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April 13, 2005

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There really isn't a third option.

There is: good socialist health care. The concept that health care has to be profitable to health care service providers (and that medical research has to be profitable to its funders) is a killer, quite literally.

As was pointed out five years ago, the US has the most expensive health care system in the world - and yet can't provide health care to all its citizens. About 40 million people in the US don't have health care insurance: over 18 000 18-64 year-olds die each year in the US because they have no health insurance.

That attitude - expressed very cogently in your post - that health care must be made profitable first, and worry about keeping people alive second - is why the US spends more than any other country in the world on health care, yet ranks 37th for overall performance, below all the other developed countries, all of whom spend less.

"Canada has only recently started to use MRIs at a level that was common about 8 years ago in the US."

Sebastian, since MRI is my field, and I defend my PhD o the 25th, I have more than a clinical interest in this :) If Canada is a MRI wasteland, nows the time to find out! ;)

So, Im asking not just to challenge you on a tanngential point,but also out of professional interest. Can you back up the assertion above with a specific cite?

I'd like to point out that at the annual meeting of the ISMRM every year there are hundreds of abstracts from Canadian researchers, and papers from clinical studies using MRI in Canada appear routinely in the clinical journals such as Radiology, JMRI, Neuroimage, etc. Youcan test that by going to www.pubmed.com and searching on "MRI" in the title, "clinical" in the abstract, and "Canada" in the author affiliations.

FYI, MRI is 30 years old.

Getting into the 'do you have a right to health care' question is the wrong way to look at things. Does a pauper have a right to easy road transport across the country in the same sense that he has a right to a fair trial and freedom of assembly? Of course not. But: does this mean the government is wrong to build highways? No.
True, there is an alternative; private companies could build the highways and demand tolls. But this would a) lead to a lot of duplication b) a lot of extra cost c) a lot more administrative expense than a government-funded socialist highway system available to everyone (regardless of ability to pay), free at the point of use, and maintained with tax revenues. The socialist highway system is good for everyone.
Similarly, I would argue, a national health service is good for everyone. It is a matter of fact that it has far lower administration overhead, far lower costs in terms of fraction GDP spent, and better results than the US system.
Is there a coherent argument for being pro-socialist roads and anti-socialist medicine?

The problem is not one of "limited supply and enormous demand." Most people demand healthcare quite rarely. When they do, however, the demand is highly inelastic; there are few to no substitutes in most cases.

Well, we can always have HMO's which seem to combine the finer point of Socialism & Capitalism.

I don't know if I qualify as a liberal anymore, but some sort of rationing like that makes sense. However, I'm not convinced that an arbitrary time cutoff is the best approach -- surely there are treatments older than 10 years that are designed for health complaints that we wouldn't consider worth covering, and there may be newer treatments that are so successful at treating serious diseases that we'd want to cover them ASAP. Wouldn't it be better to have a group of informed people evaluate different treatments and determine which ones give us the most bang for our bucks?

Always interesting topic. One of the reasons I love Japan is national health care. However, I can see the problems with rationing. For example, in dental care, almost all basic dental is paid for. However, because the doctor is reimbursed by the office visit rather than the procedure, something that would be done in a maximum of 2 or 3 visits in the US takes 8-10 visits (last year, I had my mercury amalgam fillings replaced) Also, there is less emphasis on taking care of one's teeth.

A very interesting side product is the fact that those who are outside the system (like Japanese mafia) have to pay cash and a lot of it. We took my daughter to the hospital when she had a highish fever one night (there is a rotation of hospitals staying open at night, you have to check the newspaper to find out which one is taking patients for that evening) and a rather high ranking yakuza member (you could tell because he had several younger men running around making sure that everything was just right for him) came in, with what I think was a broken arm (no blood or anything, so there was no pinkies chopped off or any notion of drama). As luck would have it, he checked out right before my daughter did, and because he had no health card (or because he didn't want to be entered into the system) he paid cash. My wife handles most of the bill paying and stuff, so I got really scared when I saw the stack of 10,000 yen notes (about $100) he had to pay.

I'm not suggesting that the US start national health care to deal with organized crime, mind you. And because the government determines which treatments are to be reimbursed and at what rates (note that abortion is an elective procedure, largely because doctors can take that income as cash and avoid taxes, which thereby encouraged doctors to limit access to the birth control pill, so there's lots of room for problematic behavior), it does stifle innovation. But, (and I think Matt Yglesias has made this point) when you look at the level of services and health provided for the percentage of GDP, it speaks to the comparative advantage of national economies to have a national health system.

Jason Kuznicki: The problem is not one of "limited supply and enormous demand." Most people demand healthcare quite rarely. When they do, however, the demand is highly inelastic; there are few to no substitutes in most cases.

True. It's interesting, in this context, that the so-called "culture of life" hardly ever overlaps with "provision of free health care". One would think, for example, that those who regard abortion as murder would want to minimize the number of abortions for economic reasons by (for example) campaigning for free health care for pregnant women and all children. After all, what price the "culture of life" if it doesn't include working to save children's lives after they're born? According to this table, well over five and a half million children in the US have no health insurance: their parent(s) are at or below 200% of the poverty line. Yet I cannot recall the last time I heard a subscriber to the "culture of life" rail against the US's health care system that ignores these millions of children.

