Some health-care links

A mini health-care extravaganza.

If you haven't seen Glen Whitman's masterful dissection of the World Health Organization's national health care rankings, I recommend it. Part 1. 2. 3.

Opinions different from Michael Moore's about the quality of Canada's health care system--and more--and Cuba's.

Some general comments on Moore's film.

Frank Lichtenberg finds that states who have the newest drugs in their Medicaid and Medicare programs have people who live longer and that those newest drugs do not, on net, seem to raise health care expenditures on average.

Finally, four discussions of policy.

Jane Galt argues that many of the ways in which we can supposedly have cheaper care in the U.S. are fantasies: "Even as we walk through the fairyland of perfectly executed policy programmes, there are some magical byways that the Ogres of Reality have blocked off."

Austan Goolsbee contends that the major changes beloved by critics such as Moore will be enormously expensive:

So, to do as Moore wants in the United States, you would need to do more than just overcome the insurance industry. You would need to cut the salaries of doctors, reform the legal system, enrage our allies by causing their prescription drug costs to escalate, and accustom patients to a central decision-maker authorized to determine what procedures they are and are not allowed to get. Unless every one of these changes comes together, Moore's new system would end up costing an enormous amount of money.

Alicia Colon discusses the work of Canadian doctor David Gratzer, who argues for less state restrictions on high-deductible but cheap health insurance policies.

Arnold Kling agrees on the need to modify state regulations, but he concludes that problems in our health care system ultimately stem from . . . us, public attitudes. I agree. Michael Moore notwithstanding, the American economic and political systems remain very sensitive to the wishes of the American public. But in this case, Americans need to have their minds changed. Kling:

The biggest problem of all is that nobody, here or in other countries, wants real insurance. Instead, everybody's idea of health coverage is to be insulated from costs.

As I pointed out in the essay, the wonks want to keep the existing system going, with a few patches here and there. If the Democrats take the wonk route, then they had better lower everyone's expectations about what they will accomplish. They certainly are not going to slow the rate at which health care spending is gobbling up tax revenues. They certainly are not going to slow the rate at which employer-provided health insurance is unraveling under the pressure of swelling costs. They certainly are not going to address the coming bankruptcy of Medicare. They are not going to come to grips with America's extravagant use of medical procedures with high costs and low benefits.

The wonks do not wish to confront Americans concerning our beliefs about health care--the belief that someone else should pay for it, the belief that cost-benefit analysis is inappropriate, the belief that someone who is suffering or dying should be spared no effort in terms of treatment, and so on. If the beliefs persist, then so will all of the major problems. There is no clever wonkish way to get around them.

Comments

[cactus]

I haven't seen Sicko, and its clear the WHO rankings and any other rankings are problematic. What is clear, though, is that in the US we pay more for healthcare than anyplace else by whatever measure, and what one cannot say is we get commensurately better care then every place else. So maybe its not Canada or Cuba, but I don't think anyone will argue that the difference between what we pay and the French or Japanese (to name two) pay is reflected in the difference in the care received by the French or Japanese. I'm not sure we could even show that Americans, on average, get better care than the French of Japanese by any measure that would be considered objective.

Now, it seems that the "pay more for healthcare than anyplace else" issue can be eliminated (by some measures) simply by eroding the value of the dollar sufficiently, but I suspect that's not an optimal approach. So what's the solution - doing less of what gives the French and Japanese systems bang for the buck, or doing more of it?

[JorgXMcKie]

It would help if people would consider what "the US pays" compared to what any other country "pays" suffers from some definitional shortcomings. In the US, a huge part of that "pays" is individuals, not the govt, paying (one way or another) for health 'care' that the individual believes (whether correctly or not) that they 'need'. How much do we pay for 'necessary' plastic surgery in the US, and who decides if it is 'necessary'?

It's not always the quality of care that is costing us nor an unwillingness to wait in line for care, it's demanding (and receiving) care that has no obvious usefulness to one's wellbeing.

Kling is right when he says that Americans pay so much for health care because they can. The minute large numbers of US citizens realize that 'national (free) health care) means they can't get what they want, the idea will go down in flames again.

Let me put it this way, if most of the money spent on health care is private (i.e. personal expenditure or forgoing hihger wages for 'employer-paid' health care), why should anyone care what the money is spent for? If France or Japan 'spends' less, is it because it is tax money and they don't allow people to buy relatively physically 'useless' end-of-life care?

Some huge proportion of all the money spent on health care in the US is spent in the last 6 monts of life. Last I remember, the Hastings Center Reports seem to find that number to be north of 70%. This includes extreme premie babies at a cost of $1.5M plus per premie (with a survival rate of 1 in 20) and the survivors take enormous amounts of care for the rest of their life, usually. Do France and Japan do this? My info is not.

