by Andrew
[In which I throw out ideas guaranteed to bring down the wrath of the ObWi comment horde down upon me.]
Health care is a growing problem in the United States. Ironically, the problem is a result of health care’s great successes of the 20th century. Life expectancy and quality of life shot upwards in the 20th century as many common illnesses and other medical problems were either defeated or made at least controllable. But, since we’ve all got to die of something, that meant people started falling prey to other diseases attributable to longer life. Medicine has developed great ways to address many of these problems, but the cures are not cheap and the combination of increased life expectancy and a massive growth in the population of the United States has combined to send health care costs through the roof. Massive use of health insurance has helped to push the costs of health care up, as the costs are hidden behind ‘insurance’ plans. Conversely, health care costs are highly inelastic to begin with, as anyone with a serious illness will not care about cost if the alternative is death. All this leaves us with many upward pressures on medical costs with little corresponding downward pressure. In light of this, the demand for universal health care will continue to grow as people have greater difficulty getting the care they want or need. Indeed, I fully expect to see government-provided health care for everyone before I die. Still, I remain unconvinced universal coverage is a wise goal.
There is a limited supply of medicine available in the United States. That supply is sufficiently smaller than the available demand that the price of medicine is greater than what a lot of people can afford. So, the argument goes, we have the government take over the health care system and the problem is solved. Except that isn’t quite so. Government taking over the system may change who gets access to health care, but it won’t address the underlying problem that demand still outstrips supply. Indeed, demand will go up if we turn health care over to the government, since people will then see it as a basic right. And when demand goes up, so do prices.
But the government will keep prices down by negotiating directly with hospitals and drug companies and the like, so we don’t have to worry about increased demand causing upward pressure on prices. That may be the case in terms of the dollar amounts expended to provide a particular drug or service, but prices are found beyond the sticker. If the government forces drug companies to sell their products for prices too low to cover the costs of research, the drug pipelines will dry up. If the government forces doctors to perform treatment for less than the cost of that treatment, the doctors will go into other lines of work or will simply refuse to treat patients who are covered by the government’s health care program. We see this already with doctors who are refusing to serve Medicare patients, because what the government pays for a Medicare procedure doesn’t cover their costs.
Ah, but the government can force the doctors to work for the lower prices. After all, the government has a monopoly on the use of force, so we’ll just make it a law that everyone has to use the government program, so people won’t be able to go outside it. Well, Canada tried that, and their court said it was a no-go. Further, even assuming the government will be able to enforce that kind of law (what’s to stop people from slipping doctors cash for better treatment?), then we’re back to watching the available pool of doctors drying up. Why would you do a job that you were losing money on, after all? And how many people are comfortable with using force against doctors to prevent them from using their skills to make money?
Well, maybe we can’t fix that, but we’ll fix the drug problem by pouring more money into research, right? That may work for you, but for me the idea that we’ll fix a problem caused by government interference by…adding more government interference, well, that doesn’t seem like the wisest course of action. Government research dollars are spent just like most government dollars: on areas where Congress thinks it will help get them reelected. There is no mechanism to make sure that government research is effective or efficient, because the only feedback mechanism is electoral. So big-name diseases get funding while less-well known problems are ignored or minimized. Drug companies have their own problems, I’m aware, as they’re unlikely to research solutions to rare problems because they won’t get their money back, but they do have feedback mechanisms that drive them to try to find solutions to big problems, as opposed to merely popular ones. The government’s success at finding solutions to any problem is not nearly good enough for me to want to rely on government dollars to be the primary source of the many new drugs that will be required to continue our progress in finding better solutions to health problems.
Worst of all, if the government does put a universal health care plan in place, we’ll never go back. If universal health care has problems, Congress won’t kill it, they’ll just ‘fix’ it, doubtless with the same degree of effectiveness they’ve had in addressing the looming entitlements crisis or in crafting Medicare’s Plan D. Once we cross the Rubicon of universal health care, it won’t matter if it works, we’ll never get rid of it. Given that fact, and government’s past record of stellar accomplishment, I’m very reluctant to allow the government to cross that Rubicon.
Good God, Andrew, you sound like a Conservative in 1948 explaining that the NHS just won’t work.
Did you look at any universal health care systems before concluding that they just won’t work for the US, though they do fine elsewhere? Or have you just swallowed whole the notion that they don’t work anywhere, without bothering to do any research beyond the propaganda?
I was assuming you actually had some facts you were basing your ideas on, but it doesn’t look as if you do.
Jes is right; it’s not like you’re Hegel, sitting in your study and dialectically proving that the Real is the Rational.
This too struck me: “If the government forces drug companies to sell their products for prices too low to cover the costs of research, the drug pipelines will dry up.”
And if the government replaces doctors with ponies, health care will deteriorate dramatically. But who said anything about that?
Aren’t the drugcos actually making $$$ hand over fist? Well in excess of research costs?
And the bit about gov’t-funded research being “more interference” is a little silly, as well as premised on the assumption that gov’t involvement is axiomatically bad. I know you think that, but it’s not something you can expect to be taken for granted.
Andrew, instead of a Canadian or British solution, what about more of a German solution: mandate that employers carry specific minimum in coverage (with tax credits); state subsidized coverage for unemployed (again with minimum standards); ability to buy supplemental insurance. Maybe one or two big insurance companies — make it five to get competition on service — and you’ll be pooling risk across the population.
What do the Dutch do? Japanese?
FWIW, this was the kind of thing I was expecting Andrew to try to refute.
This is a complicated topic, and I won’t even try to do it justice. However, just to start things off: one reason why I favor some system that guarantees universal coverage (whether a program of universal health insurance or of universal health care) is that health care really does not work like a normal market at all. Your post, I think, assumes that it does. For instance:
“Indeed, demand will go up if we turn health care over to the government, since people will then see it as a basic right. And when demand goes up, so do prices.” — This assumes (I think) that there are no other effects associated with having the government take over either health insurance or health care that would tend to bring prices down. I don’t think this assumption is right.
For starters, any program of (universal) government-provided health insurance would eliminate a lot of administrative costs off the bat — all the different forms for different insurance companies, checking to see who’s covered and for what, etc. In many markets, determining eligibility isn’t a big burden — if you can pay at the supermarket, fine; if not, not. In this market, it is, and eliminating it would eliminating a large chunk of the costs of delivering health care, without requiring compromises in health care or in the fees paid to doctors and hospitals.
Moreover, insurance works by pooling risk, and at present, insurers have a huge incentive to try to include as many healthy people as possible, while excluding those with huge medical costs. The effort to do this directly costs money, but also, to the extent that insurance companies are successful, they have an incentive not to invest in the kinds of prevention that would make economic sense if they knew that this person was someone they’d have to pay for eventually, but don’t make sense if they think they can offload the person before the serious costs kick in.
Universal health insurance, by providing one big pool from which no citizen could be excluded, would both eliminate all the energy that now goes into trying to shuck off the people with very high costs, and also eliminate the possibility of lowering costs by ditching the sick, as opposed to preventing them from having expensive complications later. This would lower costs for the nation as a whole.
Moreover, since we are unwilling to let people die on the streets outside a hospital (as opposed to letting them die of unmanaged conditions), we require hospitals to provide emergency care. This has all sorts of adverse effects — the use of emergency rooms for what ought to be clinic visits, incentives to site hospitals away from places like inner cities, where a lot of these emergencies might appear, etc. — but it’s also care that we all pay for indirectly, through higher costs for hospitals. Moreover, it’s a very expensive way to get medical care to people — under this system, you have to wait until your condition is “an emergency” before getting help, when it could have been managed much less expensively (and in a way that the patient would greatly prefer — everyone would rather just take blood pressure medication than actually have a heart attack, for instance) in ways that are, unlike emergency care, not available for free.
The US government now pays more, per capita, for health care than the UK, despite the fact that the UK covers all its citizens while we do not. It’s worth asking why. I think that while I am in general pro-markets, there are specific cases in which, for specific reasons, they don’t work well. The army is one: who wants a bunch of private armies running around, bidding on contracts? or armies that are primarily motivated by profits? Health care is another: between the fact that it does not involve transactions between buyers and sellers, but between patient, doctor, insurance company, and (often) employer, all of whom have quite different sets of interests, and the fact that it’s impossible to comparison-shop since there is very little publicly available information on pricing, it does not work the way a normal market would. Moreover, for the reasons I’ve sketched, there are costs directly associated with having a market-oriented system (e.g., the costs of having many manipulable risk pools, as opposed to one big non-manipulable one). Eliminating these costs would allow us to avoid your “demand up, prices up as well” conclusion.
I see you are taking on Jes in the other thread. It may feel like a horde, but it isn’t really :^)
Your arguments center around the notion of a free market, but given that the US is paying a price globally for not having universal care, this seems a bit problematic. frex
Other countries (like here in Japan), by adopting universal care, make themselves more competitive because the health of their population is more robust. Here, there is a national health insurance, which is based upon income of the previous year, and a set of private insurers. Employers are mandated to get their employees into a health plan.
Other countries with centralized health care can also better deal with the potential of pandemics such as bird flu
Furthermore, health is one of those fields where an once of prevention does equal a pound of cure. At my university, written into our job contract, we have to get a physical checkup every year and it is paid for by the university, and the government has a large bus set up that drives to various employment places to do checkups, with the university paying the set fee (rather small, I think, because our health plan covers a set percentage of our health costs). I, because of an approved committment outside of the university, was not there during the 2 days for checkups. Last week, I got a note in my mailbox reminding me that I hadn’t had my yearly checkup and telling me that the university would pay for whatever the cost was if I submitted the receipts, or if I went to the government health center, the bill would be sent to the uni. Thus, the government can hook into early prevention, which lowers health costs all around and contributes the a healthier populace which is what I thought governments were supposed to be working towards.
see you are taking on Jes in the other thread. It may feel like a horde, but it isn’t really :^)
I am vast, I contain multitudes! 😉 And I’ll shut up now.
Andrew: here’s a good article on the VA system. It’s particularly useful in this context because in trying to figure out why the VA system consistently beats private systems in quality tests, it concludes that a lot of the reasons have to do with the different financial incentives that the VA and private systems have,
Andrew, the US government already invests substantially in drug research, so it’s not like that would be anything new. And your prediction that “big-name diseases get funding while less-well known problems are ignored or minimized” is pretty much the way the system works now: There’s a lot more money poured into impotence–er, erectile dysfunction–than diseases such as malaria that affect the Third World because Americans can pay a hell of a lot more than Indonesian villagers. Or diseases that affect so few people there’s no real profit in marketing to them (though I believe the government has an “orphan drug” policy for dealing with that). Government follows votes, but industry follows money, and I can’t see that government-backed insurance would make things worse (just as predictions of people waiting years for treatment in a government-run system wouldn’t differ that much from HMO’s cost-cutting tactics).
There’s also a kind of peculiar assumption that consumer demand for health care will go up in a simple relationship to decreased cost. There are a bunch of problems with this.
First, healthy people have a very limited appetite for health care. I have good health insurance through my job, and I still go to the doctor very rarely. My demand for health care is very price-insensitive: I don’t want any health care if I’m feeling all right, and I’ll pay almost anything I’ve got if I’m feeling ill. (Now, I do get price-sensitive at the margin of ‘anything I’ve got’ — all I’m saying is that my appetite for health care doesn’t have nearly as direct a relationship to its price as my appetite for theatre tickets.)
Second, preventive care is going to have some effect on reducing future demand. A country with universal vaccination is going to spend less on treating measles than one without; a country with universal maintenance care for diabetics is going to spend less on amputations and dialysis than one without. (This is even ignoring the human profit in allowing more diabetics to retain their feet, etc.)
I’m not claiming to have shown here that UHC won’t increase the total demand for health care, but I am claiming that you can’t assume that it will. The confounding factors are significant enough that you have to look at the results empirically, rather than relying on Econ 101 ‘price down=demand up’. In the real world, ceteris rarely are paribus.
hilzoy,
I am not anything approaching a health care wonk; it’s just not an area that particularly interests me. (Something the commentary thus far has done much to encourage.) I can see that there could be some reduction in costs via risk-pooling and the availability of preventive care as opposed to ER care. However, I’m curious if anyone has done any studies to see if that will counterbalance the increased demand for preventive services. I may well be wrong, but I don’t believe that primary care physicians are going short of patients right now. That being the case, those we have are now going to be asked to take on more patients, which will probably mean rather extensive waiting lists to see one’s doctor. That can be resolved in the longer term by increasing the number of primary care physicians we have, but doing that requires that we pay primary care physicians more, therefore encouraging more people to go into primary care. Further, assuming Jes’s 18,000/year figure is accurate, that’s another 18k a year who need to see the doctor…those numbers add up over time. And what about illegal immigrants? That’s a lot more people who need to see doctors, who will now have the means under universal care.
So while I can see admin costs dropping and ER use going down, it seems to me that there will still be increased demand. I’m not sure if the reduced admin costs will cover that.
It’s a given that the US will never adopt a system that attempts to eliminate the notion of private insurance. You’ll always be able to go above and beyond the system if you want to.
So while I can see admin costs dropping and ER use going down, it seems to me that there will still be increased demand. I’m not sure if the reduced admin costs will cover that.
That neglects the contention that increased delivery of preventive services will in fact prevent conditions that would cost much, much more to treat later.
At worst, you get a market tilt away from specialists towards primary care, which in an era of factories closing down & moving to Mexico, isn’t breaking my heart for the medical community.
LB,
I am trying to get all the way to Econ 102, so have a little patience with me. 😉
As I noted above, I think there are some reasons to believe demand will go up beyond the basic supply/demand curve.
Also, let’s remember that we all die of something. And someone who drops dead of a heart attack produces a lot less stress on the medical system than someone who takes various BP meds for decades and then gets cancer of Alzheimer’s (sp?) disease. (Please note this is not an argument for encouraging people to die cheaply, just a point in favor of increased demand.) While preventive medicine can stave off the point at which this occurs, at some point we all get damn pricey.
Andrew: there will certainly be increased demand for primary care, and probably this will outweigh the decreased demand for emergency rooms. (The latter a marvelous development, since we now have huge waiting lines, and some patients get stashed in corners for days waiting for a bed.) But my general point was: there are huge cost savings from administration. Moreover, it’s not as though doctors don’t spend their time on administration, negotiating with insurance plans for coverage for their patients, etc., etc. So this would free up doctors’ time as well.
It’s worth reading a little about this, just because it’s a very interesting case study of an area in which there’s a serious case to be made that markets do not provide the best solution, a case that in no way relies on assumptions about magic etc., and thus it’s fun even if your primary interest is just in refining your views about when and why markets work best.
hil,
There are so many things I would love to read about, it’s physically impossible for me to hit them all. If you ever find your way to Colorado I’ll show you my library; I own several thousand books, and I’m always buying more. (BTW, see if your book’s rank jumped on Amazon. 🙂 And I’m always behind in my reading. Nonetheless, I will see if I can fit some health care wonkery into the mix.
However, I’m curious if anyone has done any studies to see if that will counterbalance the increased demand for preventive services.
Isn’t that what was meant to be presented by all the references to the fact that other countries, spending significantly less per capita than the U.S. still have consistently better health care?
The VA article is short and well-written. This (pdf) is a primer for journalists on health care proposals that one of the country’s best health care economists wrote during the runup to the last elections; it’s also short and well-written. (Health care wonkery made easy 😉 )
Does anyone dispute one of the following propositions?
1. Two percent of patients account for more than fifty percent of total healthcare cost. Looking at average (ie your own) behaviour is misleading.
2. It is also said that in your last year of your life you spend 50 percent of your total lifetime healthcare cost.
3. Fixing healthcare means tackling unhealthy lifestyles, especially obesity. Prevention pays. Some people will not like the coming sticks and carrots.
4. Some countries do well with a public system, some don’t. Some do well with private accounts, some don’t. It is not a question about market or government, but one about efficient management and accountability.
5. All healthcare systems are extremely inefficient and wasteful. Better management, better administration, better IT, better purchasing and especially better communication and cooperation is necessary.
Andrew,
for managing your books, have a look at LibraryThing. I love it having entered more than a thousand of my prrecious books. You could show your virtual bookshelves (incl. covers) to hilzoy and anybody else. Highly recommended (and addictive).
Fixing healthcare means tackling unhealthy lifestyles, especially obesity. Prevention pays. Some people will not like the coming sticks and carrots.
This is another good reason to oppose government interference, for me. The campaign against soda/fast food/sweets is already silly. I have no interest in giving government the ability to tell me what I can eat.
Andrew: no policy proposal that I’m aware of would give the government the power to tell you what to eat. Policies in which the pool of insured people is fixed would, however, have a greater incentive to cover things like smoking cessation programs, help from dieticians for those who want it, and other voluntary forms of help than is currently the case.
hilzoy,
Not yet. But we already have mandatory seat belt laws, for example, and many states have mandatory helmet laws, both justified by the theory that since the public would have to pay for that person’s medical care, the state has the right to force people to do what’s good for them. And there are already people pressing for more hard paternalism when it comes to food choices. It’s a second-order effect of government expansion.
Ugh, Andrew, that was just terrible. You didn’t address any specific plan, but the straw man of the least palatable (to you) healthcare system possible.
Other people are taking you on in the specific generalizations you’ve made, but the simple fact that you’re railing against some imaginary, made up solution without anything concrete is disappointing.
I don’t have time to get into a point-by-point today (which is too bad because this is an interesting conversation), but I would just like to mention that insofar as pharmaceuticals and research costs, other countries can be so successful because they are free-riding off of the profit that can be made in the US market (and yes the includes foreign drug companies that make a large percentage of their profit in the US–which is to say nearly all of them).
Attempting to have the major payor also become a free rider is not generally a good way of tackling the free rider problem–it tends to destroy the good in question.
The typical way to deal with a free rider problem is to attempt to impose the costs on the free riders. This solution (agreements to enforce patents in other countries) is not typically favored around here.
jaywalker,
Thanks, that looks interesting. I can see where it would get addictive quickly.
sujal,
No need to thank me. All part of the service.
Andrew: I have no interest in giving government the ability to tell me what I can eat.
I know I said I’d shut up, but:
The federal government heavily subsidizes the corn industry.
Corn syrup is thus an extremely cheap sweetener.
When I visit the US, I read the ingredients-list on the side of packaged food, and it’s astonishing to me how many processed foods contain corn syrup – processed foods that, in the UK, don’t contain nearly as much sweetener, if any at all.
(Read the Accidental Hedonist on this topic.)
The people who really won’t like government sticks-and-carrots to get people to eat more healthily are the people who profit from the US food industry –
One of the carrots (literally) to get people in my neighborhood to eat better is a government-subsidised fruit-and-vegetable co-op, that enables the locals to buy fresh fruit and vegetables far cheaper than from the supermarket, and in more variety. No one forces them to buy there: but for some years now there’s been a systematic campaign encouraging people to eat a minimum of five portions of fruit and vegetables per day for better health. I shop there when I can, though it’s actually there because there’s a sink housing estate just across the road: funding for these fruit-and-veg co-ops is available nationwide, targetted at areas where people may not find it easy to follow government advice to buy fresh fruit and vegetables.
Jes,
Thanks for the tip. I must have missed the post where I said I’m a big fan of federal subsidies for business; hopefully you can point it out to me.
You might also want to know that part of the reason corn syrup is used so extensively is government tariffs on imported sugar to protect our own sugar industry.
And it may shock you to realize that I’d be perfectly happy to tear all of that out root and branch. If we had no business subsidies whatsoever I would be ecstatic, because I’d like to get the government out of the business of choosing winners and losers.
“there is a limited supply of medicine in the US”
there’s also a limited supply of chicken. And in both cases, as demand increases and costs rise, new suppliers enter the market.
We may need to drag an economist into this discussion as opposed to us amateurs acting like we know what we’re talking about. But Andrew makes the classic fallacy of looking at the demand side only.
In the next ten years, lots of very good medications will go off-patent, allowing for generic manufacturers to make the medication at very low cost.
Having universal insurance, as opposed to universal care, does not eliminate the incentive to create new drugs. Patent protections will still exist, so as long as the new drug is measurably better than the existing ones doctors will prescribe the new one. The insurer and the drug company can then butt heads on pricing, much as they do now.
Francis,
While admittedly an amateur economist, I addressed some of my concerns regarding why I don’t know if supply will keep up with demand in the post.
And I’m not nearly as sanguine as you that universal insurance won’t torpedo new drug research. One of the ways governments keep costs down, after all, is to trim the price of drugs by setting caps on drug prices. That may not yet be a goal of current plans, but I don’t think it is unreasonable to expect that to become part of the plan as the government attempts to control costs.
jaywalker:
Fixing healthcare means tackling unhealthy lifestyles, especially obesity.
No. We can fix the US healthcare system — make it comparable to that of other developed nations, instead of *much worse* — without “tackling unhealthy lifestyles”. Unless by “unhealthy lifestyles” you mean povery and racism.
Andrew: I must have missed the post where I said I’m a big fan of federal subsidies for business; hopefully you can point it out to me.
You appeared to be arguing that universal health care would lead to the government telling you what to eat/drink. This hasn’t happened in any other country with universal health care, but what has happened is government campaigns and subsidies directed towards getting people to eat more healthily. At present, the US has government campaigns and subsidies directed (as with federal subsidies for corn syrup, making it a universal ingredient) towards getting people to eat more unhealthily.
Also, to increase demand, aren’t we going to need to take on the AMA’s ability to restrict the number of new doctors?
Ditto, cane sugar. In spades. It’s one of my favorite pet peeves. But this kind of subsidy isn’t entirely contained within the United States, interestingly enough.
Jes,
The U.S. may be four centuries separated from the Mayflower, but the Puritan ethic still is remarkably strong here. The U.S. is packed with people interested in using the power of the state to make people live ‘right.’ I see no reason to believe that will stop any time soon.
Andrew: The U.S. is packed with people interested in using the power of the state to make people live ‘right.’ I see no reason to believe that will stop any time soon.
Nor do I: but given that “making people live ‘right'” at the moment means depriving them of access to basic health care, filling them up with ignorant misinformation about prophylactics, and campaigning against marriage, it has got to be an improvement if the federal government turns away from “make people live in a moral way” and turns to “encourage people to have a healthier lifestyle”.
Andrew, it bugs me to see this debate conducted in the abstract. The fact is that every other industrialized nation has some form of national health service, and gets better care for less money than we do. I would be much more impressed by an argument that deals with how this is.
Andrew: the state is also packed full of people who resist attempts by the state to make them live by someone else’s conception of ‘right’. In this particular case, I think that trying to get legislation passed that would use the health care system to force people’s lifestyle choices would be very difficult, if only because of the conservative (in this sense) cast of the Congress.
Besides, as I said, there’s a lot of progress waiting to be made by the much less intrusive means of providing people with the help they need and want in order to make lifestyle changes voluntarily. That doesn’t involve forcing anyone to do anything, and it provides huge benefits.
(For analogous reasons, I have always wondered why we don’t fund enough drug treatment to meet the demand. I mean, do we want people to stay addicted to drugs? Do we like being mugged by addicts?)
it has got to be an improvement if the federal government turns away from “make people live in a moral way” and turns to “encourage people to have a healthier lifestyle”.
You’re agreeing that government has the right to tell people how to live, as long as you’re the one whose principles are pushed by the government. I want the government out of the business of telling people how to live.
Bruce,
As I noted above, I’m not a health care wonk. It would therefore be difficult or impossible for me to discuss specific plans intelligently. I wrote this piece based on Francis’ comment yesterday about convincing me that universal health care is a good thing to lay out some of the reasons I’m leery of a government universal health care plan.
hilzoy,
I’d like to believe you’re right, but Congress has shown itself a dismal guardian of civil liberties over the past 30 years, and the courts aren’t much better, if at all. I would prefer to avoid giving the federal government any more excuses for expanding its already excessive powers.
Andrew,
I have to agree with a couple of the earlier posters who noted that you’re approaching this as a sort of abstract philosophical exercise rather than studying the actual information about real and proposed insurance and health care systems.
Even barring real-world data on real-world health care programs, there’s one presupposition that strikes me as odd. Health Care is not a commodity good, like oranges or plasma televisions or paperback novels. If the price of getting a cornea transplant drops to $0, that doesn’t mean that everyone is going to scramble over and scoop up all the corneas they can carry.
There will always be a difference between discretionary and non-discretionary medical procedures, as well. No one’s talking about having breast enlargement paid for by the government, or something like that.
The latest Dutch system (we changed last year) works with no-claim as an incentive. Everybody gets the same basic insurance for the same price – and insurers cannot refuse people. If you do not use healthcare, you get approximately 300 dollars back that year (everytime you use healthcare you get a nice letter stating how much no-claim you have left for the year).