Liberal Japonicus- I generally agree with your post, but you didn't need "comparative" in there. Comparative advantage in the economic sense means something different.

I'd bet uninsured people would jump at that deal. And there is a case to be made that they would be better off using 10 year old generic drugs than the latest and most expensive. I'm also fairly sure that what would torpedo such a program are not liberals, but the pharmaceutical and insurance industries.

An even better plan would be to use single-payer health care to increase the supply of donor organs.

I'd sign on to that 20 year old standard-of-care business, along with a hard-core capitalist system for everything newer.

It might give everyone across the political spectrum a vested interest in seeing technological progress accelerate - anything developed now is guaranteed to everyone 20 years from now. That brand-spaking-new treatment you can't afford will be cheap for your kids. Maybe then people would be more apt to sign on to thorough deregulation of the "new" side, knowing they'll be "safe" on the regulated, subsidized side while allowing people the option to try more experimental stuff without seeking permission.

I don't know if anyone else here is chronically ill. I am, and I can say for sure that anything like "10/20 years old" is absolutely the wrong way to go. What time does with many treatments is make them cheaper, more reliable, and prone to fewer side effects. Anesthetics, for instance, get better all the time - a rollback on the anesthetics provided to those recieving government aid would end up costing more, directly and through unnecessarily lost productivity and just plain unnecessary misery.

In a comment...somewhere, possibly Washington Monthly or Matthew Yglesias' site, someone responded to Matthew's comment about the press being relatively wealthy and therefore not in a position to directly sympathize so much with the plight of the poor by complaining that a good reporter is likely to only make $65K a year or so once established. That is wealthy, relatively speaking. There are a great many workers who will never see that much money a year, or anywhere close to it, and it's enough to pretty well be out of the medical-funding crisis zone. Things are a whole lot grimmer for those who make half that, and people do. Sometimes for their whole careers, and sometimes for stretches of a year or several years when their old job folds and they can't manage to get a decent replacement.

The, or one of the, major libertarian (and, I believe, conservative) arguments is that intervention now is a bad idea because of the unknown potential of the future. Historical backing for this often includes the miseries of the early generations of the Industrial Revolution, and the greater good that followed. But I've realized (and this is what led me to give up on libertarianism, as much as anything) that I don't believe in the future in that way any more. A future will happen, but not the one I'm envisioning, and it's wrong to sacrifice others' present pain for my hopes that, history also tells me, are wildly unlikely to be fulfilled to any great degree. My fellow Americans and fellow humans who are in pain and sick and in need of shelter and all the rest right now are more real than my guesses about what wonders might come for them later.

Geez, I'd take twenty-year old standard of care (as opposed to just technology). You might actually get a nurse in the hospital.

Bruce: you have a fair point that sometimes newer stuff is cheaper than the older stuff. It wouldn't be hard to modify the standard to state that if newer Treatment A does basically the same thing as older Treatment B, but actually costs less per patient, then Treatment A gets covered. But I don't think that dooms the basic idea, which is: when a new treatment provides increased capability and increases cost too, the people who want the new capability ought to pay the increased cost themselves.

The point of the thought experiment (which I thank Sebastian for bringing to a wider audience) is this. Even if you believe in a positive right to health care-- and FWIW, I flat-out don't-- there must be some limits to it. We ought all be able to agree, for example, that Medicare coverage for Viagra is ridiculous. So where are those limits? Just how lavish a standard of care are people entitled to?

If you want to make a case that a positive right to health care can be provided in a cost-controlled manner, you have to answer those questions. There are a variety of relatively simple rules by which the care the government pays for could be constrained so as to keep costs relatively low. But if you're not willing to accept any such rules, then in the current American political culture-- not the French, not the Canadian, but our own, where people really do believe they are entitled *not to die at any cost*-- it is unlikely that your proposal will result in reasonable cost controls. And if you are willing to accept such rules, you need to say how you expect to sell those rules to the electorate-- not a fantasy electorate with great rationality and public-spiritedness, but the real electorate, the one that voted in the supposedly small-government party that passed a Medicare bill that covers Viagra.

re: supply and demand, under the current system private health networks have little incentive to pay for preventative care that may lead to less demand for more expensive health services down the road, because each individual health plan risks having some other plan reap the benefit of investment in preventative care when the patient changes plans. Because competing private plans are profit-maximizers, cost inefficiency on a society-wide basis is built into the system. Reducing inefficiency wouldn't ultimately "solve" the type price-rationing you're talking about on the margin, but it could go a long way towards reducing costs and improving outcomes.

Bruce, how would you ration health services?

Aziz, you can infer usage by reports such as here or here. In the anecdote as data category, a close friend (insured) just had an MRI after a one day wait in California for a non-emergency procedure.

Comparative advantage in the economic sense means something different.

Thanks for pointing that out Frank. I wanted to note that a nation would have some advantage(s) if a national health care system would be put in place (it is often argued that the US health care system provides advantages to the US because innovation is greater, leading to more money flowing to the US). Any googleable terms to find the kind of vocabulary they use to describe this?