We also spend enormous amounts of money on very old people who are not sick so much as dying by falling apart (as did my mother this past January). We spend billions delaying death for months or even mere days. Why? Because we can and we want to.

All those who want to 'rationalize' health care by nationalizing it should tell us in advance where they want to decrease spending, because it ain't all insurance company overhead.

[cactus]

JorgXMcKie,

"We spend billions delaying death for months or even mere days. Why? Because we can and we want to."

Four problems with this.
1. It seems what most Americans want is for there to be another far less expensive end of life option, namely euthanasia, but activist judges continue to read stuff into the Constitution that just isn't there so as to thwart the will of the people.
2. If the difference between our costs and those in France/Japan/wherever is that we put so much more effort into end of life care... one would expect that at the very least, Americans would live longer than folks subjected to care in those countries. One can quibble about whether the data showing that people in most developed countries live longer are accurate. What one cannot do is show that the average American lives longer. Holding everything constant, one should be able to show that if two people have precisely the same fatal condition, the American one should live longer. I imagine that may be true for some fatal conditions, but if it was true for very many, its something advocates of the American system would have pointed out already.
3. Is there any inefficiency whose continued existence cannot be justified by "because we can and we want to"? To a large extent, even the paying of blackmail falls under that category.
4. And who is we? A large percentage of Americans apparently cannot.

[JorgXMcKie]

Cactus: having checked my mother into a hospice (her stated and written choice) this past January and watching them do everything possible to avoid giving her the pain medication needed to ease her pain as she starved to death over two weeks, I am (and always have been) a supporter of individual choice about euthanasia. However, not everyone (nor their families) wants to ease out of life when it's time, so massive amounts of money get spent in situations where the amount of extra life gained is sometimes weeks or months but all too often days or less. That amount of spending is huge, spread over the many deaths in any given year.

And by activist judges, I presume you mean "those judges who decide cases in ways I don't like" or else you should be complaining about the more liberal justices on SCOTUS also.

Pumping more money (usually OPM) into the endstages of life *DOES NOT* lead to greater longevity. See above. When my mother developed 'dry gangrene' from unoperable blockages in both legs (following breaking each hip in separate accidents over the past two years) she was 'subjected' to 'treatments' that cost Medicare (and her private insurance and herself) many thousands of dollars in a short 2 months. They also advocated amputing either both legs at once, or as she said, "whittling her down a piece at a time." (Guess how much each of those would have cost.) They predicted that doing this would gain her "up to" an extra year of life, but wouldn't say that she could expect more than six weeks.

Life at end stage is not particularly prolonged by 'extreme measures' that way too many Americans apparently demand of the health care system, mostly because they don't see themselves as paying the cost, I think.

And you actually can find data that shows that Americans with some very severe conditions do, indeed live longer *after diagnosis* than others. However, it's hard to tell how much of this is due to early diagnosis and how much is do to better health care. Plus, having, say, 1,000,000 people live an extra 6 months (or even two years) changes life expectancy very little. The last numbers that I saw said that if everyone in the US who smoked quit today and no one started, it would increase US life expectancy by less than 2 months overall. We all die of something.

I would also ask, is there any inefficiency that can't be used to justify massive government intrusion? I'm not trying to *justify* the inefficiency, I'm pointing out why it exists to indicate how difficult it will be to change, absent massive government intrusion. If you think the general American public is going to change from "we spend because we can" to "we don't spend because some govt bureaucracy doesn't think we should" easily or even voluntarily, I want some of whatever you're smoking. Besides, if it (the overspending) brings psychic benefit instead of physical benefit, who get to decide that it's inefficient?

As for "who are we" well, in 1994 "we" turned out to be enough voters to change Congress.

I have two major points that you are either avoiding or ignoring. 1) the US doesn't spend the health care money, mostly, it is spent a large and very diverse bunch of Americans that I choose to use shorthand to describe as 'we'. 2) 'We' (the people who currently access and use the system in any form) tend to 'demand' a certain type of care that would seem not to be available under fully (or even partially fully) nationalized systems and when 'we' figure this out, 'we' are not going to be pleased.

How about this? We open up the Veterans hospital system and Medicare/Medicaid to anyone who wants to pay their share of the tax money to do so. This prevents cherry picking. The caveat is that those who choose to join the system cannot access health care outside the system that is reserved for those who have their own insurance or pay cash (and are not in the govt system).

[cactus]

"This prevents cherry picking. The caveat is that those who choose to join the system cannot access health care outside the system that is reserved for those who have their own insurance or pay cash (and are not in the govt system)."

Ah, but anyone in France or Canada can access health care outside the system. At the very least, they can always come here.

