insurance to die during the years studied, regardless of factors such as age, gender, race, income, education, health status, BMI ( body mass index), exercise, smoking, and alcohol use.
The researchers then applied that finding to U.S. census data. “We calculated approximately 44,789 deaths among working-age Americans in 2005 associated with the lack of insurance,” write the researchers, who included Andrew Wilper, MD, MPH.
[…]
No Health Insurance, Higher Death Risk: Study: 45,000 U.S. Deaths Per Year May Be Linked to Lack of Health Insurance
That controlled for age, gender, race, income, education, health status, BMI, exercise, smoking, and alcohol use. But no diet or location, so I suppose we’ll just have to conclude it’s a load of hokum.