I'd also note that if a national health care plan came into being, it would make it cost effective to conduct screenings and such because catching diseases early would lead to greater reduction in costs. I don't know what it is like in Europe (when I lived there, I was too young and irresponsible to think about things like health check ups), but here in Japan, the government not only pays for various regular check ups, there are travelling check up vans that go to large places of employment to provide the workers with a checkup for various problems, including ultrasound, eye and ear check, barium scan among other things. If anything turns up, you get a letter asking that you go to the hospital to have a more rigorous workup. For ex, my understanding is that about 20 years ago, it was noted that stomach cancer was on the increase, presumably due to increased salt consumption (it was first noticed as a problem in northern Japan, where the consumption of soy sauce is much higher than down south) Some of these northern prefectures instituted a program of barium scans followed by camera reading of the stomach (gastroscopy?) which caught a large number of these cancers in the early stages, thus reducing the cost to the government and this was adopted nationwide.

I think that, in assessing the thought experiment, it helps to consider concrete examples. Here's one: AZT, and later the various AIDS cocktails. Consider whether you'd want to watch AIDS patients die during the period between when those drugs' effectiveness was clear and whatever time horizon you choose. -- I think that the thought experiment seems persuasive if you're thinking of some already treatable disease for which a marginally more effective and very expensive drug comes along. It's a lot less plausible if you consider a case like AIDS, in which a previously untreatable and lethal disease becomes treatable.

About Sebastian's more general point: he (you) writes (write) this: "That fact doesn't go away when the government is paying, in fact it may intensify if you don't have an obvious linkage to the payment.  This is the long way of saying that rationing is going to happen on the basis of price one way or another.  Either we will significantly slow new research by making it not profitable enough to compensate for the huges risks, or expensive things will exist but be inaccessible.  There really isn't a third option." (My quibble with this para. is not with the claim that research will either be rewarded or the incentives to produce it will vanish; it's with the role of the government that the first sentence seems to imply.)

Here it's worth noting that one of the central facts in health economics is that for the overwhelming majority of people, this linkage already doesn't exist. I, the patient, want all the health care I need. The doctor wants to convince me to get as much as s/he can. But in most cases, I already don't have to ask whether I can afford it, since the costs are picked up by my insurance company, who therefore has an interest in allowing as little as the terms of my policy permit. Worse still (as far as economic theory is concerned). in many cases I don't even pay the costs of my own insurance, and thus I don't even see, in this indirect way, the costs of my demand for expensive health care. Given these facts, decisions about medical care already don't resemble normal market transactions, in which I consider how much I'm willing to pay for the goods you offer.

There are further reasons why, if this were a normal market decision, it would be one in which market failures were likely. Here are two: (1) the parties to the transaction are operating with asymmetric information. Doctors know much more about available treatments than I do, and moreover hospitals know much more about the cost of whatever treatments I am about to receive, and how these stack up against other hospitals. (2) (Related): I often do not know what costs I am about to incur (consider all those items on a hospital bill), and thus cannot do comparison shopping.

Moreover, one of the central questions in designing health care policy is: how do you set things up so that on the one hand, people are more sensitive to the cost of the health care they receive, but on the other, you don't force people to go without needed care because they can't afford it? -- I mean, we could introduce market forces into health care easily enough, by outlawing medical insurance and forcing people to pay for their own medical care as needed. But the obvious consequence of this would be that the poor would die of treatable illnesses whose cure they cannot afford. (And it would also require limiting people's economic freedom by outlawing insurance; it's insurance, not government intervention, that creates the problem. Or, more precisely, insurance plus the fact that, unlike say life insurance or flood insurance, where it's usually fairly clear when the insurance has been triggered and what the insurance company owes as a result (e.g., that someone has died, and that as a result X dollars are due to Y), here everything turns on determining things like: what is a necessary treatment? Is treatment X as good as treatment Y? Etc.)

Now: as a general rule, any step you take to make health care decisions more sensitive to market forces risks having people suffer or die needlessly, and any step you take to prevent this risks removing any sensitivity to cost from people's decisions. The trick is to find a way to set things up that prevents both sorts of bad consequences. And that's what makes health policy so hard. But it's a huge mistake to think either that absent government intervention, health care decisions will be made in the same way as normal market decisions (the existence of insurance prevents that), or that if they were made in this way, people wouldn't die needlessly.

Finally, it's also worth noting that many proposals to control health care costs do not involve, primarily, removing incentives to produce new therapies. Some involve eliminating layers of administration, which impose their own costs. Some involve educating doctors about the costs and benefits of various therapies, so that (for instance) they do not prescribe expensive new drugs when old ones would work just as well. (Note: doctors can also be insulated from the costs of the treatments they provide. I think it's better now, but as of about a decade ago, it was not uncommon for doctors not to know how much a given drug would actually cost an insurance company; and for this reason they were much more susceptible to patient requests to be given the absolute latest drug, whether it was actually any better than existing ones or not.) Eliminating ads for pharmaceuticals would save money without reducing rewards to innovators, as would reforming the practice of continuing medical education, which is essentially a very expensive form of advertising. And so on, and so forth.

The points being: (a) in this case, it's not the government that gets in the way of normal market forces; (b) allowing normal market forces to rule would have a serious cost; (c) there are ways to cut costs without reducing rewards to innovation. (Also, for what it's worth, I do not believe that people have a "right" to health care, though I also think that the government ought to adopt policies that ensure that everyone has access to affordable health insurance, however provided. As someone said above, 'the gov't should do X' does not equal 'I have a right that X be done.')