Having health insurance is obligatory, and your employer can bargain for better deals or pay part of your premium, but YOU have the contract with the insurance company.
GP’s are crucial to our system: they guard the road to specialists. GP visits are not part of the no-claim, since that might jeopardize prevention.
The basic package is rather basic. You can extend via “extension” insurance packages. Appliers for those packages *can* be refused by the insurance companies.
Kids have a more extensive package anyway, till they are 18, since that is investing in your capital of the future (to use Andrews argument pro militairy healthcare). Prevention and information both lower the need for extensive healthcare.
Insurance companies compete with additional survices, better packages, faster services, faster repayments if you have chosen the non-natura system (you choose, you pay, they repay versus they pay directly but your choice of doctors is limited).
I’ll come back with figures later, dinnertime now 🙂
Andrew: You’re agreeing that government has the right to tell people how to live, as long as you’re the one whose principles are pushed by the government.
Er, the principle of “eat five portions of fresh fruit and veg a day” isn’t my principle – it’s generally agreed to be a damned good idea.
I would, however, be opposed to an Act of Parliment or an attempt to amend the US Constitution to require people to eat 5 portions of fruit-and-veg each day or else. That would be silly. Again, as I said at the start of the thread and as others have said further down, this would be a far more interesting discussion if you weren’t consistently setting up straw men – your imaginary consequences of universal health care systems – and were instead referring to actual universal health care systems, of which there are 28 around the world to look at.
I’m in favor of federal funding for safe sex education, too. Generally speaking, I suppose you could say that “my principles” are that if the government’s going to pay for information to be distributed to citizens, it should be useful and accurate information – as useful and accurate as present-day knowledge can make it. You may feel that the government shouldn’t be in the business of giving any information to citizens, but I fear that you are on a losing course there. (And it’s an odd stance to take, too: it means you’re against the Highway Code, among other useful things.)
Andrew: I really don’t agree that universal health insurance is even remotely likely to lead to the government telling us what to eat, etc. It has not done so in any of the current government programs — medicare, medicaid, VA, etc. Why on earth would it start now?
“The insurer and the drug company can then butt heads on pricing, much as they do now.”
Unless the insurer is the government, in which case it can dictate pricing on various non-business threats (like breaking your patent or various other slightly less threatening things).
hilzoy,
Maybe I’m wrong. I certainly hope so, since I expect the government to take over health care in my lifetime. But fifteen years ago the idea of suing a fast food company because you got fat eating their food would have been laughed out of court. The drive to relieve people of any responsibility for their choices has come a long ways since then, and the train shows few signs of stopping. I am decidedly leery of providing ammunition to those who would run our lives.
The drive to relieve people of any responsibility for their choices has come a long ways since then
Or, put another way: the drive to force people to take responsibility for their choices has come a long way since then. Or don’t you regard the people who make decisions about the quality and marketing of fast food as, well, people?
Andrew: surely in that case the problem is with the tort system. (Assuming for the moment that you’re talking about suing just because you got fat, and not because of some ingredient that posed more specific health risks that the company suppressed information about, a la tobacco companies. In the tobacco case, I think it makes sense to sue if one happens to be a person who took up smoking at a time when the tobacco companies knew about the risks, and were blocking the information, and one has suffered damage — just as it would if a toy company painted its toys with paint they knew to be toxic and suppressed the evidence for that.)
Or don’t you regard the people who make decisions about the quality and marketing of fast food as, well, people?
An excellent example of what I’m talking about. If people eat too much, the fact McDonald’s advertised their food isn’t an excuse. The idea that McDonald’s or RJR or any other company should pay damages because someone did something stupid is the height of stupidity.
Though I have to admit, Andrew, that supersize me was a far better and more effective indictment of the fast food industry than any government-subsidized information campaign would be. *throws you tiny sop*
Could someone please correct the spelling of the first word of this post? Thank you.
Can any lawyer chime in on the likelihood that someone would actually win a case of the sort Andrew is describing, absent a completely flukey jury?
No one could have predicted that eating too many burgers and fries would make you fat. No one.
That is to say, the first word of the title of this post . . .
hilzoy,
I concur with your examples, and the tort system is certainly part of the problem. But given what we’ve seen with cigarette smoking and seat belts, I don’t think it’s unreasonable to think that what they can’t get through the courts, activists may attempt to get via legislation.
Andrew: If people eat too much, the fact McDonald’s advertised their food isn’t an excuse. The idea that McDonald’s or RJR or any other company should pay damages because someone did something stupid is the height of stupidity.
Until Supersize Me came out, one of McDonalds’ marketing campaigns was the claim that you could eat every meal, every day at McDonalds – that’s the claim that inspired Supersize Me.
McDonalds provides about the least healthy/most expensive food-for-kids imaginable: and targets kids specifically with marketing campaigns.
You can argue that people ought not to be stupid enough to believe the lies McDonald told about their food being healthy and nourishing, of course: and that McDonalds has no responsibility to sell nourishing/healthy food, not even if their marketing campaign says that’s what they sell.
Title fixed. Sorry about that. I haven’t slept well lately; probably should have left this topic for another day.
Jes,
Every McDonald’s I’ve ever been to offers salads and lower calorie offerings. If people choose to purchase the higher calorie offerings, that’s on them, as far as I’m concerned. Tort law ought to be restricted to negligence and misconduct.
Just a couple of points I’d like to throw out there.
Everyone seems to think that we have a capitalistic health care system right now but we most certainly do not. The AMA limits the supply of doctors and more importantly state regulations (imposed to satisfy the AMA) limit the supply of health insurance. I know of (*important qualifier) no state in the union where you can get simple catastrophic health insurance. States require that you offer a certain amount of benefits and cover a certain number of services. Most young people do not need the health insurance that is offered.
Also, I see people making the claim that both the demand for health insurance won’t rise and that people will modify their use of healthcare because of implementation of some form of universal coverage. I don’t think we can assume that people will suddenly start taking advantage of preventative services just because we have universal health coverage. Most people WITH health insurance don’t take enough advantage of preventative services.
Also, do not bet against government intervention in people’s lifestyle choices. I work for a company that does health care research for the federal government and I’ve been involved in two conversations with people much higher up in the food chain than me who have suggested that laws should be made that target obesity. Both times when I asked why the government should get involved in that they said because the government pays for Medicare. If the government was the primary player I don’t think they could resist the urge to try and reduce outlays be trying to force us to eat better and exercise more.
Also, the United States performs poorly against other industrialized nations on standard health measures for a variety of reasons. It is important not to overlook the fact that we have one of the highest rates of immigration in the world. And most immigrants come from poorer nations. There are various barriers to good health care service for immigrants (all). These would be the same in Europe and Japan if they had to face the same percentage. Similarly, measuring standards are not. The United States, just as an example, tries harder to save neonates than most other industrialized nations and counts all those 24 week neos that don’t make it in the total. Most other countries do not include those in the total.
Administrative costs in the United States are much higher. There ain’t much getting around that. But there are a lot of problems in other countries with national health insurance that aren’t being discussed here, including queueing and outright denial of services for the elderly.
All that said, I am not diametrically opposed to some of the systems currently being implemented. I think the French and German systems both hold promise. An NHS style healthcare system a la Canada or UK fills me with dread.
Andrew: Every McDonald’s I’ve ever been to offers salads and lower calorie offerings.
Yes; apparently the cheeseburgers are the “lower calorie offerings”, since the salads on average contain more fat.
As you phrase it, “Every McDonald’s I’ve ever been to” would suggest that you never went into a McDonalds before 2003, since it’s only then that they started offering salads. (I may be wrong about the exact year, but I know it was a recent development.)
As I said *throwing you a sop* (made of wholemeal organic bread and organic fair trade wine) this change was undoubtedly due to Supersize Me, rather than any government action or tort prosecution.
Try 1985, J.
Frank: The United States, just as an example, tries harder to save neonates than most other industrialized nations and counts all those 24 week neos that don’t make it in the total. Most other countries do not include those in the total.
I’ve often seen this claimed by anti-choicers, but I’ve never seen any links to actual data.
I see no reason to suppose it’s true: certainly in the UK, to the best of my knowledge and belief, if a baby is born alive (even as early as 22 weeks) the baby must then be registered (it’s a legal obligation on the parents to register the birth within 6 weeks) and I can’t see why the GRO would make an exception, or why the parents would want to make an exception, just because the baby then died because s/he was too premature to live.
Slarti: Try 1985, J.
Really? Ah well. Come to that, the last time I went into a McDonalds for any other reason than to get out of the rain was, um… 1987, probably. (When I was an innocent teenager, I tried their fries, their apple pies, and their milkshakes, and concluded they were all vile. When I tried their coffee – as the price of getting to stay dry – that was so vile I’d actually rather be rained on.)
I tried their fries, their apple pies, and their milkshakes, and concluded they were all vile.
Hey, you can insult me all you want, but I’ll not have McDonald’s fries impugned.
But fifteen years ago the idea of suing a fast food company because you got fat eating their food would have been laughed out of court.
I haven’t googled it yet, but I’m pretty darn certain that it was laughed out of court. Or, rather, dismissed. Let me go check.
LB,
That would be good news. Thank you.
Ah, well. Wiki says 1985; this says 1987. I think mid- to late- 1980s is a safe bet, but I’d lean heavily in the 1987 direction.
I used to work at McDonald’s, and I never ate there unless I was at work and had no other choice. I don’t think I’ve eaten McDonald’s food more than a half-dozen times since. That’s in over two decades.
Yep. I don’t know that no other similar suits have been brought, but I don’t believe they have.
Andrew: Hey, you can insult me all you want, but I’ll not have McDonald’s fries impugned.
Chacun à son goût.
I like fries to look like this.
http://www.oecd.org/dataoecd/7/41/35530083.xls
footnote b
“In the US, Canada and some Nordic countries, very premature babies with a low chance of survival are registered as live births”
Guess who is right above the U.S – Canada. It’s not that they are not reporting live births, it’s that they don’t have the same technology to try and save a premature baby as is available in the United States.
The linked article above was to a dismissal with permission to replead — here’s the final dismissal.
And just as no one could possibly have predicted that eating twice the recommended daily caloric intake, and that consisting entirely of fast food, could possibly make one gain weight, no one who’s ever taken a sip of McDonald’s coffee within the first hour or so of its exit from the spigot could possibly have predicted that McDonald’s coffee was hot.
enrac:
It is important not to overlook the fact that we have one of the highest rates of immigration in the world.
It is important not to overlook the fact that the two groups with the worst health records in the US, Native Americans and blacks, are the people who have been here *longest*.
I say the black population has been here longest because it is made up of people most of whose ancestors were here by 1860 — if not 1820 — which is not the case for the “white” population. None of my (Irish, German, Swedish) ancestors were here before the Civil War, for instance.
IIRC, the case filed against McDonalds for making people fat was dismissed, though the court left open the door for a future suit. I think the plaintiffs tried again and that case was dismissed too.
Don’t spill the coffee on yourself.
And certainly, after having been repeatedly notified that their coffee had caused third-degree burns on multiple occasions, McDonalds had no way of knowing that it might be a good idea to serve it at a temperature more typical of restaurant coffee. But we won’t convince each other on this one.
No, I think you’ve convinced me that McDonald’s is capable of stupidity. But I already knew that, so don’t celebrate too much.
Dr. Science,
I’m not going to argue with you there, as you have the benefit of evidence on your side. But many of the people that get the worst service already have health insurance (unless they are male) through Medicaid. How is extrapolating that to the rest of the population going to help?
Also, I belive that your points had already been raised, while mine had not. I don’t think your point disputes mine.
(Recorks champagne, finding it surprisingly difficult. On second thought, finding it unsurprisingly difficult.)
I go back & forth on the McDonalds coffee case™. On the one hand, its coffee, its hot! And it’s meant to be poured down your throat, no over your skin (IIRC, you mouth is capable of handling hotter liquids than your skin).
OTOH, multiple warnings of burns, and knowledge that the lids didn’t fit well (especially when you’re giving it to people who are driving) kinda meant they should have done something about both things.
Though I think the solution they came up with was to keep serving the coffee at the same temperature and just put warnings on the cups (I could be wrong about this).
on tort reform:
Leave it alone. If you don’t trust the govt now, why {expelitive deleted} would you trust it to act as a gatekeeper to determine meritorious vs. non-meritorious lawsuits? Frex, last I read about the McDonald’s made-me-fat case, it went nowhere. The plaintiff, stymied by the fact that he was served food, argued that the food was adulterated.
now wait a moment! Let’s assume that the plaintiff could prove to a jury that McD deliberately added an addictive chemical with no nutrient/flavor value to its fries, and concealed that conduct. McD liable? I certainly hope so.
but since there was no such evidence, the case went nowhere.
re: health care. It seems to me that the thrust of the post is that we Americans cannot be trusted to leave us alone. Certainly Radley Balko’s posts about Chicago add legitimacy to that concern.
but the current system is, essentially, dysfunctional and more expensive than any other industrialized country’s system. we should not be paralyzed by the counsel of our fears to try to do better.
(note: health care insurance is already incredibly highly regulated by states. the notion that a single federally-chartered insurer will somehow be substantially more intrusive seems unlikely. but if we insist on maintaining our federal system, there’s no reason why we cannot charter 50 separate joint federal-state insurers, each with its own coverage. of course, you’d have a real problem with people traveling to high-coverage states for elective procedures, but it would inject some competition into the system.)
OK, so in support of the idea that if we got universal health care the government would start telling us what we could and could not eat, we now have a suit that was dismissed, plus suspicions about what activists might do. Against it, we have the fact that the government has done nothing of the kind since it got into the health insurance business, plus the claim (by me) that if the government tried to e.g. ban McDonald’s, the party that suggested that would be drummed out of office.
Meanwhile, I continue to say that it is a good thing if people who want to lose weight or quit smoking or stop drinking or give up crack get the help they need to do so voluntarily — good for them, good for the rest of us (increased productivity, decreased emergency costs, etc.), good for whoever pays for their health care. Insurance companies do not now do enough of this because they can always hope that by the time the relevant habits start costing money, the patient in question will be covered by someone else. All insurance companies would be better off if all insurance companies covered this, but since there is no decision-making body called “all insurance companies”, and since it’s rational for each individual company not to do it and to free-ride on anyone who does, it doesn’t get covered. Why this is supposed to be a good idea, I cannot imagine.
I thought I heard that they’d dialed the temperature back. One thing that irked me about that whole thing was the suggestion (actually, it was an assertion) that there is in fact an “industry standard” for coffee temperature. To me, the words industry standard imply some sort of agreement, normally written, and I’d be shocked to discover that there was such a thing in effect among fast-food restaurants. I’d be only slightly more shocked do discover that coffee temperature was regulated in law by international treaty.
Enrak, I can’t access the link.
As I said, as far as I know if a premature baby is born alive, there’s a legal obligation on the parents (or, failing the parents, ) to register the baby. If you can find me evidence that this is not the case…?
It’s true that the legal distinction between a miscarriage and a stillbirth is at 24 weeks: but this is a legal distinction between a dead fetus and a dead baby. A live baby has to be registered – and as far as I know that obligation exists no matter if the infant then dies.
The truth is that all insurance companies are already free-riding on Medicare. They know that by the time most of the benes will get really sick, they’ll be able to pass the problem on to Medicare. That is why they underinvest in preventative services. There is zero incentive to invest. That’s one of the reasons disease management doesn’t work. Most of the benefits of disease management accrue over at least a 5-10 year timeframe. What incentive does that leave a health insurance company to enter a 60 year-old in their disease management program? Or really anyone else seeing as most people will change employers within 5 years.
Jes,
There’s a legal obligation, but what is your definition of alive? Not breathing, no heartbeat? In one country that would be recorded as a nonlive birth. Here in the United States there is a significant chance that they could get the baby to survive long enough to record it as a live birth.
If it’s the same across all countries than why the footnote.
P.S. Just go to OECD, follow the Health links to infant mortality rates if you don’t believe me.
Why not allow the states to try their own solutions, rather than trying to impose a federal one-size-fits-all solution?
Ditto Bruce’s position. Every industrialized country that starts with universal medical care as a requirement spends less than the US does. Many of them have better measured outcomes, and none of them are worse overall. The organization of the health care system in those countries cover a wide range: from the NHS in the UK to Japan’s system of private providers and insurers. This would seem to put the onus clearly on the other camp: exactly which benefits do you claim we are realizing by intentionally excluding universal care from our system?
Taiwan revamped their system in 1995, and included universal coverage. This article provides some summary information about their experience. The evidence seems to support the argument that reduced overhead offset the costs of insuring those who were previously not covered. Once the program was well established, public approval has been in the 65-70% range, making it the most-approved government program.
Jes,
Re: french fries, I prefer steak fries myself, but it’s hard to find good ones.
Andrew: because the poor large Midwestern and Southern states hold disproportionate power in the Senate.
Francis,
By that, I assume you mean that they are demanding federal intrusion because they don’t have the money (or don’t want to spend the money) for their own programs?
I’d like to link to a graph that shows how much the OECD countries spend on health care and how much of that is actually paid by the government.
It makes it very clear that under the current system the US government allready pays more than quite a number of countries pay *in total* (public and private spending combined).
Enrak: the immigrants usually are a lot younger too. Europa has on average a far older population, which had an impact on health costs.
The neonatal death figures are hard to compare anyway I find. Our average mother giving birth for the first time is 29, so we have more complications due to age. In the US you have more quadruplets due to commercializing of fertility treatments…
Problem with helping all those new born babies is that quite a percentage of them will be handicapped – and will thus suffer from the inadequate health insurance situation in the States.
About the sueing: that is also a culture thing. It does not happen that much here, and the ones that do happen are settled with smaller amounts. Amongst others because health costs are a lot less here…
Andrew: “Why not allow the states to try their own solutions, rather than trying to impose a federal one-size-fits-all solution?”
Given open borders, the obvious free-rider problem as people with serious illnesses move in for the purpose of obtaining treatment they could not otherwise get. Given the interstate nature of big insurance, big hospitals, and big pharma, the inability of an individual state to impose meaningful coercion on the behavior of those companies (and yes, I acknowledge that universal coverage will require some degree of coercion). The inability of the states to make large experimental changes in how Medicare and Medicaid dollars — roughly 40% of the total health care spending in a given state — are spent. The probable inability of the states to conduct all of the possible experiments; I don’t believe a state would be able to require that all doctors be employees of the state a la the NHS.
Andrew: if your concern is that universal health insurance would involve too much government intrusion, it’s hard to see how state efforts would help that. What they would do is undermine some of the considerations in favor of having a federal policy, namely: having one risk pool, and also avoiding problems like: states being worried that generous health care provisions would serve as a magnet for the poor, etc.
Ugh, in addition to the warnings, they also went to a somewhat sturdier coffee cup. (And, the particular McDonalds where the case was at significantly lowered the serving temperature of the coffee).
hilzoy,
I have many concerns, not least of which is that I still cling to an antiquated interpretation of the Constitution. I’d feel a lot better about what the federal government does if it did it by actually amending the Constitution as opposed to getting the Supremes to redefine the Constitution.
Further, I have a sneaking suspicion that when the day comes that universal coverage is imposed, the system Congress comes up with will be a bad one. At least by letting the states try their own solutions, the odds seem much better someone will come up with a good plan. With the federal government, if they shoot a brick we’re stuck with it for some time to come. Yes, it can be fixed over time, but how many bad federal programs get fixed? What’s the over-under on when we get serious about Social Security?
Andrew: I foresee an interesting argument about Social Security in our future. Personally, I think it’s fine as is; certainly there’s nothing that a bit of tweaking won’t cure. I also bet that if the Dems take over Congress, the prescription drug bill will be vastly improved; if (as seems a lot more likely) they only take one house, the chances for serious improvement go up, but not nearly as much. So the length of time we’re stuck with the worst of that, I think, depends a lot on the ’06 vote.
Universal health insurance is complicated, but it’s not that hard to come up with at least a decent solution, especially if we look at the experience of other countries.
I don’t believe a state would be able to require that all doctors be employees of the state a la the NHS.
The UK does not require that all doctors shall be employees of the NHS. Doctors are free to work in private practice or for the NHS or both.
hilzoy,
I certainly hope you’re right about the Democrats and Plan D, since I would prefer an effective plan to an ineffective one. Juts as I don’t subscribe the whole ‘starve the beast’ theory, I’m not a fan of trying to roll back government by making it as poor as possible.
As for Social Security, I’d have to look at the numbers again, as it has been some time, but as I recall, in 2017 the bills are going to start coming due, and I’d rather do something about that now than wait.
Enrak, as I thought I’d made clear: I can’t follow your link. Not won’t: can’t. It doesn’t work for me.
There’s a legal obligation, but what is your definition of alive? Not breathing, no heartbeat? In one country that would be recorded as a nonlive birth. Here in the United States there is a significant chance that they could get the baby to survive long enough to record it as a live birth.
I’m sitting here going “what’s the point?” I mean, assuming you’re right, and American doctors do spend significantly more amounts of time trying to get a miscarried fetus that isn’t breathing and has no heartbeat to achieve a heartbeat for long enough that the miscarriage is then recorded as a baby born alive that then dies? I mean, if that’s the case, it’s not “trying to save the life of a neonate” – it’s giving a woman who suffered a late-term miscarriage the recognition and respect that she lost a child, which of course, she did. And of course, miscarriage/stillbirth/premature birth rates being so much higher in the US than in other industrialized countries – the result, I think, of the US’s poor maternity health care provisions – I would guess that American doctors would be more motivated to give their patients at least that recognition/respect.
Though again, it would seem better just to improve the miscarriage/stillbirth/premature birth rates by improving maternal health care and health care generally… which is to say, by instituting universal health care.
Andrew, about the Constitution: you don’t think this falls under the Congress’ power “To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof”, combined with the Federal government’s role of promoting the general welfare? Alternately, under this: “The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States”?
I mean, I think it would be different if we were talking not about instituting a program but about e.g. regulating some independently existing form of behavior, in which case one might ask whether regulating whatever it is was one of the powers provided to the Congress. But I would have thought that when the government is instead instituting a benefit, it’s covered under raising taxes for general welfare. (Which is also, I’ve always thought, the authorization for things like federal spending for highway beautification, historic preservation, and all that stuff.)
Andrew saith thus:
True, but someone who receives treatment that prevents him or her from developing heart disease and high BP in the first place will cost even less than either of those two.
And then he added this further down:
And you might want to know that the reason for this is that, back in the early 70s, we stopped subsidising domestic sugar production on the grounds that if we gave the free market free reign, the price of sugar would go down, and everybody would benefit.
Which they did, at first. But then foreign growers ultimately kept lowering their prices beyond the point where US growers could compete, and the US sugar industry was gutted. It’s hardly a coincidence that corn syrup ultimately wound up taking sugar’s place in so many different products.
And then Enrak added this:
As for the former claim, what proponents of UHC have been saying looks more like “increases in demand will be offset by decreases in need that result from higher availability of preventative care.” Where the latter is concerned, in cases such as mine, people definitely will modify their use of health care, by using the system as something other than a last resort. I fail to to see how giving people without insurance the chance to get problems taken care of while they’re still minor ones (and thus, much cheaper to fix) is a bad thing.
Where fries are concerned, the best I’ve had are the ones at a place near where I work, where they cut a potato into cross-sections, then fry those up, skin and all. It’s like steak fries, only better.
And now, on to what Slartibartfast had to say:
The suit in question wasn’t about it being hot, Slarti, but rather about how it was hot enough to destroy human skin in a few seconds’ contact with same. And the ruling that McDonalds bore the majority of blame for what happened was, in no small part, due to the fact that they had paid compensation for the injuries of the 702 or so people who had suffered second-degree and worse burns before the woman in question asked them to cover the cost of her skin grafts, and they refused.
Pity they never got around to trying to limit liability by posting notices of what their product could do before they were told to pay the plaintiff in question the equivalent of two days’ coffee sales, innit?
Andrew: just to preview what I’d say on SS: back in the 80s we decided, prudently, to raise SS taxes to create a surplus to get us through the retirement of the baby boom generation. What happens around 2017 is: we start drawing on that surplus. Not a problem: that’s what it’s there for.
The problem is that we have been using the surplus to disguise the extent of our deficits — spending the money as it comes in, and giving the SS trust fund bonds. These bonds are good — at any rate, they had better be, since bondholders the world over would be startled to learn that the US was not good for the money it promises. However, making good on them will require paying money out of the general fund.