"I have two major points that you are either avoiding or ignoring. 1) the US doesn't spend the health care money, mostly, it is spent a large and very diverse bunch of Americans that I choose to use shorthand to describe as 'we'. 2) 'We' (the people who currently access and use the system in any form) tend to 'demand' a certain type of care that would seem not to be available under fully (or even partially fully) nationalized systems and when 'we' figure this out, 'we' are not going to be pleased."

Are you saying Americans get boob jobs but nobody in Canada does?

[JorgXMcKie]

First, my point (which you studiously avoid, so I presume it's a fairly sharp one) with allowing people to 'join' Medicare/Medicaid/vets with the caveat that in doing so is that they accept only that which is provided by the system is to heighten the contrast between what people seek and get now outside that system compared to what they could get (with obvious tax dollars) in a nationalized system. Functionally, it would create two systems: 1) a nationalized 'free' system run by the government and based solely on tax dollars, and; 2) one very similar to what we have today. People could choose, but not mix, so there would be an obvious way to see what they prefer. Quite obviously you accept the idea that most people would not, by choice, limit themselves to what the govt systems currently provide or are likely in the future to provide. Thanks. Also, of course, this (a nationalized system plus outside choices) would tend to *increase* the disparity between the rich (or at least reasonably well-off) and the poor or between those in population dense areas and those not. Are you advocating some kind of class-based health care enforced by the government?

At any rate, surely not even you will deny that any national system will necessarily ration care by some means, even as do Medicaid/Medicare/vets now?

As to 'boob jobs' no, but then I forget your tendency to avoid the major point by way of distraction. It's always one of the big signs that your argument is weak.

I am saying that a much larger portion of 'health care' (if we can call elective cosmetic plastic surgery 'health care') is much, much larger in the US because we have the resources and are not prevented from making the choices. We spend on stuff that is non-efficient in terms of longevity because: 1) we have the resources, and; 2) we have the individual choice. If those who want to take over the current system and put it in the hands of a govt bureaucracy (unless you have some other way of nationalizing health care) are using the argument (as it appears they are) that one of the major 'problems' of the US system is that we spend much more without gaining in longevity, I am pointing out that longevity is not the point of those seeking the extra 'health care' in the US, to the extent that much of the spending is on things that do not increase longevity. In other words, longevity is not a good way to measure the effect of spending *after* it is near whatever the norm (about 77 or so evidently) would be in the face of fairly normal medical practice (say the average in the top 30 industrialized nations).

Thus, if you want to 'cut' the 'cost' of 'health care' to 'the US' (i.e. not by individual choice), then you must necessarily eliminate a great deal of optional spending being done today, and the US public is probably not going to like that. Care to address the point, or would you rather duck again?

Ah, but Canada is next door to the US, where their govt can't prevent them from choosing how to choose their money. And France (15,000 dead due to care shortages caused by mandatory vacations? When is the last time the equivalent 70,000 US citizens died from something so perventable) is next door to the UK and other countries where citizens can spend freely.

I like to check out the hospital parking lots in Metro Detroit and see what percentage of license plates are Canadian. Usually 20% or more. Where do the average health care consumers go for that outside the system care if they can't get it (at least soon) within 1000 miles?

And, of course, if you decide to let people buy care outside the system, how the heck to you expect to reduce 'US health care expenditures'? Would you like to show me how much the Vets health system or Medicare pay for optional cosmetic surgery, or other non-longevity practices?

Oh, and you fail to show that *any* Canadians get cosmetic boob jobs in Canada, although I'm willing to believe that breast cancer survivors do. Got any, you know, data?

[cactus]

JorgXMcKie,

I'm not going to spend time looking for statistics on boob jobs in Canada. However, in 30 seconds on google I found this: http://aje.oxfordjournals.org/cgi/content/full/164/4/334

Clearly, given the existence of the data, there were a lot of women getting breast implants specifically in two provinces in Canada some years back. I'd be surprised if its since stopped or if these are all the women who had this surgery or if it didn't occur elsewhere in Canada. Conclusion... at least some number of women are managing to get this wholly cosmetic surgery.

I can address some of your points on rationing, but I think they're better addressed by Mark Kleiman, a UCLA professor:
http://www.samefacts.com/archives/health_care_/2007/07/rationing_health_care.php

If you can describe his experience with his insurance company with a word other than blackmail, I'd love to hear it.

Which leads to this: "you must necessarily eliminate a great deal of optional spending being done today, and the US public is probably not going to like that."

If Kleiman is lying or dead wrong, then you are correct. Otherwise, you can get a lot more out of the system simply by eliminating the extortion aspect of it. And then there is the billing functionality. There are people associated with billing overhead at every doctor's office in this country. And they're busy playing a game with insurance companies, who are busy trying to find a way not to pay for things.