Just out of curiosity, because I really don't know, what are these very expensive and life-preserving drugs and machines that have come online in the last ten years (or twenty, for that matter) that we would be giving up? Since most people die from heart disease or cancer, I'd guess they'd have something to do with those diseases, but I don't know.

Without getting into the merits (meeting in 17 minutes), I just want to point out that it is not necessary to believe in some "positive right to health care" in order to believe that a style along the line of France or Sweden is better than the system we have now.

I am so tired of being branded some kind of communist every time I point out that the current system just sucks, and is preposterously draining on the finances of American businesses and citizens.

"I think that, in assessing the thought experiment, it helps to consider concrete examples. Here's one: AZT, and later the various AIDS cocktails. Consider whether you'd want to watch AIDS patients die during the period between when those drugs' effectiveness was clear and whatever time horizon you choose. "

Yes. After all, we watch plenty of old people die because there is no treatment that can be had at any price. Anything that accelerates the development of such treatment can prevent the horrible disfigurement, disability, and slow, lingering death that we all are subect over the next few decades.

So "watching people die" is nothing new. The only way to put a stop to it is medical innovation, and lots of it. Everything else is just a temporary stalling tactic.

"Now: as a general rule, any step you take to make health care decisions more sensitive to market forces risks having people suffer or die needlessly"

On the other hand, it increases the chances of preventing nearly everyone from suffering and dying needlessly a few decades from now. Including you, if we play our cards right.

"and any step you take to prevent this risks removing any sensitivity to cost from people's decisions."

Which means we shouldn't do it. Think of the children - when they grow up, you want them to have much better health care than we have, right?

"I mean, we could introduce market forces into health care easily enough, by outlawing medical insurance and forcing people to pay for their own medical care as needed."

That's not introducing market forces - that's substituting one dumb regulation for another. What we want to do is deregulate medical insurance, and stop giving tax breaks to encourage medical insurance being bought from the company store. Individual policies would not only prevent a job loss from also representing an insurance loss and encourage more entreprenurial activity by individuals, but by allowing them to price according to risk factors, they can discourage unhealthy habits and encourage preventative medicine. They'd encourage the right kinds of preventative medicine - if the premium break for getting a checkup exceeds the cost of the checkup, getting it is a no-brainer, and it won't be a case of one company getting a break on checkups paid for by another.

Yea, I just see this whole post and most of the comments as one huge smoke screen. The fact is, our system sucks. It sucks on pretty much every metric we can come up with. It sucks so bad that other countries with far less capability do far better at it than we do. And this is pretty much undeniable.

The entirety of Sebastian's world view is that the USA is not only doing the best it can, it's doing the best possible and if it wasn't for those meddling kids - er, government - then everything would be just peachy.

Which belies simple observation. We have over 30 million people without health care in this country. A number which is or is close to the entire population of Canada. Who the frick cares if Canada's MRI use is or is not equivalent to ours? The ENTIRE POPULATION EQUIVALENT OF CANADA goes without even the barest essentials.

My lord. If you're going to bitch about the edges in Canada, at least look at the glaring wounds in our own system.

Microscopes for eyes. Geesh.

I'd ration by what best combines low cost and high efficiency. It's like defining "good writing", though - the answers get highly specific once you get beyond the basics.

The first focus should be on what keeps people healthy and makes recovery quick. And when problems have well-established solutions, those should be favored. Nurses should have a lot more diagnostic and prescriptive authority, for instance. I'd provide tax breaks for businesses that maintain sick-leave policies that pay attention to recuperation time, to reduce the rate at which infections circulate through work places because people dragged themselves back too soon because they couldn't afford not to. I'd make a bunch of vaccinations free to the public, along with allergy testing for them and for a bunch of the very common and under-diagnosed food allergies (milk, wheat, etc.). I'd push for much wider diagnosis and treatment of clinical depression, seasonal affective disorder, eating disorders, and the like - stuff that creaetes cascading complications, is often amenable to straightforward treatment, and has a lot to do with promoting psychological well-being as well as physical health. I'd underwrite regular testing for juvenile and adult-onset diabetes, and other nasty stuff that can be dealt with when it's spotted promptly.

When it comes to expensive cutting-edge testing and treatment, I'm not qualified to discuss specifics, and I doubt many others here are, either. (I'll bet some are, and look forward to reading them.) The broad principle "use what costs little and returns much" is complex in application.

right on, Hal (and st)

It's just stunning to see supposed capitalists contort to justify a system which is clearly bleeding us dry.

Ideology is a strange thing.

At Crooked Timber, Ted Barlow posts on the topic and initially makes what I think is a characteristic error on the topic: he talks about the government paying for health care as if it repeals the problems of limited supply and enormous demand.

From the perspective of an advocate of socialized medicine, you're making the mirror-image error. "Enormous demand" is a problem in relation only to the very few very ill -- for the overwhelming majority of health-care users, increasing ease of access actually decreases demand.(Think, for example, of a poor child with asthma. With single-payer health care, she gets regular maintenance treatment, which isn't all that expensive. Without, she suffers regular crises that take her into the emergency room, at greater expense and producing worse results. Rinse and repeat for most other medical care -- preventative care is cheap, emergency care is expensive.)