This is not Social Security’s problem — it is doing fine until around 2050, at which point relatively minor cuts, or else relatively minor tax increases, become necessary. It’s the general fund-s problem — it will no longer be able to draw on the SS surplus to lower the amount it has to borrow. That will require actual fiscal discipline by the Congress. But not to make up for a shortfall in Social Security, which will, at that point, have all the money it needs.
hilzoy,
I’m not certain that the preamble to the Constitution was intended to be a legally binding part of the document. If so, then why bother having a Constitution at all, since what’s written in the other articles doesn’t matter. Article I clearly delineates the powers delegated to Congress, and the Tenth Amendment makes it clear that powers not specifically meant for the federal government remain with the states.
This is, of course, a philosophical question, since the Constitution has been interpreted so liberally over the past 60 years as to make it generally meaningless, but I still find it difficult not to try and make some defense of it. The founders set this country up to have a sharply delimited federal government. If the preamble is binding, as opposed to being simply a statement of intent, then it renders the remainder of the document superfluous, since all Congress would have to do is argue that provision X is in the general welfare and, voila, the government is effectively unlimited.
I’ve been sitting here thinking what to write, and I can’t think of a thing. The subject makes my head hurt.
I second those who point out the peculiar nature of healthcare as a market, and the discussion of the application of incentives and disincentives therein makes me want to die. But, as Andrew pointed out, we will all die of something. I just don’t want to be there when it happens.
Francis’ comment that we to drag an economist into this discussion, rather than relying on we mere amateurs, makes sense (there have been very few numbers in this discussion), but it leads me to two observations:
First, Hilzoy (with tongue in cheek) dragged an economist’s words into a discussion recently in which the economist pointed out that firefighters should be delighted to expand their job “portfolios” by being required by the market to hold two jobs in order to live near the first job.
Thank you for the expert opinion. Now please take the expert back behind the potted plant. It would seem to me that needing to have a second firefighter job in order to make up for the fact that the first firefighter job doesn’t pay enough is also a reason for firefighters to become arsonists to increase demand for the first job, but then I’m just an amateur.
Secondly, I thought the whole idea of the Internet was to give free rein for the citizenry to ignore the experts and intellectuals and to speak at length about subjects we know nothing about. Just like the whole point of Boards of Education in Oklahoma is to ignore education, and evolutionary science, and gravity. Or the whole point of, say, the National Oceanic and Atmospheric Administration is to ignore just about everything they were trained to pay attention to and listen instead to amateur James Imhofe, or Dick Cheney.
But, I kid.
Having visited the Netherlands, I was impressed by the competence and the vigor of their flood control systems, and by their exacting, precise public transportation. I contrast that with the woeful experience of New Orleans and the crappy public transport in most of the U.S., and it occurs to me, as it does when discussing which public health systems work well, that the problem is not that government doesn’t work, but that Americans, to name one nationality, are just crappy at governing and we do an even worse job at being governed. When it comes to flood control in New Orleans, we decided, because we have a bad attitude about government and we actually elect people who have a bad attitude about government, to govern like Banglideshis in that one respect.
The Netherlands doesn’t seem to diminish freedom by running things well. Yet, Medicare seems to work pretty well, until recently. I can’t think why.
One item missing from Andrew’s brave foray into this subject is the idea of raising Medicare taxes so that doctor’s might be better incentivized to make the system work. Because, “why would you do a job that you are losing money on, after all?”, which is a question I ask my garbageman every day, and the firefighter, and the Wal Mart clerk, etc?.
They can’t figure it out either, but they do it anyway.
As to Jes’ rejection upthread of amending the U.S. Constitution “to require people to eat 5 portions of fruit and vegetables per day or else”, I’m not sure about this. In fact, if you included this language within the second amendment, not as a requirement but as a right, you would have a whole bunch of folks falling all over themselves exercising their right to do so because the Constitution said so. In fact, some guys would carry fresh fruit and vegetables concealed on their persons just in case. The back windows of their pick-up trucks would look like Carmen Miranda’s hat rack.
You could include some language in the Bible, too, about the five portions and folks would fall in line in the fresh produce section of the supermarket, because God said so.
And informercials late at night. That seems to work wonders. Just don’t let the government tell us to eat the five portions, because, they, of course, might be experts, and you want to keep a wide berth from folks like that.
See, nothing to say.
hilzoy,
Yes, I’m familiar with the changes to the Social Security program in 1986, and with the fact Congress has spent the money that was supposed to last until 2050. However, the fact that money was supposed to be used in that time doesn’t change the fact that money has been spent, so we’re going to have to come up with more money to cover the gap. To say this is not Social Security’s problem is to argue that as one is falling off a tall building, it’s not the fall that will kill you, but the sudden stop at the end. While factually correct, it doesn’t change the fact that you’re dead.
It is a problem, and it relates to Social Security. If you prefer calling it a general fund problem, that’s fine, but the problem still exists, and my preference remains to address that problem sooner rather than later.
Andrew: well, perhaps, but this is not in the Preamble:
“The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States.”
Maybe an actual lawyer can help me, but I thought there was a difference between two things:
(a) the federal government deciding to make something illegal, and
(b) the federal government deciding to spend money for some useful purpose, without having to make anything illegal (except for things within its own program — e.g., it gets to say: the money we appropriate can be used only for these purposes, and since those moneys would not be available w/o the program, the federal government is not regulating any antecedently existing thing.)
And I thought that (b) was generally OK under the part of Art. I Sec. 8 that I cited, but that (a) required something more in the way of Congressional powers. Which is why banning guns near schoolyards required some argument about, say, the Interstate Commerce clause, but a program to spend money buying guns from people near schoolyards would not. (Though it would be quite independently stupid.)
I think we need a lawyer to step in, though.
As to Andrew’s suggestion that the states be given the opportunity to come up with solutions, they had 180 years until the mid-1960s and it never occurred to them to do so, to any extent.
To add to my amateur opinion about economist’s opinions, I’m reminded of the time Milton Friedman pointed out that the government gave him a job as an economist in the early years of the Depression, saying that he wouldn’t have had a job otherwise and might not have made it.
And then he has spent the rest of his life proving that was a bad idea. He might be right.
hilzoy,
I remain dubious of using that clause so elastically. I’d have to pull out my copy of the Federalist Papers and see what was said about that particular clause’s intent. But I remain of the opinion that if we are to have a constitutional republic, the Constitution must place meaningful restraints on government power. A clause like ‘general welfare’ is so vague as to ripe for abuse.
And yes, I’m sure a lawyer would be better able to address this than I.
John,
I believe Woody Allen put it best. “I don’t watch to achieve immortality through my work. I want to achieve immortality through not dying.”
Andrew:
the shift may be deliberate or accidental, but in the comments you’ve profoundly changed the basis of your opposition from universal insurance being something the government should not do to being something the government cannot do.
I’m perfectly willing to debate the powers of the govt as opposed to the wisdom of having the fed govt in charge of universal health insurance, but those are two very different topics.
John,
There was not a perceived need for government intervention in health care for most of that time. The idea the government exists to care for its citizens from cradle to grave is a relatively new idea. Your complaint is similar to being unhappy the government failed to do anything about nuclear proliferation from 1789-1945.
Francis,
Perhaps I’m like the proverbial lawyer: when the facts are bad, argue the law; when the law is bad, argue the facts; when both are bad, attack the judge.
I have several qualms regarding government sponsored universal health care, and these are two of the bigger ones. I am uncertain that the government will do a good job with universal health care, and I am nervous about the unintended consequences that come out of such an attempt. I am also a firm believer in a strictly limited federal government, and I’m of the opinion universal health care goes well beyond the enumerated powers of Congress per the Constitution.
Or, to borrow from Groucho; these are my principles. If you don’t like them, I have others.
John: As to Jes’ rejection upthread of amending the U.S. Constitution “to require people to eat 5 portions of fruit and vegetables per day or else”, I’m not sure about this. In fact, if you included this language within the second amendment, not as a requirement but as a right, you would have a whole bunch of folks falling all over themselves exercising their right to do so because the Constitution said so. In fact, some guys would carry fresh fruit and vegetables concealed on their persons just in case. The back windows of their pick-up trucks would look like Carmen Miranda’s hat rack.
I read this and giggled hysterically.
I have nothing further to say.
” In fact, if you included this language within the second amendment, not as a requirement but as a right, you would have a whole bunch of folks falling all over themselves exercising their right to do so because the Constitution said so. In fact, some guys would carry fresh fruit and vegetables concealed on their persons just in case. The back windows of their pick-up trucks would look like Carmen Miranda’s hat rack.”
PotD 🙂
Unless things have changed pretty drastically in the last 5 years or so, being a grabageman generally pays quite well. No one wants to do it so they jack up the price they will pay.
Universal health insurance is complicated, but it’s not that hard to come up with at least a decent solution, especially if we look at the experience of other countries.
Netherlands: Tax rate – 34% (to 16,893 Euros) to 52% (above 51,762 Euros).
Germany: Top tax rate 42%.
Those are just the couple I saw being pointed to as good examples in this thread.
Have you read the horror stories of the Canadian and British systems? There are plenty out there…
Given our government’s track record running any national program, there is little doubt we would end up with >60% top tax rates and horror stories like those coming out of Canada.
I had “free” government provided health care for 4 years. It was called go to the clinic on post and take your chances. No thanks.
People always talk about horror stories about the Canadian system, but when I ask the Canadians I know if they’ve ever experienced [Problem X], or know somebody who has, I always get a resounding “No” from them.
Ah yes, those legendary Canadian horror stories. As a Canadian, I would love to hear some of them. Perhaps you could link to some, and then I could link to some American horror stories, even share some personal ancedotes, and we both come away unenlightened.
By almost every measurable statistic, Canadians enjoy better health, and access.
The problem with the Canadian healthcare system is not structural -> it’s funding. Or lack thereof. There’s a reason why the Cdn Federal government has been running surpluses for 10+ years.
Hilzoy – my hazy recollection from con law I (taught by John Yoo, no less) is as you say: the spending power is very broad but the power to regulate/make things illegal is more circumscribed (though as Andrew notes, its not so circumscribed these days). An example is that the federal gov’t cannot order the states to pass a law to raise the drinking age to 21, but it can withhold highway funds from those who don’t.
I always thought the problem with the Canadian health care system was that it caused the populace to have beady eyes and flappy heads, like Ike Broflovski.
Andrew: “Your complaint is similar to being unhappy the government failed to do anything about nuclear proliferation from 1789 to 1945.”
Actually, I blame the guy who invented heart attacks, tumors, and death in childbirth.
“Or to borrow from Groucho ..”
Actually, I think you borrow more from Chico regarding government intervening in healthcare, etc: “I no believe in Sanity Clause.” 😉
I always thought data was the plural of anecdote?
John,
Indeed, it is hard to argue with that.
John T,
As I recall, Chico’s line was “You canna fool me. There ain’t no such thing as a Sanity Clause.”
Hil: the Congress has broad and essentially unreviewable power to tax and spend. So Congress could certainly simply assert that all US citizens, by their mere status as a citizen, qualifies for a particular benefit (eg, universal Medicare).
where things get a lot more tricky are in mandatory programs. Could the govt charter a separate not-for-profit corporation (Meddie Mac?) and require all citizens to obtain insurance from that corp? well, the draft was constitutional, as was enrolling in Selective Service. It seems to me that Congress could argue that a well-regulated militia requires a healthy populace. (see, Jes, I worked in your point about a healthy military.)
But a deeper question is one of institutional deference. we already hear way too much about an activist Supreme Court. If Congress and the President in their infinite wisdom decide to adopt a universal health insurance policy, is it really (for conservatives) the role of the Court to strike down that law?
“But a deeper question is one of institutional deference. we already hear way too much about an activist Supreme Court. If Congress and the President in their infinite wisdom decide to adopt a universal health insurance policy, is it really (for conservatives) the role of the Court to strike down that law?”
Judicial Activism isn’t all about deference. In theory it is about what the Constitution has to say on a matter. When the Constitution doesn’t say–lots of deference. When it doesn’t, not so much. On issues where the Constitution clearly doesn’t allow the legislature to do something, an activist Court might allow it.
Great article!
It is difficult to see any major changes in the foreseeable future short of a crisis situation. There are too many vested interests (the drug industry, health plans, providers) making a lot of money just the way things are for any worthwhile changes to happen. Further, they will throw their formidable lobbying clout against any substantive reform. For example, notice how hard the health plan industry has been fighting against an Association Health Plan bill. The bill would (in theory) reduce the cost of health care coverage for small and medium sized employers. Theirs is an interesting spin on why this is bad. You be the judge.
Given our government’s track record running any national program, there is little doubt we would end up with >60% top tax rates and horror stories like those coming out of Canada.
I see fellow Vancouverian Spartikus beat me to this, but let me second the call — what horror stories?
Francis,
I commend Randy Barnett’s ‘Restoring the Lost Constitution’ to you. Barnett lays out a case in it for what he calls a ‘presumption of liberty’ in lieu of the current presumption of constitutionality the courts tend to use today. In other words, he advocates a court system that strikes down laws unless the other branches can make a compelling case that they are good laws, as opposed to the current system where the courts assume a law is good unless there is compelling reason to strike it down.
Ah yes, those legendary Canadian horror stories. As a Canadian, I would love to hear some of them. Perhaps you could link to some, and then I could link to some American horror stories, even share some personal ancedotes, and we both come away unenlightened.
Much of it is anecdotal. I am originally from upstate NY – a few miles from Canada. My father was in a hospital there for some time and I visited him often. I had occasion to speak with many (15-20) Canadians in the course of a few weeks that had made the relatively short drive across the border. They were without exception there to get services, procedures, or surgeries that they were either denied or “wait-listed past death” for in Canada. They were paying out-of-pocket, after paying all those lovely taxes that should have guaranteed them the care they needed.
Links. A goggle search would do it – but here you go:
The comparative evidence is that the Canadian health care model is inferior to those that are in place in other countries
of the OECD. It produces inferior age-adjusted access to physicians and technology, produces longer waiting times,
is less successful in preventing deaths from preventable causes, and costs more than any of the other systems that have comparable objectives.
This is by Canadians BTW:
The Fraser Institute is an independent Canadian economic and social research and educational organization.
Dantheman:
You may be right. “There ain’t no Sanity Clause”, I think, is the accurate quote. But I like mine better.
And where is Dr. Jackmormon when I need a free clinic on free-floating apostrophes?
Andrew,
“Barnett lays out a case in it for what he calls a ‘presumption of liberty’ in lieu of the current presumption of constitutionality the courts tend to use today. In other words, he advocates a court system that strikes down laws unless the other branches can make a compelling case that they are good laws, as opposed to the current system where the courts assume a law is good unless there is compelling reason to strike it down.”
Even ignoring Barnett’s mendacious tendencies on the existence of a Consitution-in-exile movement, this summary of his argument makes me less inclined to read his book. It seems he is calling for the courts to act as a superlegislature in exactly the opposite way as he decries the activist courts of the Warren era. If the complaints about judicial activism have any meaning, they can’t go away if one flips which side’s ox is being gored.
OC STeve – FYI, the Fraser Institute isn’t exactly an unbiased source, and is frequently criticized as producing politically biased and inaccurate or erroneous reports.
I’d love to talk to someone who went to the US to get treatment for a life-threatening condition. I have yet to meet a Canadian who went across the border for medical care, and I live about 45 minutes drive from the border. On the Canadian side. Among millions of Canadians.
In an actual study on cross-border healthcare, this report indicates that the actual number of Canadians seeking care in the US is miniscule.
Dan,
I have no idea what you’re talking about reference the ‘constitution in exile’ movement. However, I will emphasize what Sebastian said above: what many of us would like to see is a court system that hews to the Constitution. Judicial activism is too vague a term to be useful here. As I understood the term originally, it referred to judges who went beyond the strictures of the Constitution to approve laws they preferred. It can easily be interpreted as you have done so, however, as the idea that judges should defer to the legislature, so it’s not a good term to use.
But it is not contradictory to decry the Warren Court’s use of penumbras and emanations to create rights and to ask the Courts to overturn laws that do violate the Constitution.
hmmm: Is a law that increases the number of citizens with access to health care by 45 million an increase in liberty? What constitutes adequate evidence of Congress’s determination that the law increases liberty? Statistical evidence regarding the success of universal health care in other industrialized countries? Anecdotal evidence about the burdens incurred by those who go without?
Francis,
The presumption of liberty refers not to whether or not the law increases or decreases liberty (as, arguably, all laws decrease liberty since they by definition either restrict or require certain actions), but instead means that if the law cannot be demonstrated as in keeping with the Constitution, it will be overturned.
I should note, btw, that I don’t think there’s any way this would work absent a serious cultural change, since the American people long ago demonstrated they’re more than willing to trade in Constitutional liberties for something shiny.
OCSteve: taxes are less high these days :). And in practise we live well…
My husband is a projectmanager with a bank, he works 4 days of 9 hours so he had a day with the kids and I am a SAHM. We have three little kids of 3, 6 and 7 years. We bought a nice house (5 bedrooms), biking distance from the sea and 13 miles from Amsterdam, in a historic nice little city with all the city comforts.
We all have health insurance & dentist insurance, make enough to live comfortably and buy all the nice gadgets we like (we are nerds :)), drive a big enough nice car *and* go on holiday at least once a year.
My middle one has been operated on his ear 4 times the past two years, and needs a hearing aid. The latter we have to buy (one ear hearing aids are not covered) but we *can*. My oldes has social therapy because he has difficulty conrolling his temper and his impulses – and I only have to pay a small amount out of my own pocket.
We have a comfortable sum on the bank and both have pension build up.
It is very hard to become Bill Gates in the Netherlands, but there is a large group living quite well.
Second D-P-U’s Fraser Institute observation. It’s studies and surveys are rarely submitted for academic peer review.
My father-in-law, who was what we in Canada call a snowbird (ie. wintered in the warm climes of a state like California), contracted pneumonia and went to hospital near San Diego. There, he contracted a superbug. He developed bedsores because the nurses wouldn’t bother to flip him, as is standard practice. The insurance company deemed it better for his health and their bottom line to charter a plane and fly him back to Canada. The doctors here were horrified by the level of care he had until that point received.
It was at the point too late, and he died.
My husband
Husband? With a name like Dutch, I assumed you were a guy. Geez, they have funny naming conventions in the Netherlands.
Husband? With a name like Dutch, I assumed you were a guy.
😉 Of course, Marbel could still have a husband if she was a guy… 😉
Sorry to hear that, Spartikus. It must be maddening to hear this kind of nonsense.
Both my parents had long-term health problems during their last years, and despite their age promptly recieved things like transplants and excellent rehabilitative care here in Canada. Aside from my own desire for greater healthcare funding, I think the level of service we receive is excellent.
Some friends of mine who moved to the US during the dot com boom were horrified by the healthcare in the States, and came back with horror stories about both the poor quality of service and the enormous bureacracy.
since the American people long ago demonstrated they’re more than willing to trade in Constitutional liberties for something shiny.
Something the current administration has exploited with no end in sight.
Of course, Marbel could still have a husband if she was a guy…
Maybe Holland isn’t all bad after all. 😉
Something the current administration has exploited with no end in sight.
No argument here.
OC STeve – FYI, the Fraser Institute isn’t exactly an unbiased source, and is frequently criticized as producing politically biased and inaccurate or erroneous reports.
No argument. If I had the $ to spare I could order up a report by “experts” proving the sky is red and not really blue. That was just high on a huge list of results from google and it seemed to be correlated with other reports.
I’d love to talk to someone who went to the US to get treatment for a life-threatening condition. I have yet to meet a Canadian who went across the border for medical care, and I live about 45 minutes drive from the border
Well I can’t give you names and addresses… As I said it was anecdotal. Being the Internet and all you should give it the exact weight it deserves – 0.
If you chose to believe me, I can assure you that at least in the last few years, Canadians have had life saving procedures in the US that they could not (timely) get in Canada. I saw enough of this that I asked my dad’s doctor and his response was that the hospital was doing well because they got $cash$ payments from so many Canadians. No insurance BS, just big bucks from people willing to pay the price to save their lives.
Maybe things are better now that private practice is no longer illegal?
Andrew,
For a discussion on the Constitution-in-exile movement, including Barnett’s disavowal of the phrase, see here.
“Hewing to the Constitution” should work both ways, though. And the history of the Rehnquist court, especially Bush v. Gore and the dissenters in Kelo, shows that the so-called believers in judicial restraint have no objection to acting as a superlegislature and ignoring the historical usage of terms in the Consitution when it is necessary to reach a result they prefer. As was noted by Prof. Sunstein in his portion of the debate I cited:
“First, many fundamentalists aren’t true to their own creed. Justices Scalia and Thomas have voted to strike down affirmative action without consulting the original understanding! There’s a lot of historical work suggesting that affirmative action doesn’t violate that understanding. But Scalia and Thomas haven’t said a word about it. This suggests that part of the time, fundamentalism is a partisan program in historical guise.
Justices Scalia and Thomas have also voted to ban Congress from giving citizens the power to go to federal court to enforce environmental law—without consulting the original understanding. There’s a lot of history suggesting that Congress has the authority to allow citizens to go to federal court to enforce the law. Justices Scalia and Thomas haven’t said even a single word about that history. (I could give many other examples.)”
Dan,
I agree completely that the rules have to work both ways. If I could think of a way to produce the ‘veil of ignorance’ for court cases, I would do so.
I wouldn’t argue for a second that any justice on the Court is an exemplar of that philosophy. That does not, however, invalidate the philosophy. Of all the justices on the court now, I think Thomas is the best we have, but he still disappoints me in many cases. Scalia’s willingness to allow the 4th amendment to be throw out the window for drug cases makes him of little use to me.
Maybe things are better now that private practice is no longer illegal?
Private practice is not illegal. Because healthcare is seen as a fundamental Canadian right, one’s economic standing in society should not provide lesser or greater access to that right, in the same way that the wealthy don’t get more votes and the poor less.
If a two-tier system is put in place, there won’t be much in the way of improvement to the overall healthcare system. Some who can afford it will receive better-quality care faster, most likely taking care away from those in poorer circumstances. Which is why some are fighting the two-tier system tooth and nail. That is not an improvement to the system, it is a degredation.
And I can assure you, OCSteve, that by actual statistics, Canada is comparable or better than average in most areas.
The World Health Organization has almost every type of measure, from every country in the world, here.
The Canadian healthcare system is not the world’s greatest. But it’s above average in performance (and if funded properly, it might very well be near the top).
Thanks, D-P-U. You might be able to tell this is a button-pushing issue for me.
Because healthcare is seen as a fundamental Canadian right, one’s economic standing in society should not provide lesser or greater access to that right
Well that’s an interesting way of looking at it. I always thought a “right” was something you had that the government couldn’t take away, not something that the government was supposed to provide everyone in equal quantities. For example, does the government fund a television station for everyone so they can exercise free speech rights (assuming they’re similar to US first A. rights)? That’s kind of a facetious point, but really, how far does the above quoted statement go?
I always thought a “right” was something you had that the government couldn’t take away, not something that the government was supposed to provide everyone in equal quantities.
I just checked, and to my surprise, it isn’t in the Charter of Rights and Freedoms. Sonofagun.
The “right” in question isn’t the government providing something, it’s something that everyone has guaranteed equal access to, regardless of economic status.
Imagine getting a call from your accountant at 10pm one night, Andrew.
“Andrew,” he says. “We really need to talk. You haven’t been saving, and in a few years, you’re going to retire — and you’ll be up a creek, won’t you?”
“What?” you say. “But I’ve been putting money in my 401K, and I have a few shares of MSFT, and–”
“Oh, no.” Your accountant sighs. “Andrew, none of my other clients invested as wisely as you did.”
“What? How is that my problem?”
“I’ve been using your money to pay for my other clients’ losing stock picks for the past twenty years. I have a pile of IOUs in your file folder.”
“That’s not right!”
“Oh, the IOUs are good! You’ll just have to figure out how to pay for your retirement without them. It’s a crisis.”
And I can assure you, OCSteve, that by actual statistics, Canada is comparable or better than average in most areas
Look folks – I stated up front that most of my evidence was anecdotal – and went so far as to remind you not to believe anything you read on the Internet.
But I was there – refuse to believe me, OK. I’m just making crap up if that is what you want to believe. It won’t take much research on your part to confirm or deny.
On your side – we have bus loads of senior citizens crossing the border your way to bye meds 🙂
Capitalism – consumers drive the market. What a wonderful thing!
Andrew: Justice Thomas’s views of executive power are completely inconsistent with your own. Authoritarian is the only word I can use on this family blog. Other, stronger, expressions come to mind. Thomas’s copy of the Constitution apparently lacks that section of Article I discussing Congress’s warmaking powers.