"When is the last time the equivalent 70,000 US citizens died from something so perventable"

http://www.usatoday.com/news/health/healthcare/2002-05-22-insurance-deaths.htm - that's 18K a year from lack of insurance alone some years back. I suspect we could come up with another 50K who die as a result of spending time fighting with their insurance company.

"my point (which you studiously avoid, so I presume it's a fairly sharp one) with allowing people to 'join' Medicare/Medicaid/vets with the caveat that in doing so is that they accept only that which is provided by the system is to heighten the contrast between what people seek "

Sure... and how do we keep those on the private system from benefiting from public expenditures on health such spending on the CDC and so forth? Or is that free?

"At any rate, surely not even you will deny that any national system will necessarily ration care by some means, even as do Medicaid/Medicare/vets now?"

Of course... and I would hope surely not even you will deny that the current system necessarily rations care by some means. For example, those who cannot afford do not get it.

[JorgXMcKie]

Well, you do have one point, which I've made repeatedly: all 'systems' of health care ration. The fundamental argument for a centralized bureaucracy is 'efficiency'. I agree with that. Most tyrannies are efficient. If that is a good way to run a health care system, the old Soviet system should be the model, not France. Of course, no one seems to support that system (except when it's located in Cuba.)

The centralizers use several arguments which I find defective in one way or another. For instance, I've been trying to point out above, efficiency is not necessarily the model of choice in wealthy countries. (I did check briefly on boob jobs in Canada. They're widely available in Canada and used at probably similar rates to the US. [For argument's sake I'll assume the same is true of other, voluntary, non-essential cosmetic surgery.] However, it has to paid up-front, by the patient, it is *not* covered by the system, and the expenditures do *not* appear anywhere in the amounts *Canada* pays for 'health care', unlike the US figures.

Some of us prefer 'choice' (when it's relatively affordable) to 'efficiency'. Centralizers prefer (i.e. insist) that we not be allowed to have it. Which brings me to my second point of contention. This insistence that because some "can't afford" some particular health care they'd like to get, then the system must be centralized in the name of fairness. That is, rather trhan some not getting a particular health care treatment, we'll restrict ita access to *all*. (Well, except for whatever Nomenclatura evolves for such as Michael Moore and the other wealthy elites.) Thus, centralizatio tends to *increase the apparent unfairness of such a system and specifically punish the broad middle (especially the lower-middle) classes while allowing outside care for the privileged, which is not a trade-off I want to make.

Finally, I just love the free-rider argument. That is a strawman invented by and for centralizers that I find idiotic. Perhaps we should let citizens (and other taxpayers) access to 'public goods' only in proportion to the amount of taxes pay. Wouldn't that be fair *and* eliminate free-riders?

Look, I don't think the current US health care 'system is anywhere close to the best it could be, let alone perfect. What I do think is that phony arguments designed to stampede change in a certain direction is both dangerous and disingenuous. I'd like to preserve, to the extent possible, the individual choice nature of our system while 'borrowing' useful features from other systems. This could include more/better/cheap early childhood care. I could see a centralized feature allowing low-cost (or free, means-tested) access to *any* health care that was widely available 15 years earlier. Other than that, the individual or his insurer pays. A combination of HSA/catastrophic insurance might be able to cover just about everyone.

But let's be clear, here. The real argument is between centralizers and individualists. The first are more ;\'efficient' while the second are more 'free'. I'm in camp two.

[cactus]

"However, it has to paid up-front, by the patient, it is *not* covered by the system, and the expenditures do *not* appear anywhere in the amounts *Canada* pays for 'health care', unlike the US figures."

This is a key point. If cosmetic surgery is not a health expense in Canada but is one in the US, there is a comparability problem. That said, I'd like to see some evidence. (I do recognize that you didn't state it with certainty.)

As to centralizers versus individualists... I don't see it. We have a few large insurance companies that in effect are the central point in the system. And we all know what happens to prices when you have a small oligopoly running things. The market is efficient when there is no market power. And when people have access to some amount of information. When I worked at a Fortune 500 company, the company provided employees with a choice of plans run by three different insurance providers (i.e., the usual big names). I asked a number of colleagues... nobody really had much of a reason for picking one or another of the insurance providers. The plans they offered no doubt were different, but the fine print was unreadable. The reason for this is simple... it was in the best interest of the insurance providers for the fine print to be unreadable. They don't make money by paying for service. They make money by not paying for service. This is very different from most industries in which the interest of the seller and the interest of the buyer get more or less aligned (its in company X's best interest to sell me a good quality product at a good quality price, its in an insurance company's best interest to cancel some percentage of policies as soon as policy holders develop a condition that is expensive to treat. The harder it is for consumers to get information, the higher that percentage.).