So this demand problem relates only to the very few, very ill, and by providing single-payer health care to the rest, we've painlessly freed up additional resources to deal with them. At this point we've already massively improved the lives of most people in the country. We haven't solved the out-of-control demand problem, but do remember that this isn't a problem unique to single-payer systems; we have the same problem now.

Solving it isn't rocket science either. Right now, we ration care based on who was insured when they got sick, and who can win the inevitable battles with their insurance company over attempting to deny care. We watch people die for those reasons now. Under a single-payer system, we could take stock of the available resources, and determine which treatments, under which circumstances, are not cost effective -- too much money for too little actual improvement in health. People concerned about needing such non-cost effective treatments could buy themselves private insurance, of the sort which is now generally available in countries with socialized medicine. The innovation you're so worried about? Why wouldn't the market drive companies to come up with new treatments that were cheap enough to qualify as cost-effective? The incentives change, but there isn't a lack of incentive for innovation, just innovation in a different vein.

This entire discussion seems to imply that there is an insurmountable moral problem in not providing every existing treatment in a single-payer system, but that the current situation, in which people die for lack of insurance, doesn't pose the same problem. I don't get that distinction.

Echoing a lot of what's been said above, I think our first priority should be on funding basic, preventive maintenance and testing. Regular dental and doctor checkups, testing for common conditions... underwriting these things with tax dollars should be a no-brainer, given the benefits that would be realized by recognizing and stopping conditions before they snowball and become serious, even fatal down the road. In the long term this would pay for itself by reducing the necessity and cost of catastrophic healthcare.

Of course, my personal opinion is that basic health care should be a right, particularly in a country where half of the electorate are hung up on the notion that they're a "culture of life". It just so happens that it's the smart thing to do as well.

"Consider whether you'd want to watch AIDS patients die during the period between when those drugs' effectiveness was clear and whatever time horizon you choose. "

Yes.

Well, that was instructive.

Anarch: especially since Ken did basically nothing to explain the linkage between not funding access to AZT etc. and spurring medical innovation.

I've got no problem at all with minimal healthcare insurance.

The problem is getting people to agree on what constitutes "minimal", and under what circumstances anyone at all can access healthcare that's more expensive than the minimal. I'd guess that there would be some procedures, immunizations and regular checkups that would be available to everyone, and funded out of tax revenues. On top of that, anyone can purchase supplemental health insurance. I rather doubt that this would qualify as "good socialist health care", but "good socialist *" is almost always oxymoronic. Unless the wildcard happens to be something along the lines of "purge".

I rather doubt that this would qualify as "good socialist health care", but "good socialist *" is almost always oxymoronic.

And that was clearly a knee-jerk, Slarti. C'mon man, us socialists can occasionally point out that there are some brilliant workings within the market system. Surely conservatives can see that occasionally socialist systems have good qualities.

Case in point, Canada's healthcare system. I'm stunned that Canada has just begun using MRIs. I wonder how I came to have one done in a Vancouver-area hospital over five years ago? Some kind of time warp, I suppose.

Bruce: fine, in an ideal world that could be a workable way of rationing health care. Now explain how it's ever going to work this well when the decisions are made not by bloggers but by politicians. The inherent complexity of your method is exactly the problem. Political institutions deal very poorly with complexity; the more complex the rule the more it can be gamed, defrauded, and otherwise abused.

Oregon tried something a decade ago like what you're proposing: they got a panel of experts together and had them rank a bunch of treatment codes in order of their estimated cost-effectiveness, as measured by quality-adjusted life years per dollar or some similar thing. They then limited their Medicaid program to covering the top N treatments on the list, where N was the highest number consistent with their budget constraint. This resulted in a huge public outcry and numerous stupid lawsuits alleging "discrimination," and it failed to provide cost control; IIRC it was abandoned five or so years ago.

Slarti: "good socialist *" is almost always oxymoronic.

Nothing like letting prejudice get in the way of facts, is there?

Do you have something against the good socialist roads that the US government builds and repairs? Or the good socialist health care that members of the armed forces receive?

This resulted in a huge public outcry and numerous stupid lawsuits alleging "discrimination,"

But would the 10- or 20-year limit really be any more popular? As soon as someone sees a treatment that isn't automatically covered, there's going to be a hue and cry, no?

Actually, I think we should just drop the whole term 'socialized medicine'. Socialism is government control of the means of production; it therefore applies only to a completely government-run health care system, not to any of the various government insurance or reinsurance plans out there, including a single-payer system.

It also just inflames debate: besides the examples Jes cites, we might also talk about our 'socialist' armed forces or judiciary, both of which are entirely government-controlled. (Nb: by 'socialist judiciary' I am referring not to the views of judges, but to the fact that the judiciary is entirely run by the government.) There are some things that should not be left to the market. National defense is one: we should try introducing competition in certain limited ways, I think (competition for food contracts is fine by me), but the idea of putting the defense of the nation as a whole under the market seems to me nutty. Likewise the judiciary.