Scalia describes himself as a fainthearted originalist. In other words, he’s as results-driven as Justice Brennan allegedly was. When his pet theory leads to the conclusion he likes, there are no other possible legitimate theories of Constitutional interpretation. When it doesn’t (see, eg, Roe v. Wade, 11th Amendment jurisprudence, Bush v. Gore, etc.), radio silence.
the problem with Barnett’s book (which i haven’t read, but I followed the discussion at Volokh’s place) is that it assumes that justices will not be human. They are; positing theories of constitutional interpretation that will provide clear guidance to future disputes is just silly.
The “right” in question isn’t the government providing something, it’s something that everyone has guaranteed equal access to, regardless of economic status.
That makes more sense, thanks for the clarification.
Nothing more clearly illustrates American priorities than the fact that several people have cited, as a huge downside to systems where everyone (even the poor, even children, even poor children) has decent healthcare, high tax rates for the wealthy. Sometimes I think hilzoy has the hardest job in the world: teaching morals to Americans.
Enrak, we don’t get to tut-tut when people in other countries have to “queue” for medical services, because too many people in the US never get to stand in the line.
OCSteve:
I had “free” government provided health care for 4 years. It was called go to the clinic on post and take your chances. No thanks.
The trouble was, Steve, that you counted as a poor person, and you had poor people’s health care. Why is Medicaid a worse program than Medicare? Because Medicaid is for the poor, and “a program for the poor will be a poor program”. One big argument for *universal* health coverage is that the only way to get the poor adequately taken care of is to put them in the same boat with the middle class.
Another argument for UHC is from people like me, part of a small business. We had to shift insurers a couple months ago because our premiums were about to go up *65%*. How could UHC be more expensive than that?
Enrak, I’m confused by your comment at 1:17PM above. It seems that the data you linked to shows that Canada’s infant mortality rate is BETTER than the U.S. Am I reading that wrong, or are you? It seems like they do have the technology to save premies…
In fact, their rate is better throughout the periods covered in that spreadsheet, arguably before the greatest improvements in neonatal care. Canada’s numbers are worse in 1960, but every column after shows improved neonatal care. Coincidently, all 10 provinces agreed to implement the HIDS Act in 1961: http://en.wikipedia.org/wiki/Health_care_in_Canada
We’re also just talking about neonatal emergency care, but universal coverage would improve pregnancies and care for expecting mothers.
Sujal
Enter the economists:
Brad DeLong/Paul Krugmann
Sometimes I think hilzoy has the hardest job in the world: teaching morals to Americans.
Ouch.
That being the case, those we have are now going to be asked to take on more patients, which will probably mean rather extensive waiting lists to see one’s doctor. That can be resolved in the longer term by increasing the number of primary care physicians we have, but doing that requires that we pay primary care physicians more, therefore encouraging more people to go into primary care. Further, assuming Jes’s 18,000/year figure is accurate, that’s another 18k a year who need to see the doctor…those numbers add up over time. And what about illegal immigrants? That’s a lot more people who need to see doctors, who will now have the means under universal care.
Er . . . am I the only person who finds this ludicrous? Those people need to see the doctor now, Andrew. They already exist. They’re just using the inefficient and costly expedient of visiting the emergency room, which taxes the Er’s abilities to handle actual, you know, emergencies. Objecting to UHC on the basis that already-existing people will use a doctor’s visit instead of an emergency room trip strikes me as cutting off one’s nose to spite one’s face.
As far as illegal immigrants, their access to healthcare is a relatively low priority on my list, but suffice to say that if they’re paying taxes like everyone else — and most of them are, both via sales taxes and through payroll taxes and income tax, compliance with which I am to understand is surprisingly high — then they should get the same access as everyone else.
Jesurgislac may or may not be interested in the fact that, following the success of Morgan “Mr. Obvious” Spurlock, another woman did the same thing Spurlock did: Ate every single meal at McDonald’s, every day, for however many months. She, on the other hand, did what an intelligent adult human being would do — she exercised free will. Rather than subject herself to arbitrary and idiotic rules such a, “I HAVE to ‘super-size’ it if they ask me,” she chose wisely, and ate a complete meal each time. And you know what? She lost weight. That is what happens when smart people act intelligently rather than engaging in obvious and polemic publicity stunts.
Anecdotally, I recently had a conversation with a colleague who lives and works in the UK, and in the course of discussing various medical-related things, I said, “Well, at least you have the National Health,” at which she proceeded to unload at length about how much she hated it and how inefficient she was. And she’s not exactly a conservative. Interestingly, she’s Dutch by way of Chinese parents, so who knows what she’s comparing it to?
Not that argument by anecdote means anything, of course, but as long as everyone else is guilty, I wanted to join in.
One of the benefits of universal healthcare is that there is an incentive for everyone involved to encourage preventative care (EG – neonatal). This too brings down the overall costs to the system.
Whoops, forgot to include the link: Here’s the woman in question.
Phil: Anecdotally, I recently had a conversation with a colleague who lives and works in the UK, and in the course of discussing various medical-related things, I said, “Well, at least you have the National Health,” at which she proceeded to unload at length about how much she hated it and how inefficient she was. And she’s not exactly a conservative.
Grumbling about the NHS is a fine old British tradition. Well, actually, as British traditions go it’s actually fairly modern, given that we’ve only had it to grumble about since 1948. Grumbling is a fine old British tradition: we’re very good at it, you may have noticed. 🙂
Interestingly, she’s Dutch by way of Chinese parents, so who knows what she’s comparing it to?
The Dutch system, would be my guess. Or else she had just lived in the UK long enough to join in our traditions.
Francis,
I said Thomas was the best available. I’ve only got nine justices available; it’s not a deep pool to draw from.
As for Barnett’s book, it is not a perfect system, but I prefer a system that fails on occasion to throwing up one’s hands and saying ‘let’s just worry about outcomes.’
Phil,
Thank you for pointing that out. My question remains, however, by moving that demand from ERs to primary caregivers, how is that going to change the ability of the system to address the demand? ERs are, I believe, overtaxed now, so a universal system would reduce that problem. But unless primary care physicians are going wanting for patients, there’s still a problem of increased demand, we’ve just changed where the lines form. It is possible that, over time, the increased demand would be compensated by more physicians going into primary care. I don’t know. That’s why I ask. I’m odd that way. (And in many others that we need not get into here.)
Back from work — if we’re going in for anecdotes about waiting lists, I get to adduce the seven months it took me to get an appointment to have surgery, even though I am on the faculty at the university whose hospital I was going to, and know how to navigate it. Seven months of constant, fruitless calls.
I will look up actual data on comparisons between different systems shortly.
But before I do — Andrew, I agree with you about wanting the courts to stick to the Constitution. However, since the point that arose above was about precisely what the Constitution means on this point, and in particular why Article I Sec 8 shouldn’t be read as allowing Congress to tax and then spend money on improving the public welfare, I’m not sure that’s germane.
And as for thinking laws should be presumptively unconstitutional (which is what the idea of their having to be positively shown to be in line with the Constitution would, I think, mean), I think this would be both difficult in practice if it meant anything more than saying: well, looks like an exercise of an enumerated power of Congress. If that is all it means, then I don’t see why the enumerated power I adduced would not suffice.
Moreover, if it did mean that laws had to meet some extra burden, I think that this would raise problems that one might describe either as problems involving the separation of powers, or else as problems coming up with a plausible interpretation of the claim that Congress, not the Court, has the power to enact laws.
Look at it this way — would you rather have lines forming when people are looking for non-critical care, and they’re in a better position to reschedule? Or would you rather have the lines forming at the emergency room, where people wait until things are catestrophic because they have no other option?
I want to commend you by the way on the post and the thread. I disagree with you on a number of points, but it’s been refreshing and a very good read on all sides.
Andrew: the Dutch is geographical. When I started on the internet, in 1994, I wasn’t married so marbel was derived from Marjolein Bellinga (my maiden name). In the Netherlands I am still posting as marbel, outside as Dutchmarbel 🙂
Enrak: here is a diagram about the percentage of foreign born in the OECD countries. The differences are not as big as you think.
Oh, I do like a nice compilation of statistics 🙂
Which reminds me… Andrew, you *do* know Lizardbreath is female? Actually, there are quite some women posting here – and names can be misleading 🙂
hilzoy,
I’ll readily concede that, even with a strict system of interpretation, the Constitution has a great deal of wiggle room, no doubt an intentional feature in order to gain the votes necessary for passage.
The devil is in the details, so a means for implementing the presumption of liberty would hardly be an easy task. But assuming a law to be unconstitutional rather than constitutional would shift the burden of proof from the people to the government. Traditionally, if a law is in a gray area, the courts have sided with the government (a broad statement that I’m sure has many exceptions). This would flip that presumption, which I consider a significant improvement.
I’m not sure I follow the separation of powers argument. The court would still not have the power to enact laws, only to overturn laws passed by Congress it deemed unable to clear the presumption of liberty hurdle. Is that not their role now?
I was floored the other day when I read in the unfogged comment section that Lizardbreath was a woman. Not that there’s anything wrong with that.
And until today, I thought dutchmarbel was a guy as well.
As for me, I’m a super intelligent experimental chimp in a Canadian research facility. But a male one.
I am a luminous ball of excited neutrinos.
Jeff,
In a perfect world, I’d clearly rather have the lines at the primary care physicians. But there is more to the debate than that.
Thanks for the kind words.
Dutch,
Yes, I knew that, I was just being a wiseass. My humor is often…subtle. (Or perhaps unique to me, based on the number of times I’ve said something I found to be hilarious and gotten dead silence as a reaction.) It was also a play on the fact, in English, there are three ways to refer to Holland: Holland, the Netherlands, and the people as the Dutch. (It thoroughly confused George Costanza.)
No, I did not realize LizardBreath was female. I guess that changes the whole blogcrush perspective, doesn’t it? 😉 Not that I’m sure I haven’t blown that out of the water with this thread. Which my wife will be glad of.
I am an arme clothed in whyght samyte, that held a fayre swerde in that honde.
Alternatively, I’m the violence inherent in the system.
Or possibly just a watery tart flinging swords about.
Andrew: you missed the ‘my old Dutch’ reference, though that might me more British than American – I find it hard to distinguish between the two.
“Beep beep!”
Andrew: In a perfect world, I’d clearly rather have the lines at the primary care physicians.
I’m still wondering why you persist in treating this as an academic “in a perfect world” exercise, instead of looking at the 28 countries with universal health care systems and explaining why you think the systems used in those countries won’t work in the US.
be, not me….
it’s getting late.
Jes,
There are larger questions involved in this than that for me. Besides, I’m sure that if we put in place one of those systems, they would ‘work,’ inasmuch as they would provide everyone with some health care. Some people would have more than they have now. Some people might have less than they have now. But I don’t believe I’ve said that universal health care out-and-out can’t work here. I’ve just said that I’m not in favor of it.
Dutch,
Apparently I thoroughly missed the reference. I’m still confused on it, in fact.
if we’re going in for anecdotes about waiting lists, I get to adduce the seven months it took me to get an appointment to have surgery, even though I am on the faculty at the university whose hospital I was going to, and know how to navigate it.
Oh, I can play too! Eight months waiting for neuropsych testing — at the hospital of the university in which I’m a graduate student and TA — ordered because my doctors were worried I might have a neurodegenerative disorder of some kind. Came up clear, thank god, because I can’t imagine what might have happened to me in the interim had I been so afflicted.
[Of course, I don’t really remember much of that year so I can’t be too thrilled at how things turned out…]
Dan,
I should note that I reread that link you sent. (I had seen it before, actually.) I see nothing to suggest Barnett is lying, so I’ll assume that’s not where you came up with that claim. I do think he’s got some good points, though. If we have a Constitution, we really ought to come up with some generally accepted principles for interpreting it. Otherwise we ought to just throw it out, because if it falls in the Humpty Dumpty category, there’s little point in keeping it around beyond cheap symbolism.
I’ll readily concede that, even with a strict system of interpretation, the Constitution has a great deal of wiggle room, no doubt an intentional feature in order to gain the votes necessary for passage.
IMO, the “wiggle room” exists so that the Constitution can be a cornerstone of government instead of an ossified paean to a group of 18th century legislators. IOW, it truly is a feature, not a bug.
Andrew: But I don’t believe I’ve said that universal health care out-and-out can’t work here. I’ve just said that I’m not in favor of it.
So, you think people who can’t afford health insurance deserve to suffer and die? Funny, I thought when you said you liked to see poor people suffer you were being ironic, but I guess not.
So, you think people who can’t afford health insurance deserve to suffer and die?
If it makes you feel better to think so, knock yourself out.
this thread is complex enough that i’m going to request / urge / suggest that constitutional hermaneutics (look it up yourself) be a separate topic.
Andrew: you are, duh, entitled to your view that you’re not in favor of government-sponsored universal health care insurance. But leaping into this breach yet one more time:
a. Statistically, the US spends more than any other industrialized country per capita, for very average returns.
b. 40+ million people don’t have health insurance, which means that they live constantly on the edge of panic that something will go moderately (or, worse, chronically) wrong.
c. The free-rider problem, transactional costs and labor mobility impacts are having a measurable impact on our society. Fewer and fewer have health insurance, so it’s getting more and more expensive (see, eg, GM). We are currently in the vicious circle. GM may be driven into bankruptcy, with tremendous adverse consequences to its retirees and the American taxpayer.
d. Not all universal care programs are the same. Ezra Klein had an interesting series of posts on the different systems in UK, Canada, Germany, Japan and France. (France, oddly enough, appears to have a very successful system.)
e. For most of us, the personal is the political. I have excellent health care via my wife, who’s an employee of the County of Los Angeles. You get VA health care. But I avoided a serious car accident by a whisker at a time when I was uninsured. My life and the lives of my parents, sister and nieces would all have been very different if the family would have had to pay those costs out of pocket.
Luck and choice of parents should not play such an important role in paying for medical care.
So, do you believe that the current system is sustainable despite the evidence to the contrary? even if sustainable, is it fair? just? reflect American values?
If not, what do you suggest if not one of the essentially statist models of the other industrialized nations?
cheers. Thanks for sticking up for your viewpoint against almost universal opposition.
Garibaldi: “Beep beep!”
Londo: “‘Beep beep’? It must be Earth Humor.”
Andrew, am I to understand that it is not the Universal Healthcare you do not like, but the fact that you think the US can’t handle it as well as the other countries with universal healthcare?
If not: what *is* the problem you still have with the idea? I’ve not read anything fact-based yet and so far the ‘gut feelings’ have been contradicted by facts.
Francis,
I must again beg off a full answer until tomorrow, as it is close to my bedtime. I will note a few things, however.
For me personally, universal coverage would still be a boon. Sooner or later I am probably going to demobilize, and I will be back in the same boat I was in before mobilization, without health care. Better yet, I’m currently taking three prescription medications, so I’m either going to have to stop taking those meds when I demobilize, or find a way to cover the costs of the doctor’s visits and pills out-of-pocket. So my personal situation is such that government-sponsored universal care would still be a significant benefit to me.
As I noted in my original essay, I think that the system will eventually move to a government plan.
Fairness is such a relative term I dislike getting into it. Who gets to decide what is fair? Find me an objective definition of fairness and perhaps I can answer the question.
As to its justness, I don’t honestly know.
Reflect American values? Which ones–rugged individualism and self-reliance? I think that American values tend to conflict in this, and many other areas.
Personally, I’d love to make a deal: give me ten years of a wholly unregulated system. See what the market does in that period. Maybe hilzoy is correct and this is a market failure, but it’s rather difficult to tell when the government has so thoroughly queered things over the past 60 years. If things get worse (or don’t get better), then you can have all the universal health care you want.
Thanks for sticking up for your viewpoint against almost universal opposition.
Now you know why I love Rocky. 😉
Dutch,
Consider me a Jeffersonian. Which is ironic, since my favorite founder is John Adams, but there you go.
“If you see something with eight legs go running by, tell me at once. I have to kill it before it develops language skills.”
Andrew: do meds go unchecked unto the market in your unregulated system? No FDA or anything?
Dutch,
I’d trim back the FDA to only check safety of medicines, rather than requiring them to prove efficacy. And I’d probably beef up the FTC to protect against inaccurate claims of efficacy.
If things get worse (or don’t get better), then you can have all the universal health care you want.
Errrr… what happens to everyone who gets shafted during that decade?
Anarch,
What difference does it make? It’s never going to happen.
Anarch,
It is a counterfactual that can never happen, because as you are no doubt referencing, the transition would be too abrupt. I’d need a time machine to go back to WWII and stop FDR from imposing wage and price controls to really see what might happen.
Andrew said: “I’d trim back the FDA to only check safety of medicines, rather than requiring them to prove efficacy. And I’d probably beef up the FTC to protect against inaccurate claims of efficacy.”
For the FTC to be able to do that, it would have to have (a) medical expertise and (b) consistent standards for what kind of studies constitute proof of efficacy. In other words, it would be the FDA. I fail to see what you’ve gained.
one last point then we can pick this up again tomorrow if you’re so inclined.
Insurance has been an intensively regulated industry since before the American Revolution. Given that insurance regulation has historically (and still is) a province of the States, what you have now is about as much of a free market as you’re going to get,
(distorted, of course, by Medicare and Medicaid — but if you are really arguing for a 10-year forebearance for those programs then (a) Jes may actually have a point and (b) you’re floating in some libertarian fantasy land unconnected to our reality).
(kinda like your and SH’s opposition to ag. subsidies. If you want to be a conservative, you have to live with ag. subsidies … or change the Democratic party to suit your views.)
The intent would be to get drugs to market more quickly, but still provide some protection against specious claims. It’s a tough line to draw. How many people die every year waiting for the FDA to approve a drug? How many might die if they approve too many? I don’t know where the right place for that line is, but I’d like to find some way to let potentially terminal cases get their hands on drugs sooner rather than later.
(a) Jes may actually have a point and (b) you’re floating in some libertarian fantasy land unconnected to our reality
And that seems a terrific note for me to call it a night. I’m happy to confirm any stereotypes you may have.
Andrew: according to the wikipedia Jeffersonians are in favor of education of everybody, no matter their status in life. Why is the attitude towared healthcare different?
“You know, I used to think it was awful that life was so unfair. Then I thought, wouldn’t it be much worse if life were fair, and all the terrible things that happen to us come because we actually deserve them? So, now I take great comfort in the general hostility and unfairness of the universe.”
Dutch,
I was thinking more of ‘that which governs least, governs best,’ but you have a point, given Jefferson’s involvement in the University of Virginia.
Although he did originally want the funding to come from the students, other than an initial loan from the state to build the physical plant.
Furthermore, just because one is in favor of something, it does not logically follow that one believes it should be provided by the government.
“What the hell is your problem?”
“For starters, I don’t know you, therefore I don’t trust you.”
“The universe is full of people you don’t know.”
“I know. I worry about that all the time.”
And on that note, I really must go. Doubtless to kick puppies, scream racial epithets, and spit on poor people.
“And that’s when I shot him, your honor.”
“I have been nothing but compassionate and understanding. I mean, all you had to do was to admit you were wrong and I was right and everything would’ve been fine!”
way past bedtime here, goodnight!
Would I be right in assuming that one of those two posts was from a fake-Andrew? The juxtaposition’s a little odd there…
Anyhoo:
BachelorAndrew #1: What difference does it make? It’s never going to happen.I assumed that you (?) were enunciating a possible plan, not simply shooting the breeze.
BachelorAndrew #2: It is a counterfactual that can never happen, because as you are no doubt referencing, the transition would be too abrupt.Actually I wasn’t referencing the transitional costs, although that’s also a factor. It’s simply that the free market is not well-known for its ability to (consistently) look after the needs of the poorest members of society. This isn’t a particularly pressing matter when it comes to, e.g., theatre tickets (pace LizardBreath), but it is when we’re talking about matters of life and death. Suppose then we were to transition to a ten-year plan; ignoring transitional costs, which are a nightmare all their own, what if the free market health care system of which you spoke simply doesn’t work, due to the various reasons enumerated upthread? For that matter, what if the health care system suffers a market failure? [Horribly bloodless term for something so brutal to those crushed at the bottom.] It’s one thing if you missed a chance to see Cats; it’s quite another if your leg needs to be amputated because you were unable to get proper diabetes medication for a decade. To whom would such people turn? What redress would they be offered?
I recognize that you’re talking about a hypothetical here, but I don’t think you’re adequately following through the consequences of such a scenario. And this is, peripherally, one of the things that bugs me about these health care debates (and discussions of “truly” free-market health care systems in general): it’s a given that any free-market economy is going to be cyclic, with expansions and contractions, but the real human costs of such a contraction is, IME, rarely made explicit, or even considered. Health care is not a luxury; it’s not something you can simply opt not to use without ill effect (the classic “bandage on a broken bone” syndrome); it’s not in any meaningful way fungible, unlike other necessities like food; it’s not, in short, a commodity like any other — if it even is a commodity under the normal definitions, which I’m somewhat dubious about — and treating it like one seems to me to be guaranteeing that some people are going to get screwed, and screwed hard.
On your original post, I agree with everyone who said read Ezra Klein. His series describes the specific features of different state health plans and various measures of their success; it’s a shame that that kind of discussion is so rare.
Anyway, I disagree with most of your post, but I like the way it’s written; this kind of honest attempt to lay out a conservative viewpoint for a mixed audience is part of why I love this blog.
Apart from wishing for more reference to evidence, my main problem with your post is this bit: “If universal health care has problems, Congress won’t kill it, they’ll just ‘fix’ it, doubtless with the same degree of effectiveness they’ve had in addressing the looming entitlements crisis or in crafting Medicare’s Plan D.” I think you’re arguing against your own point there without realizing it. Both the ill-conceived Social Security “reform” proposals and the monstrously incompetent (and, to some of my patients, genuinely dangerous) design of Medicare Part D did not come from some timeless, universal, abstract Congress; they were pushed through by the current Republican administration, which believes privatization is the answer to every problem; they weren’t so much trying to “fix” those systems as replace them with entirely incompatible systems based on an opposing ideology. To take their failings as a sign that government just can’t do anything right is a bit like saying “Sure, these square-wheeled cars are a pain, but why bother making round wheels? The auto industry would just screw them up somehow, like they did with the square wheels.”
Also, at least there’s some leverage for changing government programs. The current mishmash of private insurance has its own massive inertia that is not going to change as a result of any private agent’s motives.
Andrew,
“I see nothing to suggest Barnett is lying, so I’ll assume that’s not where you came up with that claim.”
The lie is claiming there is no such thing as a Constitution-in-exile movement, while writing a book entitled Restoring the Lost Constitution for a movement which argues that what is generally viewed as Constitutional interpretation today is substantially different than the “proper” Constitutional interpretation used in the past. In other words, he is claiming that there is no such movement while simultaneously leading it.
“If we have a Constitution, we really ought to come up with some generally accepted principles for interpreting it. Otherwise we ought to just throw it out, because if it falls in the Humpty Dumpty category, there’s little point in keeping it around beyond cheap symbolism.”
Unfortunately, since everyone who does the interpretation ultimately does their own Humpty Dumpty impersonation, even those who loudly proclaim that they are not, I see no point in people loudly claiming there are such principles. While I don’t really want to sidetrack this thread any further by going into the Kelo dissent, the same people who are leading the Constitution-in-exile movement are also loudly arguing for a position which has no support in the literal language of the Constitution, nor in the way it was interpreted during the period they are holding up as the proper period of Constitutional interpretation.
“I’d trim back the FDA to only check safety of medicines, rather than requiring them to prove efficacy.”
Hilzoy probably has indepth knowledge on this, either way, rather than my layperson beliefs; but most medicines & drugs have side effects, including unsafe ones. (That’s a foundational arguments for prescription drugs right there — they may do what they’re intended to do, but they’re only viewed as safe for the consumer when considered as part of an overall medical condition by a doctor and pharmacist).
If you’re only caring about safety and not efficacy, how do you decide whether a product is “safe enough” ? And if the market is wholly unregulated, do you want every drug to be sold ‘over the counter’?
Political philosophy isn’t an end in and of itself. Politics is about something concrete: how a society is shaped, how it’s governed, how it allots its resources, and to whom.
Political philosophies need to address the actual consequences of their realization, and be judged on that basis, rather than on some Platonic level of abstraction where things always happen the way they’re supposed to. Saying that Philosophy X “would have worked if everyone followed it correctly” is the same shoal on which Christianity and Communism ran aground.