As I noted earlier, health care already doesn't function like a market in some crucial ways. Moreover, there are some parts of it that most people do not want to see governed entirely by market forces -- e.g., treating people with gunshot wounds. Because we don't want this to be allocated on the basis of ability to pay, we are already paying for it, by subsidizing, both through taxes and through higher insurance rates, hospitals who provide such services to the indigent. But because any alternative to our present way of doing so gets called 'socialized medicine', we are stuck doing it in a way that makes no sense from any point of view. Far better, I think, just to ask: what is it we want the health care system to do, and what is the best way of getting it to do this? The answer will probably not be either a pure free-market system or anything it would be accurate to call "socialist medicine".

Do you have something against the good socialist roads that the US government builds and repairs?

Odd, those always just looked like regular roads to me.

Sebastian- I think you missed the point of the original crooked timber post. Using 20 year old equipment and meds eliminates the need to use stuff that is under patent. A big part of the problem in our current system of socialized medicine is that things we buy are often still under patent protection. That gives companies incentive to overcharge the government.

I agree this idea is a pipe dream though one dear to my heart. No one can tell US (citizens) things we don't want to hear.

Liberal Japonicus- I think I would have just said advantage, but competitive advantage would also have worked. Certainly workers in good health are more productive. Thats probably a significant factor in why American workers are falling behind in hourly productivity. (now number 3 or 4)

Double-Plus-Ungood- I think the point of the stat on Canada's use of MRI tech is that they use it about as much as we did 8 years ago. That is probably about when the fad for healthy rich people getting MRIs just in case started in the US.

I hesitate to broach this since the discussion is being so civil, but I think that for Republicans the fact that the US offers terrible health care at high financial cost to poor and especially black people is a feature not a bug.

Slarti- Didn't you ever wonder about the fact that tolls are both infrequent and small? I hate to be the one to break it to you but most of the roads in this country are paid for by the gov'mnt. Its a communist plot I tell you!

Da, hilzoy. Just want to underscore this: there's no surer way to turn this into a partisan battle doomed to failure than to tag it with "socialist health care". As evidenced by the last half-dozen or so posts (mine included).

And about the Oregon plan: I don't recall the lawsuits. The first Oregon plan was rejected by the first Bush administration as discriminatory towards the disabled, on grounds that I thought were somewhat lame. It was then revised, and the Clinton administration, which was more keen on state experimentation in this area (contrary to popular belief), gave it a waiver. It is still in effect, as far as I know; at any rate, it was still around a couple of years ago. It has allowed the number of uninsured to be cut much faster than in most other states, at less cost than one might imagine. The interesting thing is that while the original idea was to limit the procedures covered by insurance available to the poor while greatly increasing the number of poor people covered, it accomplished only the second goal. The number of procedures ruled out is not that great (when I read about it last, the cutoff came at treatments for pinkeye, with all proven treatments for life-threatening diseases being covered), and some new ones (e.g., mental health care, prenatal care) being added. And the reason for this seems to be that the program was very, very popular, and also that it reframed the issues: in Oregon, legislators have to decide what level of funding to provide, and that level determines which treatments will be covered, so it's easy to say, "you aren't going to treat this??"

I suppose this may a thread-jack, but I just was thinking about Slarti's contention that "good socilaist" is oxymoronic.

I live in a Canadian housing co-op. This is a socialist institution, quite popular in Canada. It's a democratically-run housing complex with over 500 members of varying incomes. The rent is cheap, and the place is well-functioning. I've lived in five housing co-ops in Canada, the largest being in Montreal, with over two thousand members.

I commute to my workplace by bike. Most of my bike gear (several thousand dollar's worth) has been purchased at this enormous outdoor gear co-operative. It has two million members, provides excellent quality merchandise, and has ten huge stores across Canada. It too is a socialist institution.

I keep my money in a very large Canadian credit union. It provides excellent service, and minimal banking charges ($6/month). Criedit Unions are socialist organizations.

While commuting to work, I do so over Vancouver's wonderful bike routes. These have been set up by the city council (currently dominated by socialists) not because they're profitable, but for the common good in reducing traffic, pollution, and improving the health and saftey of the citizenry. Again, socialism.

At work, I've just completed first aid training, and have my ticket. My province requires that every workplace have a certain number of trained first aid attendants. BC has over 16,000 trained workplace first aid attendants, and as a result, we have a lower number of workplace deaths, injuries, or work-related disabilities. Government meddling, some may say. Good socialist policy, I say.

If anyone from my workplace does have to go to the hospital, they do so without worrying about the cost or coverage. And as a taxpayer, I know that our healthcare system offers better care than that of the US (per capita), that it does so at half the price, and that we live longer in Canada, and less of our infants die.

Make cracks about purges if you like, Slarti, but it does more of a disservice to your reputation than it does to the political philosophy.

hilzoy- The problem with asking what we want the health care system to do is that you will get ~300,000,000 answers.

I actually used the Oregon health plan, and much of it worked great. It wasn't abandoned, it was killed by people who otherwise make a lot of noise about respecting federalism.

Hilzoy: Socialism is government control of the means of production.

No, that's Marxism. Socialism predates Marxism by about a century or so.

But I'm really not being especially rational about this, and I admit it: I simply don't think that the US system can be defended as either moral or rational in light of other nations' results, and I don't much respect the arguments being mustered in its defense. I am myself too ill, and know too many other ill and disabled people, to take this calmly. We are being made to suffer unnecessarily for the sake of...damfino. Greed and ideology, basically. I am not a dispassionate bystander - the realities of health care were central to my changing a whole lot of political philosophy to bring it into line with my overall moral code.