A healthcare system is also a concrete thing, with a purpose: to cure the sick, heal the injured, and possibly even keep them from relapsing. Healthcare isn’t an option, and the need for it is often not a matter of choice. Denying healthcare to people because they can’t afford it is – never mind the moral/ethical issues – nonefficacious because unmet health needs affect more than just the people suffering from them. Making healthcare available to everyone is a societal benefit; denying healthcare to people (particularly on the basis of economics) is a societal failure.
To oppose or criticize a possible healthcare model, particularly a model which is proven to work better than the one we have now, and to do so purely or mostly on the basis that it doesn’t fit one’s political philosophy, is to miss the point entirely of what political and healthcare systems are for.
I am for the most part inclined to agree with various sentiments expressed by Andrew on this issue: I don’t think it’s the job of government to provide health care.
However. A couple of years ago (I know, I’ve told this story before) I was having a discussion with a friend of mine, a guy who’s been around the block a time or two in the world of medicine, also somewhat of a dweeb. That last I say in respect and admiration. The topic: this one. Anyway, I’m saying how I don’t think it’s the job of government to provide, yadda yadda yadda, and Andy says something a lot like “we already have universal healthcare”. To which I say something intelligent, like “Eh?” And he says: here’s how it works. People who are too poor to afford doctors use the emergency room and various other resources. They can’t pay, so it just raises hospital cost for the people who can pay, and so who pays? The insurance companies. Oh, sometimes it’s people who barely have enough money to pay, too. So, he says, the real question is: given that we already have universal healthcare of sorts, and given that what the uninsured have to avail themselves of is just about the most expensive way to deal with their health issues, and given that many of these people aren’t doing anything resembling preventative healthcare, like periodic checkups, neonatal care, pediatric care, etc, doesn’t it make sense to at least consider that there is a) no escaping that we already have healthcare for everyone, and b) doesn’t it make sense to have it be by design rather than by accident? Having it be something geared toward keeping health rather than cleaning up after years of neglect; that too would be worth considering.
I had to conclude that he had a point.
I know, anecdote.
Slarti: he definitely has a point. Doing it in a sane way would be cheaper. It would also be better for the people involved — I mean, most people would rather deal with their medical problems before they require emergency care, rather than after. And there are all sorts of cases (documented in the literature, etc.) of people who go into the ER for a medical emergency, get treated, are told to take some medication, or return for follow-up visits, or in some other way use non-emergency care to treat the underlying condition, say ‘but I can’t afford that’, and end up back in the ER a few months later, completely needlessly.
Except that sometimes they die first.
Not a good way to do things, all told.
I appreciate Andrew laying out his views. The problem with medical bureaucracy encouter anecdotage is that very few people have comparable encounters with 2 different bureaucracies, and so it is easy to lose perspective. This is why it is really vital to go to some sort of overall view.
I am a bit taken aback by the fact that Andrew is against government control in this instance, because the absence of government control means that private enterprises control most of the information, and there is less possibility of oversight in that case than in the case of the goverment. Also, the argument that because now, ERs function as primary care, we have to be careful to not change the status quo so as not to overload primary caregivers, seems like someone who goes on a camping trip and forgets a knife to spread the canned sandwich spread, and then coming back and insisting that because it worked on the the camping trip, we should go out and find 10 can lids rather than get appropriate silverware.
“IMO, the “wiggle room” exists so that the Constitution can be a cornerstone of government instead of an ossified paean to a group of 18th century legislators. IOW, it truly is a feature, not a bug.”
Sure, but what precisely does that have to do with modern liberal theories of jurisprudence? “Wiggle room” is not the same as “penumbras wherever I want” or outlawing things that were specifically contemplated in the Constitution (death penalty).
Andrew: If it makes you feel better to think so, knock yourself out.
No, it makes me feel worse to do so: I just don’t see any other possible conclusion. You’ve acknowledged that an estimated 18,000 people die each year because they can’t afford health insurance and therefore don’t get the health care you need. You can’t be unaware that lack of health care means suffering.
You just explicitly said that you “don’t favor” a system which would save those lives and alleviate suffering: you would rather those people suffer and die. And you have not given any reason other than personal preference why you favor these people suffering and dying.
Sebastian: “Wiggle room” is not the same as “penumbras wherever I want” or outlawing things that were specifically contemplated in the Constitution (death penalty), slavery.
End italics.
Sod! There should have been a /Italic after “death penalty”. That’ll teach me to try doing clever formatting tricks pre-coffee.
Jesurgislac, accusing the other that appearantly they are so bad that (s)he wants this really bad outcome is NOT a great way to make people listen to your arguments. Espacially if the bad outcome is something you KNOW they don’t want even though you think it is an unevitable part of their preferred solution.
Say for instance that I would not phrase it like this gentle reminder, but instead came up with something like: “but you know this is a stupid way to present the argument. It has been brought to your attention repeatedly. If you than still use the tactics I must assume that you really are that stupid and that you are either to stupid to know, to uninterested to care or that you WANT to be seen as this stupid.”
Now, I don’t think you are stupid at all and that would not be the way I would put it *if* I thought you were stupid. But can you see that the outright attack does not make someone more receptive? And I prefer dialoque myself, which works better with receptive parties.
Marbel: Espacially if the bad outcome is something you KNOW they don’t want even though you think it is an unevitable part of their preferred solution.
Andrew knows that the bad outcome (poor people suffering and dying) is an inevitable part of his preferred solution – no universal healthcare. It’s not just inevitable – it’s intrinsic: Andrew wants the people who can’t afford healthcare not to have healthcare.
I do Andrew the credit of assuming that he’s not fool enough to suppose that this solution entails no suffering, and he knows that it entails 18 000 people dying needlessly each year in the US. If you assert that Andrew doesn’t want these people to suffer and die, you are asserting he is a fool.
Do you realize that with your kind of reasoning… eh…let’s find and example… the people that defend Lebanon want Isreali’s to die, the people that defend Israel want the Lebanese to die and the pox-on-both-their-houses people want both nationalities to die since they obviously don’t want a solution?
Do you really not see the difference between the consequences of what someone proposes and what that person wants?
Slartibartfest: I like your anecdote!
Marbel: Do you really not see the difference between the consequences of what someone proposes and what that person wants?
If a mugger hits me and grabs my purse and runs off, yes, I suppose I can see there’s an abstract difference between what the mugger wanted – money for a fix – and what happened to me – I got hit and lost my money.
And you could say that one is an unwanted consequence of the other, if the mugger is a crack addict desperate for a fix: what the mugger wants is a fix, and my getting hurt and robbed is just a consequence. We should not talk about muggers wanting to hurt/rob people.
Andrew? Do you accept this as a fair distinction – that just as crack addicts shouldn’t be condemned for robbing people, you shouldn’t be condemned for arguing that it’s better for poor people to suffer and die?
I think it’s possible to believe, in all good faith, that there is an irreducible element of misery involved in a social or political situation, and that while my approach X does in fact lead to N deaths and miseries, any other would lead to more in the long run. For instance, any supporter of a revolution does believe this.
It’s also possible to be the sincere victim of a long-running and well-crafted campaign of deliberate deception, and I think this is true of most middle-class opponents of national health care in the US. Teresa Nielsen Hayden has written well (and with great depth of reference) about just how thoroughly astroturf is entrenched in our discourse. It’s not going too far to say that any publicly circulated fact used as justification against national health care is either fabricated or taken out of context. No arguement against it that refers to any data at all can be presumed honest unless the arguer has personally traced them all back to original citations and verified both the correctness of the quote and its appropriate context.
(Once we get past the lies and data abuse generated by authors who turn out to be getting payola from groups who profit from the current arrangement without mentioning these ties, there’s the category of true but not decisive data. Cherrypicking on waiting times for specific procedures is one form of this, while ignoring the very clear overall results like longevity, work time lost to illness, harm from the costs of catastrophic illness, and degree of satisfaction with the system. It’s focusing on the quality of pedicures while foot amputations are becoming commonplace.)
I just think that once one looks at the comparative data, then sooner or later a defense of the American system is going to have to say explicitly, “I think these deaths and this misery are more desirable than X” and explain just what that X is. And the older I get, the fewer Xes I’m willing to respect. This is particularly true with what boil down to comfort arguments. As with matters from jury duty to the recognition of marriages of a sort you personally wouldn’t want to engage in or solemnize, I tend to feel that your fellow citizen’s life and basic health trump your comfort zone and mine with regard to dangly bits of our discretionary spending.
One X I do respect is the incompetence of the Republican Party’s ruling faction. I certainly wouldn’t want to give them power to set up a big program for anything at all. But then I regard their removal as required for the survival of the republic at all.
An expansion (and with apologies: I hope you haven’t started composing a reply to my earlier comment)
Marbel: let’s find and example… the people that defend Lebanon want Isreali’s to die, the people that defend Israel want the Lebanese to die and the pox-on-both-their-houses people want both nationalities to die since they obviously don’t want a solution?
Actually, no. But the people who want Israel to bomb Lebanon, want Lebanese civilians to suffer and die. The people who want Hezbollah to bomb Israel, want Israeli civilians to suffer and die. Andrew wants poor people to be deprived of health care: he wants poor people to suffer and die. A mugger who hits me and takes my purse wants to hurt me and take my money. True, there are other motivations going on in all instances, but only a fool would allow the bombers or the muggers to pretend that an intrinsic result of their action does not exist merely because it’s not their goal.
On a personal note, I’ll add that researching health care had a lot to do with my abandoning libertarianism. I found that so much of the anti-government intervention argument was founded on willfully wrong claims of fact and tremendous deception about self-interest. (This BusinessWeek article about Michael Fumento’s payola from Monsanto is depressingly typical for both individuals and groups.)
Neither I nor my libertarian friends were willingly part of any cover-up or deception – we thought we were drawing on good research into uncomfortable-to-the-other-side facts. But the leaders of our side…well, to quote Teresa Nielsen Hayden, “Just because you’re on their side doesn’t mean they’re on yours.” We were lied to. The lies are still out there, but there came a point when I felt I had to separate myself from them, and then I found the same liars and lying methods in cause after cause I’d supported. A big chunk of my current hostility to American corporate business as usual is because of that – people who turn so readily to lies are not deserving of social or economic power.
Since they will not choose to stop the lying, the only alternative is to do what we can to reduce their power…and that starts leading in all kinds of directions.
Including the direction of relieving the misery of my fellow citizens with regard to health care.
The juxtaposition of Bruce and Jes comments is enlightening. Bruce, referring to his own evolution of opinion, suggests a path for Andrew to take without referring to want he ‘wants’, while Jes concludes that Andrew’s position is a direct result of his desires, which include wanting poor people to be deprived of health care, suffer and die. Adducing Andrew’s feelings in this way, she feels that she can then attack Andrew’s position with impunity. Unfortunately, I find it hard to see how this is going to induce Andrew is reconsider his position (if this is the purpose of the exercise)
Of course, at this point, Jes could argue that she is only trying to get Andrew to see the inevitable results of his preferences. However, seeing those inevitable results really have nothing to do with what Andrew ‘wants’ (because Andrew’s desires have no effect on the results and are only cited as a reason for why he holds the beliefs he does), so bringing them into the discussion really serves no purpose, unless there is some desire to make everyone realize how morally bankrupt Andrew is so as to encourage all of the other commentators to pile on. Seeing this as the inevitable result of this sort of argumentation, one could conclude that there is a desire on the part of Jes to create precisely such a mob mentality. Would that be a fair statement?
I have no fears that everyone else at Obsidian Wings will pile on Andrew: I’ve registered in the past that I’m virtually the only person here who thinks that people need to own the known consequences of their actions, whether or not those “known consequences” are the person’s stated goal.
I’m aware that this is not a pleasing conclusion for people who want (for example) an airforce to be allowed to claim they don’t target children, they just drop cluster bombs on streets where children play, knowing that children will die or be horribly maimed as a result.
And plainly, it’s not a pleasing conclusion for people who want a conservative to be allowed to claim that he doesn’t want poor people to suffer and die, he just wants them not to get the healthcare they need.
It’s not just an unpleasing conclusion, it makes the possibility of change thru dialogue impossible. This is the reason why mindreading is such a strong taboo in blog comments and email lists, because it not only short circuits current discussion, but it does so to future discussion, even though our underlying opinions have little or no real world effect on the subject in question. If Andrew really wants poor people to suffer and die, this gives you license to be completely nonplussed to bring up this fact when he argues for aid to Sudan or something like that. This rhetorical move seems so powerful that it comes across to me like an excuse to completely reject anything that Andrew or any other conservative says. You’ve done this with Sebastian, von and Charles, so it shouldn’t be surprising but from my standpoint, you are simply encouraging people to ignore any good points that you have because you seem (and here I click into mindreading mode) to have a desire to prove that you are morally better than other people rather than actually move the ball down the field. This is unfortunate not only from the standpoint that people start to turn you off (how many people do you think follow the ‘Bush stole the election’ comments and how many simply skip over them) but from the fact that temperatures rise and people get angry, leading them to say things that are harsh, which are pounced upon as further proof of bad intentions. The not pleasing conclusion is that you aren’t interested in change, you are only interested in proving that you are right and others are wrong. If you were to assume that Andrew’s impulse stemmed from a perfectly understandable notion (such as that he feels that the government should not have such control of certain aspects of our life), and attempted to establish some framework for understanding, while you might have to let go of the notion that Andrew is an amoral monster, you (and we) might be able to be better able to understand why this notion could undergird such a powerful rejection of what seems to be an appropriate use of the state, which would be the maintanance of the health and vigor of its populace.
I just don’t see any other possible conclusion.
I’m thinking it’s because you don’t want to.
See how handy that sort of character assassination is? All you have to do is assign evil motives to the other person, and you win!
Dan,
I think Barnett’s objection to the ‘Constitution in exile’ claim is that Sunstein wants to use that term (and other loaded words like ‘radical,’ etc.) to discredit the argument, rather than laying out reasons why the argument is a bad one.
Perhaps it is a lost cause. But I am of the opinion that, if we are really going to be a constitutional republic, we ought to try to come to some understanding on how that document is interpreted beyond, hey, if five Supremes say it’s good, it’s good.
Brian,
That’s an excellent point. Particularly given the list of various nefarious side effects that my meds may cause that the pharmacy hands me every time I renew my prescription, I should have thought of that. Perhaps the FDA we have is the best compromise we’ve got after all. I would still like to find some way to let certain cases bypass FDA approval, though, in the case of people who are going to die otherwise. Conversely, there’s the whole question of how you test the drugs properly without double blind studies, etc. It’s a complex question, and one I’m not competent to answer. So I’ll end by saying just this: the goal should be to get medications in the hands of patients as quickly as possible while ensuring the most common risks are reasonably well known; how to accomplish that, I’ll leave to health care wonks while acknowledging that the system we have may be the best we can do.
Jes,
“Mr. Garibaldi. I have been on this station long enough to know that you don’t ask leading questions unless you already know the answers. So, why don’t we just pretend I’ve lied about it, you’ve caught me in your web of insufferable logic and cut to the point.”
It is my experience, after attempting to communicate with you since I arrived here, that you have already determined my answers in advance. Therefore, I see little point in going down the same roads over and over again only for you to once again conclude that what you think is the only possible answer to the questions you pose.
Nonetheless, if only because I seemingly cannot resist tilting at windmills, I will sally forth once more in my vain quest.
I have never said that I want 18,000 people to die every year. Nor have I said that I do not want the poor to have better health care than they currently enjoy. That is not the debate we are having. If that were my goal, I would be attempting to pass laws requiring cash down at medical clinics or some such in order to further degrade the health care available to the poor. (I’d also have a Snively Whiplash mustache to twirl during these posts, but I suppose you don’t know that I don’t.) The argument is whether or not the government should step in to take over the country’s health care system. It is possible, believe it or not, to believe that some solutions to a problem would be worse than the problem itself. This is the case with me and universal health care.
It is a difficult subject. Many people have made some good points in this thread. I am well aware that my position may be wrong, and I will continue to consider the question. I confess, however, that being merely human, reading your insults is generally quite sufficient to convince me to stand my ground, if only to ensure I am not rewarding such incivility.
Andrew,
“I think Barnett’s objection to the ‘Constitution in exile’ claim is that Sunstein wants to use that term (and other loaded words like ‘radical,’ etc.) to discredit the argument, rather than laying out reasons why the argument is a bad one.”
We must be looking at different discussions. In the one I cited, Sunstein starts off explaining what is wrong with the movement’s thinking, and Barnett ignores Sunstein’s arguments to go off on him for using the Constitution-in-exile term.
I agree we need to agree on how the Constitution is interpreted. But the answer to how it is interpreted is a different one than how, under some people’s theories it should be interpreted. Therefore, the fact that the champions of the Constitution-in-exile movement do not follow its dictates when they believe strongly about an issue is very probative evidence that their theory does not explain how decisions are actually made.
Dan,
I suppose that depends on how you define the ‘champions of the movement.’ As I noted yesterday, none of the justices on the Court are really originalists. Perhaps I’ll start another thread on this topic at another time.
Andrew,
As noted before, even Barnett and his fellow Volokhers do not follow their theories in cases like Kelo. Indeed, they are at the forefront of claiming that Kelo is abhorrent law, without ever noting the history of eminent domain for private purposes in this country, with cases allowing it for private canals and toll roads in the first years after the Consitution was ratified.
I have never said that I want 18,000 people to die every year. Nor have I said that I do not want the poor to have better health care than they currently enjoy.
You have said that you are opposed to universal health care – that is, that you believe some people should do without any health care, or get only the health care they themselves can afford to pay for when they need it. If you are incapable of figuring out that this means many people will suffer, and some people will die – and that poor people will not get better health care – then I confess it: Marbel was right. You don’t want people to suffer and die: you just want those people not to have health care.
Silly puns R us.
M: (Knock)
A: Come in.
M: Ah, Is this the right room for an argument?
A: I told you once.
M: No you haven’t.
A: Yes I have.
M: When?
A: Just now.
M: No you didn’t.
A: Yes I did.
M: You didn’t
A: I did!
M: You didn’t!
A: I’m telling you I did!
M: You did not!!
A: Oh, I’m sorry, just one moment. Is this a five minute argument or the full half hour?
M: Oh, just the five minutes.
A: Ah, thank you. Anyway, I did.
etcetera
It’s nice to see that the “objectively pro-X” accusation still has legs — I hated to think of it sitting all alone in some dark corner, wallowing in self-pity, pining for the glory days of the run-up to the Iraq war.
Don’t forget the abortion threads. It’s a pretty wearying argument to get into; I’ve decided the best response is just to say, “Why, yes. I do want thousands of poor people to die because they’re poor. You’ve found me out!” and move on to the next conversation.
Don’t worry, Andrew. We know you’re not plotting genocide, of classicide, or puppy-kicking. I agree with Jes on a lot of things, but she has a strong tendency to assign a numerical value of deaths to anyone’s ideological position based on various estimates, and spend a week or so insisting that anyone who disagrees with her is clearly and obviously motivated by a desire for those people to die.
I think there would be very dire consequences to the idea of ‘Giving the free market ten years to REALLY handle things.’ The whole point is that people ‘falling through the cracks’ of the health care system is both a moral problem and a pragmatic one for national productivity. ‘The Market’ is very good at getting optional things into the hands of the right people, but it’s very bad at making sure that everyone has some particular thing.
Spending ten years to see if the Market happens to manage something it’s not good at in the first place — when the consequences are death — strikes me as a flawed plan. I know that you’re not seriously suggesting it as a new government policy, but you did seem to suggest that it was your ‘perfect world’ solution.
I just choose to believe that you haven’t followed the thought-experiment through to its eventual conclusion, rather than believing that you actively desire those negative consequences.
I second Jeff Eaton’s thoughts.
I just choose to believe that you haven’t followed the thought-experiment through to its eventual conclusion, rather than believing that you actively desire those negative consequences.
Indeed.
But rather than permit Andrew to stare peacefully at his thought-experiment without ever thinking it through, I prefer – as with denial of legal abortion, as with cluster-bombing cities – to point out that when you advocate a “thought experiment”, these are the ideas you are advocating.
To do otherwise seems to me to be as irrational as assuring a small child that they can light fires whenever and wherever they feel like it, and there will never be any consequences other than the pretty, pretty flames. Fire burns. Denying people health care kills.
Just to take one futile little stab at it:
Normally, when we say “I want X”, we mean that we regard X as a good thing, something we would actually like to get. Whereas some of the foreseen consequences of what we do are things we are willing to accept for the sake of something else, but do not actually want.
Thus, I want to see a movie. I do not want to hand over eight dollars to the movie theater (meaning: this is not something I in any way see in a positive light.) I do want the combination: (seeing the movie at the cost of eight dollars). But I do not want to pay for the movie pure and simple — the payment is something I am willing to accept for the sake of seeing the movie, but not something I in any way desire in its own right.
If someone advocates something (X), and you think that person recognizes that X has some consequence Y, then it is fair to attribute to her a belief that (X and Y) are desirable. If Y is bad, it is fair to say that she wants (X at the cost of Y). Also, of course, that she wants X.
But it is not fair to say that she wants Y, since she might think that Y is completely regrettable, and wishes there were a way to get X without it. (Similarly, I wish there were a way of teaching honestly and honorably that didn’t involve ever failing my students. I hate failing my students. I wish I never had to. But since some of them will persist in e.g. not doing any of the work, the only alternative would be to pretend that they have done passing work when they haven’t, or else to establish ‘nothing’ as the threshold for passing.)
Recognizing that it is wrong to say that I want to fail my students, or to give money to the cinema, in no way fails to get me to own the consequences of my action. That is perfectly well secured by saying that I want (to see the movie at a cost of eight dollars), or (to have standards in grading, even if that means that some students will fail.)
While it does not prevent us from recognizing my responsibility for the consequences of my actions, however, it does allow us to mark the immensely useful distinction between those consequences that we would gladly not incur were there any way of doing so — consequences we regard as costs — and those we actually want — that we think of as benefits of our chosen policy, or as reasons to pursue it.
“Is the dark side stronger? No, no, no. Quicker, easier, more seductive. But how am I to know the good side from the bad? You will know… when you are calm, at peace, passive. A Jedi uses the Force for knowledge and defense, never for attack.”
In my opinion, Andrew is well on his way to escape from the dark side. As many ObWi conservative posters have mellowed (with one notable exception in the gamma quadrant), Andrew will see his positions change – post by post.
The principled stand of conservatives (and also of diehard leftists) unfortunately does result in a narrow view where other people’s suffering does not enter their calculations. See the Schiavo case where saving a living dead (dead living?) person was considered more important than the family’s grief. See the abortion debate where the death of a foetus trumps a woman’s dignity, pain and anguish. There is this invisible, suffering America that conservatives ignore. But the transformation cannot come through accusation but by encouraging them to look around (and abroad).
Don’t worry, Andrew. We know you’re not plotting genocide, of classicide, or puppy-kicking.
Sometimes puppies just need kickin’
(sorry, couldn’t resist)
jaywalker: there are times when doing the right thing requires that you allow other people to suffer. Grading is an obvious example, for me: it would be wrong to say that I am indifferent to my students’ suffering, especially when they express it in tears in my office. (Note: I am not heartless, and will generally try to find a way to let them pass that involves enough real effort on their part that none of the other students will think that it’s unfair. But sometimes they don’t take it.)
In a sense, it’s true that I don’t let it “enter my calculations” — I have decided, rightly or wrongly, that having standards in grading is the right thing to do, and that the point of grading is not to make my students happy, but to honestly assess their work. Thus, I normally don’t consider how unhappy my grades will make them. But that’s because I have a broader view, which I at least think I can justify, according to which I should not be guided by their happiness or misery in giving them grades.
The general point being: I don’t think that not considering suffering per se in making some specific call makes a view narrow, let alone wrong. The reason it might be in this case has to do with the specific question under consideration. But here I’d expect some libertarians, who might or might not include Andrew, to say: it is wrong for the government to intervene in a range of issues, including health care, in order to prevent misery.
Again, it’s not crazy to think that there is some range of decisions in which the government should not intervene in order to promote happiness. For instance, one might take the present rate of divorce to show that people would, all things considered, be happier if they were assigned spouses in a lottery. (Lower expectations might well lead to a higher rate of successful marriages.) But even if that were true, it wouldn’t be a good reason (I think) for the government to deprive us of the right to choose our spouses for ourselves.
The question is: is government intervention in the health care market more like intervention in choosing spouses, or like “intervention” in national defense, or what?
Hey, sorry about the gender confusion — I think of my handle as a transparent version of my real first name, which isn’t ambiguous. (And no, the blog-crush isn’t cancelled. It was instituted in the specifically “This is the kind of thing I’m very happy to hear anyone say, particularly conservatives” category, which requires some conservative views, regrettable though they may be, to qualify for.)
Substantively, I think Slart’s anecdote makes the serious point that demonstrates that Andrew’s ‘ten years of no government intervention’ is a bad idea. There probably are efficiency gains to be had from going to a pure, no-more-regulated-than-any-other-market approach to health care. But those gains come from not providing health care to people who can’t afford it. If you get shot in the parking lot of a hospital, and don’t have the money to pay for surgery, then letting you bleed to death will ease the strains on the system.
But we won’t do that, because we’re decent people. The system we’ve got now assumes that anyone, in a real emergency, gets care regardless of capacity to pay (because it’s ad hoc and badly organized, there are big unpleasant exceptions to that, but it is the assumption). And unless we walk away from that assumption, we don’t get the efficiency gains you’d expect from not having universal health care.
I don’t mean to accuse opponents of universal health care of being bloodthirsty and callous. But I do think that, if you aren’t going to be bloodthirsty and callous about it, then your economic arguments stop making sense.
hilzoy,
Your stab was neither futile nor little. Well done.
I think more to the point, my anecdote underscores that because we (as a society) are not callous, we give aid to those in need, and do so in a fashion that I like to understate as suboptimal.
So I think that it’s easy to become fixated on that first question that I see popping to Andrew’s mind (I know: mindreading penalty)…should we?…has been rendered irrelevant. Something is already being done. The question is, I submit, what should we design to make it better, more efficient, less costly and more effective?
And, secondarily, how can we fix it so that the devised solution isn’t subjected to variations in attention, funding, commitment, etc typical of our government?
Thank you, Hilzoy. I wasn’t up to explaining that distinction last night, and hoped you or someone else would be by to do so.
Actually, one of the things that really surprises me in this discussion is that anyone who’s ever gone to an American elementary school could think “Lizardbreath” is a *male* name, when it’s a playground (or sibling) variant of a common *female* name.
So I think that it’s easy to become fixated on that first question that I see popping to Andrew’s mind (I know: mindreading penalty)…should we?…has been rendered irrelevant. Something is already being done. The question is, I submit, what should we design to make it better, more efficient, less costly and more effective?
This, I can endorse.
And to Doctor Science: That’s what I would have thought too, but in practice people get it confused fairly often. I think if you’ve never run into the nickname in real life, it’s not as obvious a version of ‘Elizabeth’ as you’d think. Luckily, given that all this interaction is just words on a screen, gender confusion isn’t particularly important — I’ve ‘known’ people online fairly well for months who turned out later to have thought I was male.
There are, in essence, two grounds for objecting to govt-sponsored universal health insurance: practical and moral.
Practical — the govt is incapable of doing the job right. Response — quite probably so. Let’s talk about the systems established in other countries that depoliticize the delivery of health care.
Moral — the fed govt should not be in this business. Response — but it already is. At the very least, it requires that emergency department treat everyone regardless of ability to pay, and reimburses a portion of those treatment costs.
Also, you simply have to recognize that a majority of the voters in this country will continue to believe that this is appropriate, so the govt (ie, we americans) will continue to impose this obligation no matter how fervent your belief that this is an inappropriate role for govt.
“There probably are efficiency gains to be had from going to a pure, no-more-regulated-than-any-other-market approach to health care. But those gains come from not providing health care to people who can’t afford it. If you get shot in the parking lot of a hospital, and don’t have the money to pay for surgery, then letting you bleed to death will ease the strains on the system.”
Much more to the point, it is fairly intuitive that if you smoke for 20 years and get lung cancer, “society” probably shouldn’t pay for your treatment. Emergency treatment for random events is one thing (and you won’t find nearly as much conservative resistance on it). Long term treatment for lifestyle choices isn’t.
The conservative version of this intuition is to let you get whatever enjoyment you get out of smoking for 20 years and let you figure out how to pay for it.
The liberal version is either to absolve you from the responsibility of smoking (current model but with dramatically rising costs) or ban the smoking (probable future model).
Both have their negative side effects. The conservative version seem mean. The liberal version (current) positively incentivizes poor personal choices (not easily fixed by public relations campaigns) or becomes increasingly dominating of personal choices.
“See the abortion debate where the death of a foetus trumps a woman’s dignity, pain and anguish. There is this invisible, suffering America that conservatives ignore.”
Like locking people in welfare for multiple generations? Like building projects that trap poor black grandmothers with drug dealers? There is a type of suffering that liberal policies can cause…
Much more to the point, it is fairly intuitive that if you smoke for 20 years and get lung cancer, “society” probably shouldn’t pay for your treatment. Emergency treatment for random events is one thing (and you won’t find nearly as much conservative resistance on it). Long term treatment for lifestyle choices isn’t.
But you still end up in the emergency room with your emphysema, and your lung cancer, and your diabetes from overeating, and your heart disease from overeating and smoking. Whatever you say about the conservative attitute to providing treatment for lifestyle choices, you’ve got two choices — provide that treatment on some level or turn people out of emergency rooms to die in the parking lot.
No one wants to do the latter (or at least I’ve never met anyone I’d attribute that position to). But if you don’t, then you still spend an awful lot of money on uninsured patients, and it’s not clear that you spend much less money than you would by giving them access to care before they’re actually dying.
Is chemotherapy an emergency treatment? Is a liver transplant an emergency treatment?
Andrew wants the people who can’t afford healthcare not to have healthcare.
Well, no, Andrew wants the people who can’t currently afford healthcare not to have government-provided healthcare. That does not mean he is not in favor of pursuing alternate solutions geared towards getting those people insured or otherwise getting them better access.
There are, as I’m sure you’re aware (or maybe not? You often act as if not) often more than two potential solutions to each question. “The government” or “nothing” do not comprise the entire solution set.
Now, if you were really interested, you might actually politely ask Andrew what are some alternate solutions he’d like to see pursued, then debate their relative merits vis a vis UHC. Instead, it appears that you’re more interested in attempting to cast him publicly as a monster at worst or an idiot at best. Which reflects more poorly on you than on him.
PS: The fact that X number of people die each year as a result of lack of healthcare access does not in any way logically require that access to healthcare will save X lives. It may well save X-Y, where Y is some number who would have died anyway but whose lives might be prolonged slightly or their suffering eased as they die. I know that you know this, and I also know that continually slinging the number “18,000” around makes a useful moral cudgel with which for you to beat Andrew. Nonetheless, it merits pointing out for the benefit of others.
Is chemotherapy an emergency treatment? Is a liver transplant an emergency treatment?
They are if you don’t have an oncologist or a primary care physician and only end up discovering/seeking treatment for these conditions when it’s too late.
Phil: That does not mean he is not in favor of pursuing alternate solutions geared towards getting those people insured or otherwise getting them better access.
Ah. The magical, faith-based solution, “if I close my eyes and wish….”
What Andrew has actually expressed is a wish for the free market to cover it: that is, if he understand how the free market works, for people who can’t afford health care not to have health care. That’s how the “free market” works.
When all you have is a hammer…
politely ask Andrew what are some alternate solutions he’d like to see pursued,
He’s said ten years of no regulation. No regulation, literally, means people dying in parking lots — the reason people don’t get turned away from emergency rooms is that there are regulations against it. I don’t think he wants that, but that is the solution he’s advocated.
Is chemotherapy an emergency treatment? Is a liver transplant an emergency treatment?
In the second case, literally it is, but it’s one that we now let people die without if they don’t have insurance. How about kidney dialysis? It’s an emergency treatment if your kidneys have failed, and the emergency goes on for as long as you’re being treated. It would save a lot of money not to provide dialysis for uninsured patients, but it would result in an annoying buildup of corpses outside the emergency rooms.
Slart: Health care costs money. In an unregulated market, goods that cost money go only to those who can afford them. Given that some people who need health care can’t afford it, in an unregulated market they wouldn’t get it. You may have ‘non-hammer’ tools for getting around that fact without government intervention, but I must admit I can’t imagine what they could be.
Sebastian: “The liberal version positively incentivizes poor personal choices …”
For smoking, in particular, how does the liberal version do that? Clearly, neither you, a conservative, nor I, a liberal, have taken up smoking because we have been incentivized by the expectation of painful, but free chemotherapy for lung cancer, or horrific but free therapy for emphysema, or painful, but free flight-for-life to treat massive heart attacks. Nor do the two of us view monetary awards from tobacco companies to plaintiffs as a temptation to light up a Camel nonfilter and win the lottery.
So, how does this work?
Besides, smoking has declined in the face of the rise of subsidized medical care of one kind or another and the rise of the plaintiff’s bar.
The answer to that may well depend on the form that the intervention takes. Carried to an extreme — the government essentially taking complete control of the health care industry in an effort to provide universal care and control costs — such intervention might look, at least to the people on the inside, quite like choosing spouses. True universal care requires more than simply insurance coverage. It includes the problems of physician shortages in rural areas. It includes the problems of out-of-hours non-emergency access for the single mom working two minimum wage jobs. It may potentially include the problem of finding a physician who will accept government-provided insurance — certainly some of today’s Medicaid and Medicare patients experience that.
While I strongly favor universal care, I am also interested in the broad policy question of what is the minimum amount of interference that will be needed to really deliver that. I interpreted some of Andrew’s follow-on remarks as reflecting a concern that only massive interference can deliver universal care; so massive that he is willing to accept the downside of not taking those steps.
Oh, I agree wholeheartedly, Jes. I just think that it’s disingenuous and unhelpful to keep saying that the person actively desires those negative consequences, even has them as a primary goal, when the point of disagreement is whether those negative consequences will in fact happen, and whether they outweigh negative consequences from other courses of action.
One can even say, “I think that you’re deliberately ignoring the negative consequences (more deaths, in this case) because they would force you to question your ideological premises.” That is a very different thing than saying, “You want more death.” It seems… obvious to me. But it keeps coming up.
On the subject of kidney dialysis in particular, the POLITICAL problem for well-meaning libertarians in the Republican Party who can justify having Medicare, for example, not pay for it (I’m a liberal, big government-type, but I have personal experience with the “costs” of long-term dialysis treatment, and they are enough to make one “consider” the unspeakable, which is to cease the treatment) is that the religious wing of the Republican Party will not go along with it, unless they would be quiet for several million Terry Schiavos.
Except for Pat Robertson, of course. He would examine his faith and his libertarian principles, and go with whichever is more profitable.
John: is that the religious wing of the Republican Party will not go along with it, unless they would be quiet for several million Terry Schiavos.
One of the many reasons Terry Schiavo was the perfect candidate for Republican sympathy (religious or not) is that her estate was paying for all her treatment. There was no question of the state keeping her body breathing for free.
Yeah, there was a case a little while after Schiavo with a hospital cutting off life support for a dying woman while her family begged them to keep her alive until some family member could get there. I don’t remember how the details worked out, but it didn’t turn into a cause celeb at the Schiavo level for the religious right.
Jeff: That is a very different thing than saying, “You want more death.” It seems… obvious to me. But it keeps coming up.
Ah well, I think then we come back to owning the consequences of your decisions.
Andrew doesn’t want to own that the consequence of his decision (in his own mind, I’m not saying he’s actually *done* it) to deny healthcare to people who can’t pay for it, is that those people will suffer and die. But their suffering and death is intrinsic to Andrew’s decision to deny them healthcare. Andrew wants to play this like an academic game: “let’s suppose”, “let’s pretend”. Healthcare is no more an academic game than war is an academic game, or torture.
“Let’s suppose that torture does get results, doesn’t that justify using it even though some innocent people may be tortured?” “Let’s suppose that healthcare would work best as a free market, doesn’t that justify abandoning healthcare in the US to the free market even though some people on an income too low to buy healthcare die slowly of diabetes?”
Should someone who argues that he’s just speculating that torture might work, and if so, isn’t it justified, be allowed to get away with saying that he doesn’t want people to suffer, he only wants the information that he thinks might be gotten out of torture victims?
Should someone who argues that he’s just speculating that health care is better on the free market, be allowed to get away with saying that he doesn’t want people to suffer, he only wants people who can’t afford it not to get health care?
Dialysis is actually an interesting case. iirc, it used to be rationed by hospitals, since it was so expensive, until it started to be clear that the groups making the decisions about who would get it were using criteria like: who is a fine, upstanding member of the community? whose life is especially worth saving? at which point the Congress stepped in and said: wait, we’ll pay for it across the board. — This was in the early 70s, before health care costs had skyrocketed. But it was a very explicit response to rationing, and to the criteria being used.
Jes: “Should someone who argues that he’s just speculating that torture might work, and if so, isn’t it justified, be allowed to get away with saying that he doesn’t want people to suffer, he only wants the information that he thinks might be gotten out of torture victims?”
Yes, unless he’s a sadist and actually does want people to suffer.
As I said above, you can get people to own the consequences of their actions by just saying: you want no universal health care even at the cost of people dying. You don’t have to say that anyone wants people to die, unless people dying is something that person regards as a net plus.
This is not about owning consequences; it’s about the use of the term ‘want’ in standard English.
You all have done a wonderful job of laying out the negative side of our current health care system. But you keep calling it a “free market” system.
It is decidedly not. There are a vast number of supply side restrictions (CONs, the AMA, restriction on what health insurance must offer). These have costs.
Also, the claim is that we can switch to universal health insurance in a cost-free manner. We most certainly cannot afford the same defense structure we have now with universal health insurance. Now, I think a good deal of you are fine with that, but it is a cost.
Also, there are unintended consequences to moving to UHC as well. It is very likely that our current pace of investment in medical technology and drug development would diminish. I believe this would kill more than 18,000 people a year (in terms of lives saved foregone). YMMV. But I don’t think you can just ignore it. And if I were to use a certain someone’s logic I could say you are advocating the death of 10’s of thousands of people each year. What’s wrong with you?
P.S. I can’t for the life of me figure out why you are responding to Jes, Andrew. Nor can I figure out why Jes is talking to you. You’re an advocate of murder, who wants to talk to someone like that?
“You’re an advocate of murder, who wants to talk to someone like that?”
She obviously intends to save his soul.
Free of charge?
Wow. That would be like “charity” or something right? Reading this thread one would assume that there is no such thing in a “free market” system.
LSNED.
“the claim is that we can switch to universal healthcare in a cost-free manner.”
Oh, it will cost.
(I’m slow, but ‘LSNED’? All I’m getting is ‘Ellisoned’ and that doesn’t get me any farther. Harlan? Larry?)
Learn something new every day.
I didn’t think it was in common usage. I’m just lazy.
I was just being a wise-a** anyways. Feel free to ignore.
No problem. Thanks for the explanation.
Lizardbreath: I’ve ‘known’ people online fairly well for months who turned out later to have thought I was male.
I think you need to stop writing like a guy.
<ducks>
Jesurgislac said:
What if it’s not an unstated goal, either? I disagree with Andrew on the question of UHC, but I don’t see his position (stated or un-) as being that he doesn’t want the uninsured to be deprived of the healthcare they need, but that he feels the costs of providing it to them via a universal system would outweigh the benefits.
There are two basic possible outcomes of that line of thought. Either one believes that because the costs of providing universal care would be too great, nothing should be done, or one believes that because the costs of providing universal care would be too great, we should find a different way to provide care. So far, Andrew has yet to give me reason to believe that he’s not in the latter camp, rather than the former. And telling him that he just wants poor people to accomplishes nothing except giving you the chance to feel superior, while simultaneously alienating other commentors to the thread. (Which touches upon the subject of owning the consequences of your decisions, as it happens, except that in this case we’re discussing your decisions rather than Andrew’s.)
As for what Andrew has said about deregulation and the FDA, I feel the need to point out that the lack of regulations in place in the early 20th Century are why we got the FDA to begin with – ever read The Jungle, Andrew?
John Thullen had this question:
As best I understand it, the line of argument is that it incentivises it by providing the smokers with a way to make someone else pay the cost of their self-destructive behavior. Something along the lines of “If I get sick, I’ll just sue somebody.”
Lizardbreath had this to say:
It was a woman who’d immigrated to Texas, and whose care was to be cut off due to a Texas law allowing hospitals to end the medical care of a patient who is unable to pay (if they can’t find another facility to take the patient off their hands.) She was hoping to see her mother before she died, but the hospital administration was unwilling to continue treatment for the amount of time it would take, even if expedited, to get her mother the documents she needed to come to the US from her home country.
And then Enrak made this claim:
Provide the name of the person or persons making that claim, and the exact words which they used to say it, please.
It is very likely that our current pace of investment in medical technology and drug development would diminish.
why? drug developers would have to deal with a single purchaser in the US, which would likely require pretty low prices, but is there any substantial evidence that drug developers would really reduce staff and research budgets if the US went to a single payer plan?
Hilzoy: This is not about owning consequences; it’s about the use of the term ‘want’ in standard English.
I don’t agree. Or rather, I don’t agree for anyone over a certain age of mental responsibility. If I see a small child trying to push a fragile vase off a high shelf so as to bring the vase down to floor level so that the child can look at it, I’ll believe the child only wanted to look at the vase, and just couldn’t imagine it breaking. If I see an adult doing the same thing, even if the adult says apologetically afterwards “Damn, who’d have thought that pushing a vase that fragile from a high shelf on to the floor would make it break!” I will not believe they didn’t want it to break.
You’ve argued in a past column that Bush & Co do not care about the situation in Iraq, because if they cared, they would have foreseen the consequences (and, presumably, not acted as they did). I think that they did foresee the consequences and wanted them: I cannot believe that they were, individually or collectively, stupid enough not to foresee the consequences – and while at the moment it’s not clear why Bush & Co want chaos and death in the Middle East, all their actions suggest they they do.
The furthest I could go is, in the sense in which you used “don’t care”: Someone who expresses a wish for health care to be on the free market doesn’t care about the suffering and death of people on a low income. (Unless they’re in the military, in which case Andrew acknowledged it was functional to keep them healthy.)
In an academic discussion, there’s a difference between “I don’t care that people will suffer and die because of what I want” and “I want people to suffer and die”. In reality, however, no: if Andrew were running the US, and turned the health care system entirely over to the free market, in the sure knowledge that this would mean homeless people who developed cancer screaming themselves to death unless someone charitably gave them enough morphine to dull the pain, I’d say yes, President Andrew wants people on a low income to suffer and die.
Just as the person who abstractly says “Sure, I think we should torture prisoners of war, they might have useful information we need” is – you might say – not actually wanting to put the PoWs in pain, he only wants the information he thinks he can get. But, if that person were set to torture a PoW, they would perforce become someone who wanted to have that PoW suffer: that’s what happens to torturers. Taking ownership is acknowledging that this happens.
That if you want someone tortured, this means wanting them to suffer, and perhaps die. That if you want to withhold healthcare for people who can’t afford it, this means wanting them to suffer, and eventually die.
why? drug developers would have to deal with a single purchaser in the US, which would likely require pretty low prices, but is there any substantial evidence that drug developers would really reduce staff and research budgets if the US went to a single payer plan?
There’s a facial validity to that; lower prices with the same costs would mean lower profits–that leads to reduced research and expenditures given that the incentives are lowered. I look to analogies to rent control.
Not that I’m against another system of universal health care, but this is not a factor to ignore.
I was referring to the hammer being used to bludgeon Andrew. But hammer is probably wrong; however, something like “hand-shaped ham” doesn’t flow quite as well.
“drug developers would have to deal with a single purchaser in the US, which would likely require pretty low prices, but is there any substantial evidence that drug developers would really reduce staff and research budgets if the US went to a single payer plan?”
Drug research is paid for by high US profits. If the single purchaser US government dramatically lowered those profits, the investment currently attracted to high profits in the drug industry would invest their money in things that made more money.
Jes, is it fair to say that you wanted Saddam and his family to remain in power in Iraq, and wanted his victims to continue to be tortured and killed?
Prodigal:
Thanks. I know that is the probably at least part of the line of argument. But, in practice, who has said that to themselves, and then used it as incentive for poor personal behavior?
Like Kierkegaard said of Hegel (paraphrasing), alluded to way up thread, he explained the workings of the universe and the human race but failed to explain his own behavior on an ordinary Wednesday afternoon.
Provide the name of the person or persons making that claim, and the exact words which they used to say it, please.
Well, it was pointed out above that the US pays more per capita for its non-universal care than several other countries do for their universal care. It’s not quite the same as the quoted assertion, but it’s in the ballpark.
Prodigal,
That is a good catch. I wish I had more time to devote to this, as the conversation here is very good (aside from one notable exception). I made a rather drastic charge, when it was really more of a feeling I got from the thread.
What I should have said is that I don’t think there has been enough discussion of the costs of switching to UHC.
Drug research is paid for by high US profits.
Really? Which sector is overpaying — insurers, the government, individuals?
If the single purchaser US government dramatically lowered those profits, the investment currently attracted to high profits in the drug industry would invest their money in things that made more money.
So the driving force in medical research is the drug industry’s cost of capital? Or share price of Big Pharma?
this issue is too important to be supported by argument by assertion. evidence would be nice.
Liz: In an unregulated market, goods that cost money go only to those who can afford them.
Actually no, in a competitive market, you will find different value propositions at different price points (Ferrari, Toyota, …). This is the key point of the discussion: Other nations provide comparable or better healthcare at cheaper cost than the US. The US has a huge lead catering to the botox crowd, though.
US doctors pay extreme amounts for malpractice protection. This is a state guaranteed money transfer to the lawyers. A huge amount is also invested in advertising for medical products (Viagra spam anyone?). Most European nations limit advertising for medicaments. Fun fact: US pharma spends more for advertising and marketing than R&D (eg latest quarter Pfizer 3.9 bn for Selling/General/Admin. Expenses; 1.8 bn R&D).
Second fun fact: R&D spending and breakthrough medicaments have a low correlation (ref. missing, I think I read it in the economist. Google brings you this non-pharma specific Financial Times article For innovation success, do not follow the money by a MIT scientist). Look at the history of medical inventions, money was the least problem. The costly thing is the regulatory process which, as some joked, would never clear aspirin today. Witness the problems the pharma giants face when their pipeline dries up.
US doctors pay extreme amounts for malpractice protection. This is a state guaranteed money transfer to the lawyers.
‘Lawyers’, there, should be ‘insurance companies’, no?
So the driving force in medical research is the drug industry’s cost of capital? Or share price of Big Pharma?
this issue is too important to be supported by argument by assertion. evidence would be nice.
How about Economics 101?
Look, this isn’t that hard to understand. Lower profit means lower drive to invest. That’s standard stuff they teach in business school; that generally has been one of the more undesirable results in rent control, when they’ve also tampered with supply and demand; and generally that’s the behavior in venture capitalism when you start up companies AND that’s the general spending pattern of larger companies, in most any field.
Now, let’s turn it around. There’s prima facie evidence that lower profit would mean less investment and some empirical evidence. What patterns would occur to sustain high investment if there is lower prices at the front end?
‘Lawyers’, there, should be ‘insurance companies’, no?
No, without verifying: the insurance sector in the US is quite competitive. Doctors can and do shop around. The premia (?) paid will cover the expenses which are insurance company expenses (largely for lawyers) and profit, victim compensation and lawyer expenses. Given the current legal system, a large share is pocketed by lawyers.
Enrak: “Also, the claim is that we can switch to universal health insurance in a cost-free manner. We most certainly cannot afford the same defense structure we have now with universal health insurance. Now, I think a good deal of you are fine with that, but it is a cost.”
First off, even if universal health care cost a lot, we could have universal health care plus our current defense structure by the usual expedient of raising taxes. Alternately, we could save a lot of money by deciding once and for all to cut Star Wars, since after all this time it still doesn’t seem to work.
However, since you bring up transition costs: you are of course right that we need to consider costs. As I said here, our present system is very inefficient, and a number of the inefficiencies are the result of its being fragmented. Single-payer would solve that. It’s worth asking: how much of the costs of a single-payer program would these savings cover?
As it happens, we can look at the example of Taiwan, which switched to a single-payer system about a decade ago, and has been studied since then. Here is what actually happened:
So while in most cases one would of course expect big costs, in the specific case of health care there’s reason to think that we could go to single-payer without paying much more than we already do.
gwangung,
the government is quite used to bargaining. The defense industry is similarly consolidated and does not starve.
Lowering profit margins of breakthrough products is not the point. The prime way to lower prices is promoting cheap generic products.
The prime way in helping pharma companies is speeding up the approval process. Every month a patented product is not on the market means enormous foregone sales. There are win-win possibilities. One can improve the healthcare system without hurting the pharma industry.
Personally, I am mystified by the willingness of people who normally advocate free markets to say that in this one specific instance, we should not let consumers bargain over prices because the producers need the money so badly. Also, by the idea that if we bargained, the result would be reduced profits, as opposed to (for instance) the drug companies raising prices in the rest of the world to reflect the fact that we are no longer willing to serve as the vehicle for everyone else’s free-riding.