Didn't you ever wonder about the fact that tolls are both infrequent and small?

Define "small". I will semi-agree in that the toll roads near me (of which there are at least three or four) will continue charging the same tolls after they've paid for themselves, and their revenues siphoned off for other purposes.

But to answer the question, no, I don't wonder about it. We as a nation hold road-building as a good, and have agreed to use a portion of the tax revenues to pay for them. Hardly libertarian, but I'm not a libertarian.

Frank: that's why we have a duly elected legislature.

Hilzoy- Well in that case I guess the system we have now is the one the American people want. Unpleasant to believe we could so stupid, but here we are.

Slarti- Geez you can dish it out but you can't take it?

Here's an article on the Oregon plan. If the article is correct, it looks as if it's not that much use as an example to anyone -- the rationing of services never actually happened to any significant extent. The plan itself has been very successfull, but through conventional means like negotiating managed-care contracts, and because it's very politically popular.

"the system we have now is the one the American people want"

Or at least the one that those who have pull with legislatures (i.e. health industry lobbyists) want.

Canada has only recently started to use MRIs at a level that was common about 8 years ago in the US.  How does this meet with liberal expectations about health care? 

I maintain that this tells us very little about relative effectiveness. As Frank suggests, not all MRI's are equally productive in terms of improving health care. If an MRI is like every other tool in the world there are situations where it is very useful and others where it is less so. In term of outcomes what you want is more high-value MRI's. That probably means making them more widely available, not simply increasing the per capita number.


I don't even know what a "Though Experiment" might be. Is it a 'despite the fact experiment'? Not sure how'd you even set it up...

Frank: that's why I'm sitting here, trying to persuade people to want something different.

Well in that case I guess the system we have now is the one the American people want.

That presumes that the legislature confines itself to doing what the American people generally want, and actually does it. Which, eh, not so much.

hilzoy- Sorry. I am feeling snarky today.

Though (this to Frank): to be fair to my earlier comment, what I was saying was that an elected legislature is a good way of figuring out how to transform millions of answers to a question about what we want into one coherent policy, not that the legislature always does this, and still less that present policy is necessarily wanted by anyone, even if (as in the case at hand) it's the result of a lot of odd and disconnected decisions, not any one coherent choice.

That presumes that the legislature confines itself to doing what the American people generally want

yeah, that bankruptcy legislation was something I'd been hankering for...

I agree that preventative maintenance is indeed beneficial in all the ways described, but, expecting Americans (at least those that I know, including me) to decide on their own to get checked up more often is a bit of a pipe dream.

I'd think we'd have to mandate this even to the point of when the check-ups would occur lest everyone try to get in a week before the due date.

I hesitate to broach this since the discussion is being so civil, but I think that for Republicans the fact that the US offers terrible health care at high financial cost to poor and especially black people is a feature not a bug.

Perhaps next time the length of your hesitation could last to say, infinity.

Slarti- Geez you can dish it out but you can't take it?

In general, probably true. But if you're looking for specifics, context would be handy.

Otherwise known as: what on earth are you talking about?

crionna- nope. Ignoring the elephant in the room doesn't make it go away.

Slarti-

"Do you have something against the good socialist roads that the US government builds and repairs?
Odd, those always just looked like regular roads to me."

Posted by: Slartibartfast | April 13, 2005 01:17 PM

Are you claiming this was a serious comment? I thought I answered you in the spirit you offered with this:
Slarti- Didn't you ever wonder about the fact that tolls are both infrequent and small? I hate to be the one to break it to you but most of the roads in this country are paid for by the gov'mnt. Its a communist plot I tell you!

Posted by: Frank | April 13, 2005 01:20 PM

And you came back with this:

Didn't you ever wonder about the fact that tolls are both infrequent and small?
Define "small". I will semi-agree in that the toll roads near me (of which there are at least three or four) will continue charging the same tolls after they've paid for themselves, and their revenues siphoned off for other purposes.

But to answer the question, no, I don't wonder about it. We as a nation hold road-building as a good, and have agreed to use a portion of the tax revenues to pay for them. Hardly libertarian, but I'm not a libertarian.

Posted by: Slartibartfast | April 13, 2005 01:24 PM

Nitpicking in other words. I just wondered what was up with that.


I'd think we'd have to mandate this even to the point of when the check-ups would occur lest everyone try to get in a week before the due date.

Or incentivize it? There was an article in the NYT magazine recently about paying doctors at least partially based on results rather than for the actual care that was provided (which as I recall is being tried at Kaiser in California). Then a letter writer suggested something similar for patients (e.g. in the form of bonus payments or tax deductions) to ensure that patients do what they need to do to manage their own health (apparently the prospect of good health isn't enough incentive for many people to, e.g., take the entire course of a prescribed medication).

Incentivisation is cool too KenB. However, that then brings us toward incentivisation as it relates to the value of time. I think you'd have to work really hard to find incentives that would match everyone's expectations of what their time and health are worth.

Slarti: there's no surer way to turn this into a partisan battle doomed to failure than to tag it with "socialist health care". As evidenced by the last half-dozen or so posts (mine included).