However, being a conciliatory sort, I propose to combine single-payer health care with a gift to the pharmaceutical industry: ban direct-to-consumer marketing of prescription drugs. While the levels of spending that each firm engages in are, I assume, rational given that all the other firms are advertising this way, a lot of this spending is only rational given that assumption. It’s like the arms race: once it gets going, it’s not rational for any individual to fall behind, but it would be better for all concerned if it had not got going in the first place.
They spend a lot of money on TV ads. They can use it to replace any damage to their bottom lines.
I shudder to think of what that’d do to the direct-to-physician advertising, hilzoy.
Lowering profit margins of breakthrough products is not the point. The prime way to lower prices is promoting cheap generic products.
The prime way in helping pharma companies is speeding up the approval process. Every month a patented product is not on the market means enormous foregone sales. There are win-win possibilities. One can improve the healthcare system without hurting the pharma industry.
Help me to understand, then, as I may be unaware of nuances.
Cheap prices come from the use of generics. But generics come onto the market AFTER the patent period runs out. Moving up the release time isn’t connected with that (and is more often connected with safety issues, and may not be able to be contracted).
I think there are win-win situations, but I think I need your help in seeing them, because it isn’t obvious to me where they are in the areas folks are pointing to (with the possible exception of direct-to-consumer marketing, as hilzoy points out).
Slarti: never fear: a rather important professional group is organizing a Great Big Panel to consider the issue of industry sponsorship of medical educational stuff (including continuing medical education, which is a story unto itself, and a locus of attempts at persuasion.) Guess who gets to be on it, speaking for the true, the right, and the just?
I wish I had time to address all your points Hilzoy (or frankly the intelligence), but I’ll take a crack at just one.
I don’t think anyone is saying we shouldn’t let consumers bargain. For me the problem comes when we let the government bargain. The government under SPHC can basically set the price. That is what they do for physician services.
This leads to my more general objection. What this does is take the market out of the equation. Say what you will about the evils of the market (and you all have done so very well), it is the best information delivery system ever created. The government is, how shall I put this…not.
I spend a lot of time working on the current payment system and we spend a lot of time trying to use data to “guess” what the correct payment rate or price is. We can’t do it as well as the market (trying sure is fun though). The reason we can’t do it is because the system is just too dynamic. We are always setting prices such that they are pretty good if nothing changes. But actors (in this case Drs.) are always reacting to the prices we set.
I still can’t see how having the government allocate resources can be anywhere near as efficient as the market. It just can’t. Now, if you want to say I’m willing to sacrifice that efficiency because I don’t want people to go without health care AND THERE IS NO OTHER WAY FOR THEM TO GET IT, then go right ahead. But don’t try and tell me that the system is going to be as efficient as the market. It’s just not.
Does that mean I don’t think SPHC can deliver quality care? No. I think it can, but it will come with a cost in terms of efficiency.
Man. I am rambling and not saying this very well, so I’m just going to stop here.
“Personally, I am mystified by the willingness of people who normally advocate free markets to say that in this one specific instance, we should not let consumers bargain over prices because the producers need the money so badly. Also, by the idea that if we bargained, the result would be reduced profits, as opposed to (for instance) the drug companies raising prices in the rest of the world to reflect the fact that we are no longer willing to serve as the vehicle for everyone else’s free-riding.”
I’m all for consumers bargaining on price. I’m skeptical of governments because they can bargain on things other than price. Like whether or not you will ever get a patent again. Like whether or not this patent will get rescinded.
How will companies enforce higher prices everywhere else? They can just break the patent and give it to a generic producer. That will completely kill off pharma research in the future, but I’m sure they would only do it for ‘crucial’ drugs.
“They spend a lot of money on TV ads. They can use it to replace any damage to their bottom lines.”
Not hardly. I suspect you are relying on the old saw about “marketing and administration” being more than research. This line item in 10-Ks includes the cost of all non-research employees, office paper, envelopes, air conditioning, heating, cleaning, tax administration (really nasty when you sell to all 50 states) and most of the other non-production costs of running a modern company. The marketing aspect includes giving away drugs to people who can’t afford it (very common with high priced cancer drugs) and giving away samples to doctors.
The idea that cutting television advertising could significantly replace profits needed to fund research is wrong. (If you look at the Pfizer 10Ks for instance you will see that the ratio of that item to research expenditures is about the same even when you look back to the time before such advertising was allowed.)
returning to drug development, it seems to me that one particular argument which comes up a lot is:
a. Lots of new drugs is a social good.
b. The best way to obtain this social good is to subsidize new drug development by having the federal government overpaying for approved drugs marketed by pharmaceutical companies.
c. This overpayment can be distributed by the pharma companies to their shareholders.
to which i answer: huh? If we want to encourage the more rapid development of quality drugs, this is one of the dumbest things I’ve ever heard.
what is especially galling is that the very people who complain about market failure in going to universal health care insurance are the ones supporting this market failure in drug development.
I don’t think we were advocating for the Part D drug benefit, so I’m not sure your assertion b stands up to to scrutiny.
I don’t want the federal government laying down the price of a good. Too much power.
I’d also like to point out that the Pharma companies need to be paid for the risk they take. Developing drugs carries a huge risk because most don’t work.
So drug companies may be taking in accounting profits, but that does not necessarily mean they are taking in economic profits (it doesn’t mean that they aren’t, what with barriers to entry and whatnot, but we can’t just assume it’s all economic profit). Which I’m sure you all know, but I wanted to highlight it.
Enrak: “But don’t try and tell me that the system is going to be as efficient as the market. It’s just not.”
Well, let’s start with some data from a study in the NEJM:
“what is especially galling is that the very people who complain about market failure in going to universal health care insurance are the ones supporting this market failure in drug development.”
What market failure? The market failure is in ignoring market forces and having the government set prices. Labeling the government “consumer” when you are trying to have it become the whole market isn’t proper labeling.
Would Soviet price controls have been more effective at stopping shortages if the USSR government was the ‘consumer’ of food and then they handed it out to everyone? Clearly no. The problem is the government price fixing. If you have only one possible consumer (the government) you don’t have the kind of competition that defines a “market”.
Hm. I think folks aren’t aware that a LOT of new drugs fail, even in the confines of big pharma. When you extend that into the startups, the number grows even larger. Money for those failed drugs ultimately stems from the big successes…so cutting down on the profits of the big successes has an impact on the funding of new drugs.
Now, if you can get around that, I’d like to hear it….
One more thing about efficiency: Medicare had administrative costs of 1.9% in 2004. The percentage has not been above 2.0 in the last decade. Try to find a private plan that has done nearly as well.
I hate to be so simplistic, but that study does not prove the Canadian healthcare system is more “efficient” at delivering healthcare resources to patients than the American system. Lower administrative costs, yes. But economic efficiency and administrative costs are not the same thing.
Are the resources going where they need to go efficiently?
If we implement SPHC, will we still see the same quality of doctors? How will health care be rationed? How will we know how much to pay a doctor for a knee surgery? A lung transplant? How about for a service that hasn’t been invented yet? Will we see the same level of technological acceleration in medicine?
I think we do suffer from high administrative costs in the United States (especially since you have pointed it out with like facts and data and stuff). But how much of that is bureaucratic red tape imposed by the Federal Government? By state governments? How much has been transferred onto the patients in Canada?
Also, you made the point that we could raise taxes before rather than sacrifice defense spending. Yes, but that comes with a cost as well. We can already see the lack of economic growth in Europe which I maintain is because of the high tax rates. Again, you may think it is worth it, but I just want to point out that it isn’t costless.
BTW, I’m not 100% convinced SPHC doesn’t work, I’m just terrified of what might happen were the United States to implement it. Right now, for me, the risk outweighs the reward, but I’ve been wrong before.
“Medicare had administrative costs of 1.9% in 2004. The percentage has not been above 2.0 in the last decade. Try to find a private plan that has done nearly as well.”
Part of this ‘efficiency’ is done by outsourcing the administrative costs to the doctors.
Let me give an example of what I’m talking about.
Maine has a high preponderance of dual-eligibles (benes elig for Medicare and Medicaid). Reimbursements for both systems have been declining. The Medicaid payment system pays doctors a different amount depending on whether or not they are employees of hospitals. In fact, Dr’s can generally expect to receive 76% of their costs from Medicaid if they are employees of a hospital or a clinic and only 40% if they are in private practice. Needless to say, Dr.s are switching to either working in hospitals or RHCs/FQHCs. This means they have to move farther away from their homes (and in many cases their patients) fire their staff (because hospitals and RHCs/FQHCs have minimum education levels on employment and therefore certain medical assistants and mid-level employees don’t qualify) and more complicated billing for their patients (hospitals have much more complex billing systems than physicians in private practice).
Now, administrative costs for Medicare and Medicaid are declining as they don’t have to deal with as many individual doctors. But is this more efficient?
Part of this ‘efficiency’ is done by outsourcing the administrative costs to the doctors.
Is there any reason to think the administrative burden on doctors is higher for Medicare than for private plans? If there is, I’m unaware of it. And if there isn’t, your point is irrelevant.
Seb: Private insurers also outsource their administrative costs to doctors. That’s why I started with the NEJM study, which estimates that admin. costs for our health care system as a whole — doctors included — is around three times Canada’s. That’s a lot of money.
There are reasons for this. In a single-payer system, no millions of different kinds of forms, no seeing who someone’s insurer is or whether the person is still covered, no millions of different companies with different eligibility criteria to navigate, etc.
Also, no companies trying to find ways to offload their sickest patients or deny coverage or shape their risk pool, and so on and so forth.
It’s really not possible to say that private insurance is more efficient in the sense of delivering services with less overhead. They just aren’t, and by a very large margin. And (Enrak) this isn’t because of government red tape; it’s in the nature of fragmented insurance markets.
Enrak: “Are the resources going where they need to go efficiently?”
Here we get into the thrilling question: what determines “where they need to go?” I will forbear pointing out that in an everyday sense of ‘need’, lots of needs are going unmet, and assume that you’re talking about something like: where market forces would send them.
In response to this — well, I’ll probably write a post on why health care is just not a normal market. There are too many players, for one thing: consumer, provider, insurance company, employer. Neither need nor pricing is known to the consumer. (I mean, have you ever tried to get a hospital to tell you up front what things will cost?) This in addition to the fact that consumers are, in this area, very unlikely to be adequately informed, and will probably end up depending on the advice of their doctors.
All this means that the demand side of the information that markets normally transmit is likely not to be any good. Also, that this just is not a normal market situation at all. Plus, there are a host of special problems associated with the role of insurance in all this.
As I said somewhere, I am generally a market-oriented sort of gal, but there are exceptions. I assume that I have to provide some reason for saying that something is an exception, and in the longer post, if I write it, I’ll try to. But the normal benefits of markets really do not obtain in this case, quite apart from the fact that, as you noted above, it is not now a free market by any stretch of the imagination.
As to some of your concerns: single-payer doesn’t mean rationing, nor is there any obvious reason to think that we’ll go there. Rationing is wildly unpopular, and suggesting it would probably be political suicide. Personally, I think that this is in some respects a bad thing (for reasons that would, again, require a whole new post), but it should be some comfort to you. I don’t see any reason to think that the quality of doctors would suffer.
I mean: single payer isn’t about having the government take over the whole health care system; it’s basically having the government take over the role of health insurance. The delivery, and the need for doctors and hospitals to compete, remains the same.
LizardBreath,
Have you ever filled out a form for the government? I used to work at a manufacturing company that did most of its sales with private companies, and maybe 10% with the government. Invoicing for the government was much, much harder than for the private companies.
And that, is my nonconclusive anecdote of the day!
I submit for your amusement,
Tufts Health Plan Provider booklet:
http://www.tuftshealthplan.com/providers/provider.php?sec=provider_manuals&content=MP_HMO_provmanual
Now go peruse the CMS website ici:
http://www.cms.hhs.gov/ElectronicBillingEDITrans/01_Overview.asp#TopOfPage
See which takes you longer to figure out.
Oops, left off my conclusion, which was: given that health care is not a normal market, the idea of “where they need to go”, if determined by the efficient functioning of a market, has no content.
Err, while I share your concerns and I understand why the health care market is not normal I don’t think you can then make the leap to say that there are no efficiency gains from using a market.
That is to say, just because the market is imperfect does not automatically mean that government intervention will make the outcomes better.
Yarp, there are huge informational assymmetries in health care, and moral hazard and adverse selection, and inelasticities and all sorts of gobbledygook. That’s why I’m not opposed to catastrophic SPHC.
But how is the government going to bargain with providers under SP? You say the government is just going to be the insurer, but insurers pay the providers. Who will set the prices when there is only one payor?
I don’t understand how single-payer for pharmaceuticals can function as anything other than price controls–with all the bad effects which come with price controls.
Do you think that insurance companies don’t bargain for a good price?
general question:
how are prices set currently in the private marketplace? do insurers set a take-it-or-leave it price list and then doctors select which insurers they’ll accept?
Enrak
I don’t think you can then make the leap to say that there are no efficiency gains from using a market.
and I don’t think one can make the leap that all efficiency gains are going to be benefit the patient. Clearly, efficiency is a value neutral concept, and just because something is more efficient for the private companies does not mean it will be more efficient for the consumers down the line.
I gotta back Sebastian here re: the common misunderstanding of trying to attribute the whole of S,G&A on an income statement to “advertising and marketing.” Not even close. As he points out, it’s all non-R&D costs; ads and marketing are but a fraction of it.
What’s more, the numbers quite literally do not ad up. Upthread it was pointed out that Pfizer spent $3.9 billion on S,G&A in the latest quarter. Now, the single most expensive network program on which to advertise is American Idol; FOX charges $700,000 for a 30-second spot in the Wednesday results show. Their S,G&A cost would be the equivalent of 5,500 Idol ads. Does anyone really think that Pfizer ran 5,500 30-second advertisements on American network television between February and April of this year? I don’t.
I share concerns about bureaucratic red tape and I’ve heard doctors complain about the amount of paperwork* involved in complying with Medicare rules.
What is curious about all of this is its circular nature. The public (taxpayer, voter) demands accountability from the government and its employees, who then institute accountability measures, which then the public complains about as onerous.
“You must track every dollar” says the doctor in his guise as taxpayer. “Why do I need to track every dollar?” asks the taxpayer in his guise as doctor, etc.
My wife is a scientist for the Federal government (not healthcare related) and the amount of time she spends justifying every single expense to do her job is onerous for her and the taxpayer. Oddly, though, the taxpayer doesn’t trust her to make the decisions herself, so layers of accountability bureaucrats are employed, who the taxpayer also doesn’t trust and, in fact, resents.
Whose fault is this again?
We, the taxpayer, of course, will buy a stock recommended by Jim Cramer or a voice on the other end of the phone and we will, of course, cram those medicinal supplements down our throats based on the barest, least trustworthy claims.
But we aren’t sure we can trust the FDA’s testing procedures because, well, now I can’t remember why. Oh, yeah, because they studied the subject for a little too long at taxpayer’s expense, which is a red light right there.
BY the way, 10Ks are required by Federal regulation and are a costly intrusion on Pfizer’s business, so I’m not sure I would trust them. 😉
*My intuition is that government forms are made up by the same folks who write the assembly instructions for kids’ toys, small appliances, and do it yourself furniture.
That might be a large part of the problem.
Phil:
You may be right, I don’t know. But Pfizer also pays an advertising firm to develop an advertising campaign and to produce the spots.
Phil, you are right (about the budget and the shout out to Seb), but one has to note that budget includes things like this
Free lunches like those at the medical building in New Hyde Park, N.Y., occur regularly at doctors’ offices nationwide, where delivery people arrive with lunch for the whole office, ordered and paid for by drug makers to the tune of hundreds of millions of dollars a year.
Like the “free” vacation that comes with a time-share pitch attached, the lunches go down along with a pitch from pharmaceutical representatives hoping to bolster prescription sales. The cost of the lunches is ultimately factored in to drug company marketing expenses, working its way into the price of prescription drugs.
Seb and Phil,
office supply and heating expenses are not troubling Pfizer management or any other pharma company. Pfizer does not give further breakdowns of their cost structure, but Roche lists adminstration expenses to marketing and sales as 1:5, so by a rough analogy, you have a marketing and sales expense of 3.3 bn for Pfizer, much of which will be spent for personnel (direct and indirect sales force).
The point is not that all the Selling/General/Administration Expenses could be eliminated but that they are far larger (2-2.2 times) than R&D expenses.
So, if profit margins are squeezed, before cutting R&D, it might be sensible to trim the sales force. Just like P&G deals with Walmart, so Pfizer will deal with Washington reducing the need for an army of reps.
I’m not a businessman, so take this with a however much salt you’ve got on you.
I’ve heard that the absolute LAST thing you trim the budget on is the sales force. It may not be sensible, but I think that is the way businesses operate.
Enrak, your notion is correct. But: One of the major trends has been disintermediation. The internets and better communication technology has not been kind to all kind of reps and agents.
One of the prime reasons for the frantic merger activities in the pharma sector during the last decade has been slashing marketing costs by reducing the number of reps of the combined company.
To bed.
Today my (Dutch) Newspaper reported that our national organisation of general practitioners want to start an action to stop prescribing Livitor (cholesterol lowering medication from Pfizer) and move all patients over to simvastatine. The latter is about one third of the price of Livitor.
After an agressive marketing campaing Livitor suddenly became the best sold medicine in the Netherlands, but quite a number of GP’s say that the interpretation used in the study about the differend medications is not objective. They claim that simvastatine is as good, and a lot cheaper.
These doctors do not gain from their action of course. But the market is influenced by a lot more than supply and demand. And universal health care does not mean that everybody suddenly spends like crazy.
I think that is the way businesses operate
not trying to make a snarky return, but this is the locus of a lot of the problems us UHC supporters have with the notion that the free market works better. As Hilzoy has pointed out, the consumer does not have the power to simply do without, so there is an asymmetry that doesn’t exist in usual transactions. If a free market could give rise to new business models that would deal with this, I think that some of us might be more inclined to accept argumentation against government intervention, but I don’t think that is the case. What the insurance, pharma and hospital industries do is the akin to what Ford did with the Pinto.
“As Hilzoy has pointed out, the consumer does not have the power to simply do without”
Is the consumer currently doing without the life-saving drug that has not yet been discovered?
How much is that undiscovered pill worth?
Sebastian,
What consumer is saying ‘I’ll wait for the after holiday sales on dialysis’?
What consumer is saying ‘Instead of the operation, I’ll buy all the tools and do it myself?’
What consumer has his or her child in tow, and drives around to the local hospitals to find out where the best deal on appendectomies is?
Enrak: “That is to say, just because the market is imperfect does not automatically mean that government intervention will make the outcomes better.”
Thus the data, and the arguments.
Advertising itself is a rather perverse inflator of costs.
Say there are five drugs on the market to treat a specific affliction. Drug A has been found by objective peer-reviewed studies to be the most effective in keeping people alive with a decent quality of life. You would think the makers of drugs B, C, D, and E, would, for the good of America and the human race, say, O.K., we’ll call it a day.
But they don’t. They adverstise a different tack. Our drug is cheaper, it has a smaller dosage, the woman in the commercial is more sympathetic, etc. They fight it right down to the bitter end. Sometimes they say their drug is better despite all evidence to the contrary. What is that called?
They could say, please, everyone use the most effective drug. In that way Drugmaker A could sell more dosages and maybe lower the price. And they wouldn’t need to advertise. They could make the choice, also, to ignore the urge to then charge what the market will bear, given that there is now no competition .. until a BETTER drug comes along..
But they won’t. Such is the nature of the beast. But it doesn’t have to be that way.
But, yeah, I know, we live in a relative world and who is to say what is the best and, moreover, people should be allowed to make the wrong choices, because it is somehow ruefully satisfying to observe the consequences.
O.K.
LJ:
Excellent rejoinders. Of course, “consumer” is not the correct word, like it would be for an individual seeking shoes or ice cream. “Patient” is the word.
So, maybe, “market” is not the exact right word to describe what happens when one seeks medical care from others.
Come up with the right word and start the thread over again.
Sebastian: As the beneficiary of a lot of stuff (mostly diagnostic gear) that didn’t exist when I became chronically ill, I certainly have an interest in supporting healthy R&D for the indefinite future. But I also have a concern about present needs, needs that we could be meeting but are choosing not to. There are times when too much concern about the future strikes me as a willingness to sacrifice large numbers of other people’s lives and well-being for the sake of hypotheticals.
However, if they do offer after holiday sales on dialysis, I might take the whole family in for a week’s worth …. because it’s a deal, and the consumer can’t pass up a deal, if we insist on using the designated vocabulary of the only permitted economic model.
John,
I’d also see if you can get a group discount on appendectomies, and have them all out at once. Share a room and save more! Of course, if your family is too big so that you have to pay full price for the 5th one (a result of the buy 3 get one out free sale), perhaps you can figure out how to do it yourself. Dental floss for stiches, and exacto knives for scapels, the possibilities for saving are endless!
Slightly OT:
My favorite advertisement of late is, if I’m remembering this correctly, one formulation for Advil. The zinger is this line: No other pain reliever has been proven stronger than Advil. Kinda makes you think “wow, it must be the best”, until you actually consider what they’re saying. Google search on some key groups in that phrase and you’ll see that pretty much everyone says that, and not just about OTC pain medication.
From this I hypostulate (yeah, I know) that they’re pretty much all the same strength and speed, or there’s sufficient spread in results that you can’t tell one from another.
Drug A has been found by objective peer-reviewed studies to be the most effective in keeping people alive with a decent quality of life. You would think the makers of drugs B, C, D, and E, would, for the good of America and the human race, say, O.K., we’ll call it a day.
Yes, John, but it’s not that simple. It turns out that drug A interacts badly with drug X, so if you take X you can’t take A, and need B. Or A and B are dangerous for pregnant women, or diabetics, or who knows who.
And cheap matters, like it or not. It might mean 100 people get a slightly worse medicine instead of 90 getting a slightly better one.
Not a question of wrong choices, so much as of complicated ones.
“so much as complicated ones.”
Wait a minute, my ideology said it would be simple.
LJ:
We’ve already done the appendectomies. A guy named Vinnie did it out of his van at the medical flea market on the edge of town.
If you see him, could you ask him when he might be swinging back into town for the hepatitus and gangrene seminars he promised along with the aquarium of giant Borneo leeches.
John,
story of my life. I go out and get something and then I go around the corner and find it at 10% off, plus bonus points. mark my words, next time, I will check out all the options, even if it means having my wife and children push the hospital bed around town.
next time, I will check out all the options, even if it means having my wife and children push the hospital bed around town.
Well that’s your problem right there. Trade your wife and kids up for the discounted model — now with UltraBonus Points! — and you’ll be right as rain. Or at least, it’ll take less time for them to canvass you a new kidney.
Yes, John, but it’s not that simple. It turns out that drug A interacts badly with drug X, so if you take X you can’t take A, and need B. Or A and B are dangerous for pregnant women, or diabetics, or who knows who.
Indeed — to let out an embarrassing fact about myself, I take medication for overactive bladder, reducing my need to leave my desk to use the toilet from about 20-25 times per work day to about 6-7. There are at least three such medications on the market, and I am on a rotating prescription for all three. Why? Because due to the way they work, your body becomes acclimated to their effects, so that they’re eventually only 80% as effective. Then 70%. And so on.
By rotating them, I become less acclimated to each medication’s effect over time, and even experience some bounceback in effectiveness.
Oh, but if only there were only one of these medications! Then, then I could take it for a year, have it become useless to me, and return right back to the old problem. As Stimpy might say, “Joy!”
Note: This is not to imply that I don’t support UHC, because I do support a single-payer system. I grew up with it as a military dependent, and it worked. But arguments like this are not arguments for UHC; they’re arguments for an unapproachable utopia the likes of which libertarians are regularly disparaged for around here. It would be heaven if we only ever needed one drug for every condition, and the first guy through the gate could produce it forevermore. Unfortunately, human bodies don’t work that way.
Have you ever filled out a form for the government? I used to work at a manufacturing company that did most of its sales with private companies, and maybe 10% with the government. Invoicing for the government was much, much harder than for the private companies.
Have you ever done the insurance paperwork for a private insurer? It is horrendous. My friend is an opthamologist in a medium sized practice (9 doctors). They have three full time employees whose job is nothing but filing insurance claims and dealing with all the insurance companies.
The other huge advantage of UHC, and the main reason that European systems achieve better results than ours, is that they tend to focus on preventative medicine, not expensive treatment.
Hilzoy,
You have done a nice job providing data and arguments. I knew about the administrative costs, but the study in Taiwan is very interesting. I’ll be interested to see how it plays out over the next 5 to 10 years.
But my argument has been and continues to be that there are costs to UHC. People keep telling me that it is anecdotal and there are no horror stories. But I have to ask, how many of you are over age 65? How many of you know Canadians over age 65?
According to this study I found on google (and feel free to tell me if they are some conservative thinktank or other biased source, I have no idea), the median wait time between referral and treatment from an orthopedic surgeon increased 19 percent from 1994 to 1998. Canada is losing surgeons and the surgeons they currently have a aging rapidly. MRI wait times are long and getting longer. These are the exact problems we have been discussing.
These are not things that show up as administrative costs, or in life expectancy statistics, but they are a cost. And joking about driving around searching for “bargains” on appendectomies is fun and all, but it doesn’t make these costs go away.
Not that I want to let Canada have all the fun.
http://rheumatology.oxfordjournals.org/cgi/content/full/43/3/353
Here’s the link to the Canadian study that I forgot to include above:
http://www.coa-aco.org/library/health_policy/canada_in_motion.html
And joking about driving around searching for “bargains” on appendectomies is fun and all, but it doesn’t make these costs go away.
Well, I will admit that I had a bit too much fun with that (though I blame Thullen), but when someone suggests that a magical potion is right around the corner and consumers need to balance their needs of the moment with that possibility, well, fun is about the only thing one could have. Though I’m sure wiping out erectile dysfunction in our lifetime is a goal Albert Schweitzer would have swooned over.
Statistics about median wait times and such have to take points like this into account
The data published on this website represent all non-emergency patients who received these services, but the wait times are not currently broken down further by urgency or priority of patient need. Physicians assess each patient and determine how urgent their need for treatment is, and as a result the wait times may be very different for a patient who requires surgery but is medically stable and able to wait at home and a patient who is classified as urgent and requires surgery as soon as possible to prevent their condition from worsening.
In addition, this pdf offers a different view of wait times
All of this, of course, makes the important assumption that significant waiting lists in Canada exist in the first place. Those who oppose the Canadian single-payer system, including the American health insurance industry, have long used long waiting lists as an argument against single-payer health insurance, citing anecdotal evidence, various surveys, and media reports. Despite this, an objective look at the issue reveals that the evidence for waiting lists is inconclusive. Indeed, while waiting lists certainly do exist for certain non-emergent procedures, it is not at all clear that the “waiting list crisis” that is so often talked about by the media and opponents of single payer actually exists(emphasis from link)
The site that this is from, AMSA, has a number of interesting pages here and is a pretty interesting progressive organization.
“but when someone suggests that a magical potion is right around the corner and consumers need to balance their needs of the moment with that possibility, well, fun is about the only thing one could have.”
The fact that you want to make fun of research concerns suggests you either don’t understand the issue or don’t want to really discuss the implications of different approaches to paying for health care.
Enrak: But I have to ask, how many of you are over age 65? How many of you know Canadians over age 65?
Both my parents are over 65, as are many of their friends. (This is UK, not Canada, but I assume you want horror stories from any country with a universal health care system, and I’m delighted to tell you I can’t oblige you.)
And my Canadian grandmother and my Canadian step-grandmother are both way over 65. (Or rather, my Canadian grandmother was over 65 when she died, three years ago.) My Canadian aunt is just under 65, and her husband is several years over. All of them have grumbled about the universal health care system in Canada: all of them have said, spontaneously, when discussing health care, that while things can be bad in Canada, at least they don’t have to live in the US.
My great-aunt, a lifelong Conservative voter and generally right-wing, wrote to her (then-Conservative) MP sometime in the 1990s to tell him that she was switching her vote from the Conservative party at the next election because she abhored the way the Conservative Government was treating the NHS. She would then have been in her 80s. Well over 65.
In general, my impression is that the older you get, the more you appreciate the NHS: the fact that when my father fell and broke his wrist, and complications ensued (he was then just turned 80) he had daily home visits from the local practice nurse until he was well enough to make the trip to his local practice by himself, and his wrist was operated on by the best orthopedic surgeon in the region… at no cost to himself, or to ourselves. It’s been two or three years, and he is fully recovered: able once again to type, carry shopping, and make his own bread. What kind of insurance would he have had to be paying to get that kind of healthcare in the US – that he got in the UK as of right?
Why is it that leftists (!generalization warning!) have a good deal of fun making fun of conservatives over their prudishness toward sex, but love to make fun of the fact that ED drugs are one of the number one sellers in the U.S.? Is sex good or bad here?
I’m serious. We use QALYs to estimate many things in health econ, and erectile dysfunction imposes significant reductions on QALYs. Why do we get to laugh about it? That’s like saying to someone that can’t taste that they shouldn’t worry so much about being able to taste, you get all the nutritional benefit anyways.
What’s so funny about ED?
I don’t think you’d laugh so much if Clinton had been pitching viagra instead of Bob Dole. 😛
What’s so funny about ED?
Dicks just are funny. See any Greek comedy for the longstanding (sorry) nature of this joke.
Thanks for not accusing me of wanting to kill the elderly Jes.
Kidding aside, I’m not sure I see why people in the UK are more thankful not to be living in the U.S. once they are over age 65. We HAVE UHC for the elderly in the U.S. Now with a drug benefit!
Not to mention that the elderly are the wealthiest subpopulation in the United States.
LP: I’ll take a look at what you linked to at lunchtime. I just would like to point out that the trend in both Canada and the UK is of decreasing services for some key specialties. This is a supply issue arising from a poorly planned payment system. This isn’t because of negligence or stupidity. This is a fundamental flaw of trying to artificially generate the information that a market naturally generates. It is structural. If it wasn’t ortho, it would be something else. The system is too dynamic and the informational costs are just too extreme. If they weren’t, the USSR would still be with us today.
The fact that you want to invoke magical potions invites a certain amount of fun. I’m happy to talk about research concerns, but ‘that undiscovered pill’ seems remarkably vague, even if it is orthogonal to the topic of UHC. If it were for black fever, I might be interested, and if there were more enterprises like this dotting the landscape of pharmaceutical research, I don’t think I would be so suspicious of Big Pharma. But there ain’t, so I’m not.
I didn’t post this, but from the wikipedia link to AMSA, there was this Christian Science Monitor article about the AMSA ‘PharmaFree’ movement, with this tidbit
spending on marketing to physicians jumped from $12.1 billion in 1999 to $22 billion in 2003 ($16 billion of which was in free samples), according to data from Pharmaceutical Research and Manufacturers of America (PhRMA).
Given that the organization is not by any stretch of the imagination opposed to big Pharma, it really suggests that the Pharma model is a business model ran amok.
Why do you keep writing about magical potions? Who are you talking to?
Do you mean magical potions like lipitor? Synthroid? Claritin? Novasc? Fosamax? Prilosec? The HIV drugs that came on the scene within 15 years of the discovery of AIDS? Third-generation anti-biotics?
Which magical potions are you referring to exactly?
Dicks just are funny.
Who needs Greeks when we have Neil Simon?
“Words with a “K” are funny.”
my ideology said it would be simple.
All ideologies say that. They’re lying.
You mean like “Enrak”.
Damn. Thank goodness I spell my real name with a “c”.
Enrak; I’m not sure I see why people in the UK are more thankful not to be living in the U.S. once they are over age 65
Who wants to live in a country with a health care system that ranks lower than every other industrialized country, except the poor souls who don’t know any better and think that what they get is the best it can be?
A health care system that’s founded on the principle of providing health care first and making a profit second provides superior health care to one which is founded on the principle of making a profit first, and taking care of patients second.
Plus, home visits by your own doctor when you need them. How many family doctors do home visits in the US?
Well, laughter is the best medicine for what ails ya.
I admit to misallocating two chuckles and a guffaw on this thread, but the incentives of the discussion made me do it. Due to government interference, I laugh in church and during Viagra commercials, though there doesn’t seem to be anything funny about either. Once, I took Viagra before church … but nevermind … talk about prayers being answered.
But seriously, this is a good thread with much important input. Phil is right, of course, I live in a dreamworld.
The solutions are diverse, part market and part collective, if you’ll excuse the expression. The folks who can come up with the gears to mesh these disparate methodologies will get my vote, and my shareholder dollars, and my charitible contributions, not necessarity in that order.
Enrak,
That was my first ED joke ever, so I don’t think you should take it as a liberal tendency. If you are talking about Rush getting caught with viagra, well I believe that I am the first to note it here in these hallowed halls.
As for magical potions, I was referring to this comment (not yours) However, I don’t view any of the drugs you list as magic potions. Anti-AIDs drugs certainly don’t fit, as they have to be combined in cocktails taken at specific times. 3rd gen antibiotics are more in response to the evolution of resistant super-bugs, and a longer view with patients not minimizing hospital stay time might have slowed the development of those types of bugs. Lipitor treats a symptom that could also be addressed with healthier living habits, so in a sense, it is solving a problem that can be linked to the absence of a national health policy and a UHC. Synthroid is in the process of being withdrawn because it does not have FDA approval. Claritin was the drug that pioneered DTC advertsing, for non life threatening allergy symptoms that were treated in an equally effective way by other current drugs, but had gone of patent. Novasc, as a beta blocker, has not been the cure all that it first appeared to be and again treats a symptom of unhealthy living. Fosamax treat osteoporosis, which puts it ahead of the other drugs you list, but still, healthier living would relieve a lot of this. Prilosec deals with heartburn, which can be very painful, but it is not life threatening. In fact, the only two drugs that are life saving on your list are Anti-AIDs medications, and 3rd gen antibiotics, with the first rather complicated and the second arising to treat a problem exacerbated by the business model of health care.
This is not to say that we can’t have a business model in dealing with health care, just that the list of drugs you give are not the argument busters.
Ah, only life-saving drugs count for your purposes?
Is the same true of life-saving procedures? Hip replacements–never? Should we bother setting bones? Would you pay for X-rays to set bones or is that a waste? Do you have serious allergies?
I’m beginning to see why you think national health care might not be so expensive.
Wow, LP. We are living in a time where magic potions actually do exist and you keep using it ironically.
I list two actual life-saving drugs (according to your criteria) and you just brush them off. Anti-biotic resistance is a problem across nations not just in the United States. Also, you kind of slipped the old “might have slowed the development”, and then a more definitive “to treat a problem exacerbated by the business model of healthcare.” Well it might have. Then again it might not. In the literature I have read the large problem is overprescription and lack of adequate dosing instruction (ie, people stop taking the medicine when they no longer feel the symptoms).
How about diabetes medication? Drugs that help kidney function? The new 3 in 1 HIV pill? The HPV vaccine? Anti-cancer drugs?
You sort of blithely shrug off the non-life-saving drugs with an *eh*, but I think you might not be so blase were you to suffer from one of those conditions.
P.S. Laugh all you want about Rush. I have never listened to his show, and he does appear to be rather hypocritical with his stance on drugs.
John: Well, laughter is the best medicine for what ails ya.
Not if you have broken ribs.
Enrak, your links aren’t embedded, and thus aren’t usable.
Here is a handy guide to HTML tags.
You can find to “link something.”
Here’s how you link (you can copy this and paste it as necessary, if you can’t remember): <A HREF=”URL”>Words</A>
Do that, and your links will be usable, not broken. Feel free to ask any questions, and to experiment. Just put the URL in where it says “URL” and any words where it says “words.” The rest is just what you type (or paste). Oh, and caps aren’t necessary.
Gary,
Thanks. I know how to do that I am just extraordinarily lazy.
I always through that you could just cut and paste them into a web browser.
See, I can do it. I was just transferring the costs to the user. Like Medicare or private health plans.
spending on marketing to physicians jumped from $12.1 billion in 1999 to $22 billion in 2003 ($16 billion of which was in free samples), according to data from Pharmaceutical Research and Manufacturers of America (PhRMA).
I don’t why that $16 billion in free samples to physicians is something to be upset about. After all, to the extent physicians distribute the samples to their patients – and they certainly do this – you are criticizing the companies for providing patients with free medications. That hardly seems fair.
Anti-biotic resistance is a problem across nations not just in the United States.
Amusing statement, since one of the main causes is overprescribtion. (prescription? I’m to lazy to look it up).
Waiting lists are not an entirely fair system to compare. Firstly because the don’t measure the time between complaint and solution (it sometimes takes a long time to actually *make* an appointment, and that time is not in there). Secondly because it does not show any prioritisation due to urgency, thirdly because they do not always take account of the reason behind it (we have a waiting list for non life-threatening things if you are treated in a hospital outside the Netherlands, because we like to stay free of the antibiotic resistant bacteria), fourthly because comparisons usually are not unbiased. I hardly ever see Germany or France used as an example – both UHC countries – because they chose overcapacity instead of waiting lists.
My mother had Graves (a complication of thyroid disease, in her case affecting the eye). Her eye doctor at the University Hospital said that he’d rather have her under treatment of one of the endocrinologists there instead of her GP. He warned us about waitinglists – and indeed it was almost three weeks before we saw the endocrinologist (who had all the labtests, because an invite to do all those was enclosed in the letter giving us the appointment).
My mother-in-law was treated for breastcancer: time from first appointment till operation was less than a month.
And I live in a country that *has* a waitinglist problem.
Sorry, wasn’t able to stay up last night. The mob seems to have moved on, but a few final points.
Sebastian, the whole notion that we can’t have UHC because it would disincentivize the process of making drugs is one of the wackier arguments you have made. Because this has been discussed BA (before Andrew), I’m not going to hold him responsible for arguments you make, but the notion that US consumers need to have a crappy healthcare system so as to create magic bullets for medical problems, many of which arise because of the absence of a nation wide medical policy, that are then purchased for a lower price by countries with UHC strikes me as pretzel logic. At any rate, I realize that the drug industry is one of those subjects on which you are convinced that you are right and everyone who disagrees is wrong, but trying to expand it into a discussion of UHC is close to a threadjack.
Enrak, I don’t know who this LP guy is, but it seems like you tried to intimidate him by throwing out a list of drug names and he called you on it. Speaking for myself, I’m certainly happpy that we have a wide range of drugs to deal with various health problems, but there is certainly a notion that has arisen that if you take a pill, your problems are solved, when the pill may lead to other problems. Given that the big concern Andrew (that you seem to agree with) is that UHC may have unpredicted costs and consequences, you should be equally wary of something like an anti-obesity drug that permits people to eat as much as they want, or some other drug that deals with the symptoms of a problem rather than the root of the problem. If you want to argue for the status quo, it seems that you don’t get to pick and choose which status quo you like best.
Bernard,
16 billion in free samples is not something that I’m ‘upset’ about, but it suggests to me that the model is not about providing for the health care needs but for finding a way to establish brand dominance for formulations that may differ only slightly as Slarti pointed out here
“(prescription? I’m to lazy to look it up)”
Generally speaking, if you come reasonably close, all you have to do is drop a word into the google box in your browser (I trust you have a google box in your browser), and it will either let you know you have it right, by offering the definition, or ask “did you mean [word]?”
I actually do this a fair amount. It takes no time or effort at all, practically speaking.
From John:
Prodigal,
I fear we are talking past each other. I mean efficient in the economic sense. I do not deny that UHC (or some variant thereof) have lower administrative costs than our system. That does not mean that resources are going to their most efficient use in an economic sense.
I put an example above of what I am talking about.
LP: I didn’t try and intimidate you I was just flabbergasted that you would try to say that drugs are not a net benefit to modern society. I think I must be misunderstanding you. (I also don’t understand what exactly you think you “called me on”.)
Who is “LP”?
“That does not mean that resources are going to their most efficient use in an economic sense.”
Would letting people drop dead be among the most efficient use of resources in an economic sense?
And can a blogowner get rid of the spam, please?
Gary,
Maybe, but not likely. Using a silly example like that doesn’t do anything to advance the conversation. Are you making the case that we should throw out modern economic theory strictly because it leads to silliness such as that in the extreme? It is still a very useful abstraction with a great deal of predictive power.
I understand and appreciate all y’all’s moral sense. My point is stictly that there will be a cost to switching to UHC that I don’t feel anyone here is addressing.
No one has responded to my examples above except with sarcasm and extreme examples that do nothing to move the conversation forward. But by all means continue to have fun.
New lung transplants! Get’cher new lung transplants! 1 for 50,000 2 for $150,000!
“Are you making the case that we should throw out modern economic theory strictly because it leads to silliness such as that in the extreme?”
By no means. I am not, however, convinced that it’s the most relevant value as regards people’s health, and what we as a society might wish to do as regards policy.
It’s certainly a consideration, but I wouldn’t think the most relevant one. Would you disagree?
Sebastian, the whole notion that we can’t have UHC because it would disincentivize the process of making drugs is one of the wackier arguments you have made. Because this has been discussed BA (before Andrew), I’m not going to hold him responsible for arguments you make, but the notion that US consumers need to have a crappy healthcare system so as to create magic bullets for medical problems, many of which arise because of the absence of a nation wide medical policy, that are then purchased for a lower price by countries with UHC strikes me as pretzel logic.
Sorry, but it doesn’t strike ME as preztel logic (and I’m one who supports universal health care). What it seems to me is that the higher drug prices in the US are subsidizing the lower drug prices elsewhere; as well, the prospects for big payoffs in drugs are attracting money for applied research. Removing the payoffs would lead to money and research time being spent elswhere and drug development time would lengthen quite substantially.
If that goes along with a healthier, preventative health approach, let’s be clear about that–we’re talking tradeoffs. But let’s not ignore what is a probable occurence if universal health care is implemented.
gwangung: Personally, I’d rather address this directly and in some targeted way (more support for research? Longer patents? a serious effort to minimize the time drugs have to spend in the FDA system? And certainly, as I said above, eliminating direct to consumer marketing), rather than saying: well, we have to allow other countries to free-ride on us by paying higher prices than we could get if we bargained in order to provide money for R and D, even though we have no idea at all how much decreasing profits would affect R and D (as opposed to other shares of pharma companies’ budgets), and even though it seems like an extraordinarily inefficient way to support research. Sort of like trying to increase home ownership by handing out large piles of cash to people on the street.
Enrak: sorry if I didn’t reply to some of your examples (I assume I’m not responsible for the sarcasm? If I am, sorry). Which is it? (I tried to go back and check, but got bewildered.)
My point is stictly that there will be a cost to switching to UHC that I don’t feel anyone here is addressing.
You’re right about that, in that a great many people are employed in the US healthcare industry whose jobs are essentially a waste.
For instance, there’s an office at my primary care physician group (3 MDs) with 2-3 people whose only job is to fight insurers. And then there are all the people at the insurance companies whose jobs are to fight doctors and patients.
There would definitely be transition costs in moving all these people to jobs that are actually worthwhile — but that’s what capitalism is for, isn’t it?
gwangung: Personally, I’d rather address this directly and in some targeted way (more support for research? Longer patents? a serious effort to minimize the time drugs have to spend in the FDA system? And certainly, as I said above, eliminating direct to consumer marketing), rather than saying: well, we have to allow other countries to free-ride on us by paying higher prices than we could get if we bargained in order to provide money for R and D, even though we have no idea at all how much decreasing profits would affect R and D (as opposed to other shares of pharma companies’ budgets), and even though it seems like an extraordinarily inefficient way to support research.
I think it’s important to consider these effects; I certainly am not thinking that we HAVE to have free riders. It’s that there are factors people seem to be overlooking or oversimplifying—and I think any honest debate should consider them.
Eastbrook Pharmaceuticals’ extraordinary commitment to research excellence is exemplified by their new ACE inhibitor, a breakthrough medical approach that will protect millions from heart disease. ….. A few things I forgot to mention. Ed Vogler is a brilliant businessman. A brilliant judge of people, and a man who has never lost a fight. You know how I know the new ACE inhibitor is good? Because the old one was good. The new one is really the same, it’s just more expensive. A lot more expensive. See, that’s another example of Ed’s brilliance. Whenever one of his drugs is about to lose its patent he has his boys and girls alter it just a tiny bit and patent it all over again. Making not just a pointless new pill, but millions and millions of dollars. Which is good for everbody, right? The patients, pish. Who cares, they’re just so damn sick! God obviously never liked them anyway. All the healthy people in the room, let’s have a big round of applause for Ed Vogler!
I’m going to fire Cameron.
I’ve got no kids, my marriage sucks; I’ve only got two things that work for me: this job and this stupid, screwed-up friendship, and neither mattered enough to you to give one lousy speech.
I’m going to fire Cameron AND Wilson.
I thought this thread was dead (maybe it is, the House/Cameron stuff seems nailcoffin like). However, to me, it seems when I answer Sebastian, Enrak responds and when I answer Enrak, Sebastian responds. All a bit confusing.
Sebastian (not Enrak), my mother’s a nurse and recovering from cancer surgery at a spry 72, my father is 80 and doing well, but that’s because he was a government employee and has Blue Cross, I believe my daughter’s current good health is due to an appropriately timed dose of IVIG (along with a 3 week hospitalization, part of it in the ICU to deal with Kawasaki’s syndrome (that resulted in a 2 year struggle with insurers and payments), so all of this ‘you obviously don’t appreciate modern medicine or understand how much it costs’ not only seems to miss the mark, it’s more than a bit rude. I mean, all of this started with when you took part of a response of mine to Enrak where I said to Enrak
“As Hilzoy has pointed out, the consumer does not have the power to simply do without”
and you took that as an invitation for the following:
Is the consumer currently doing without the life-saving drug that has not yet been discovered?
How much is that undiscovered pill worth?
I will assume that the escalation of snark is as much my fault but on the assumption you were trying to make an honest point laconically, I think there is an Orwell quote about how the promise of a nearly perfect future can’t be invoked to short circuit progress now. Undiscovered pills and life saving drugs are the promise of a nearly perfect future and in a discussion of UHC (which you claim to support) it is meaningless and a threadjack. Unless you are trying to catch Andrew’s back and protect the conservative end of things, which is understandable, but intellectually not very honest.
Enrak,
you seem to think that my sarcasm is directed at you (you did see this comment?), and then you fret that no one is addressing the transition costs, presumably because you’ve been overrun by sarcasm. My apologies for the collateral damage and for not clearly noting I was addressing Sebastian. If you subtract my sarcasm from the thread, I think you will note that no one has addressed transition costs and I think this is because we (or at least I) don’t understand exactly what you mean by ‘transition’ costs. For example, you suggest that there will be a supply problem which one might classify under ‘transition costs’. But for me, the question is not whether someone who blows their knee out playing pickup basketball (an example chosen from personal experience) has zero waiting time for an MRI, the question is whether people in real emergency situations have to wait. If the supply of services, facilities and medical personnel can cover emergencies at peak times, then is it a wise investment to demand an increase so it can cover all uses? I don’t think so.
You also suggest that the problem in Maine is indicative of what will happen. However, this sort of efficiency can encourage other solutions, such as this one. As Hilzoy noted, a private insurance plan has every reason to try and reduce its risk pool by trying to eliminate high risk patients. The starting point of UHC assumes everyone has to be covered, so that avenue of revenue enhancement is closed and many of the commentors here feel that is appropriate. I don’t know if you think so, but here, you argue that a longer time frame is needed to see benefits in preventative medicine. But if you limit the time frame to determine transition costs, you are excluding those benefits which may result in greater savings down the road. Perhaps we won’t see them, but our children will, which seems appropriate to me.
Again, my apologies if you thought my sarcasm was directed at you. Though I think the thread will be pushed below the horizon, I would be happy to discuss it (or have a new thread about transition costs if someone wants to post one)
Thanks for all your responses.
I should point out that I wasn’t upset by the snark, I just felt it did little to advance the conversation. Most of it seemed of the laugh so you don’t cry variety anyways.
This was a very interesting thread for me. I should point out that when I talk about costs, I don’t necessarily think those should outweigh the moral component of a healthcare discussion. (i.e. Gary, no I do not disagree)
I’ll be back for the next healthcare thread.
Apparently there are a few bumps in the road:
Hospitals across the country are imposing minimum waiting times – delaying the treatment of thousands of patients.
After years of Government targets pushing them to cut waiting lists, staff are now being warned against “over-performing” by treating patients too quickly. The Sunday Telegraph has learned that at least six trusts have imposed the minimum times.
In March, Patricia Hewitt, the Secretary of State for Health, offered her apparent blessing for the minimum waiting times by announcing they would be “appropriate” in some cases. Amid fears about £1.27 billion of NHS debts, she expressed concern that some hospitals were so productive “they actually got ahead of what the NHS could afford”.
The whole thing is worth a read, and I’d be interested in what any of our (few? many? just one?) UK residents might have to say about this.
Behind this global Universal Health Care if there mind people….