Were I running the US government, I would think of a sweeter tag for the socialist health care system that the US so desperately needs than "socialist health care". Since so many people have been taught to equate that with "bad!" even though they so desperately need it.

But I'm not, so hey! I get to call a spade a spade, instead of obfusticating around with euphemisms, and watch you keep digging yourself into the same old rut with that spade: unable to deny that the socialist roads built by the US government are a good thing; unable to deny that the US really needs a socialist health care system... and unwilling, thanks to your rooted prejudices, to admit that socialism works best for things like roads, and healthcare, that everyone needs.

Let me throw out an example of someone I know who's a pretty good illustration of what's wrong with U.S. healthcare. Maybe the libertarians can explain how her problems would be solved in their utopia.

She's in her mid-40s and has two boys, ages 8 and 10. About five years ago, she was diagnosed with colon cancer. She's had surgery and multiple courses of chemotherapy. For the time being, she's beating the odds. She's alive and generally has a decent quality of life, five years into a disease that kills about 90% of its victims within five years. The disease will get her sooner or later, but her doctors keep working to slow it down, and they're doing pretty well. We who are close to her live in fear that things could start deteriorating dramatically, but so far, so good.

Before she was diagnosed, she worked as a waitress in a high-end restaurant and made enough to provide a decent standard of living for herself and her boys. Since her diagnosis, she's worked part-time off and on when she was healthy enough, but she can't work anywhere close to enough time to get health insurance, and she is, of course, uninsurable on the individual market.

Because of her illness, she's stayed married to her estranged husband, from whom she's been separated since before her diagnosis, because he works and can keep her on his group health insurance. That complicates life quite a bit for both of them, but it gets her the medical treatment that's keeping her alive.

This is quite obviously nuts. I don't think anyone on this thread disagrees.

But a couple of points:

1. Re the "thought experiment": she'd be dead. It's new chemo drugs and new protocols that keep her going. Personally, I'd find it hard to explain to her boys that we're just going to have to let their mother die unless she can come up with tens or hundreds of thousands of dollars a year for chemo drugs. They aren't cheap. And no, she doesn't have the money.

2. I'd really like to hear a libertarian explanation of how a free market in health insurance would provide policies that would cover chronic illnesses adequately. It's a prime example of the sort of risk-sharing that insurance is supposed to be good at. But in the universe I live in, the economically sensible course for insurers will be to sell relatively inexpensive policies to everyone and then cancel the coverage of those who have the temerity to develop chronic illnesses. Could someone stop bleating about the marvels of the market for long enough to explain why I shouldn't worry about that?

This, to me, is an illustration of the real issue with health coverage. It's true that we, as a society, are unwilling to have too many people dying in the streets because they lack health coverage. But the issue isn't really about whether or not there's a right to health care. What it's really about is how we're going to allocate risks. Most of us can afford to pay something resembling our pro rata shares of the total cost of health care consumed in this country. Few of us could afford to pay the cost of a severe illness or injury out of pocket. Our current system does a pretty lousy job of spreading the costs and the risks. I have yet to see a plausible free-market alternative. That leaves the government.

Let me throw out an example of someone I know who's a pretty good illustration of what's wrong with U.S. healthcare. Maybe the libertarians can explain how her problems would be solved in their utopia.

She's in her mid-40s and has two boys, ages 8 and 10. About five years ago, she was diagnosed with colon cancer. She's had surgery and multiple courses of chemotherapy. For the time being, she's beating the odds. She's alive and generally has a decent quality of life, five years into a disease that kills about 90% of its victims within five years. The disease will get her sooner or later, but her doctors keep working to slow it down, and they're doing pretty well. We who are close to her live in fear that things could start deteriorating dramatically, but so far, so good.

Before she was diagnosed, she worked as a waitress in a high-end restaurant and made enough to provide a decent standard of living for herself and her boys. Since her diagnosis, she's worked part-time off and on when she was healthy enough, but she can't work anywhere close to enough time to get health insurance, and she is, of course, uninsurable on the individual market.

Because of her illness, she's stayed married to her estranged husband, from whom she's been separated since before her diagnosis, because he works and can keep her on his group health insurance. That complicates life quite a bit for both of them, but it gets her the medical treatment that's keeping her alive.

This is quite obviously nuts. I don't think anyone on this thread disagrees.

But a couple of points:

1. Re the "thought experiment": she'd be dead. It's new chemo drugs and new protocols that keep her going. Personally, I'd find it hard to explain to her boys that we're just going to have to let their mother die unless she can come up with tens or hundreds of thousands of dollars a year for chemo drugs. They aren't cheap. And no, she doesn't have the money.

2. I'd really like to hear a libertarian explanation of how a free market in health insurance would provide policies that would cover chronic illnesses adequately. It's a prime example of the sort of risk-sharing that insurance is supposed to be good at. But in the universe I live in, the economically sensible course for insurers will be to sell relatively inexpensive policies to everyone and then cancel the coverage of those who have the temerity to develop chronic illnesses. Could someone stop bleating about the marvels of the market for long enough to explain why I shouldn't worry about that?

This, to me, is an illustration of the real issue with health coverage. It's true that we, as a society, are unwilling to have too many people dying in the streets because they lack health coverage. But the issue isn't really about whether or not there's a right to health care. What it's really about is how we're going to allocate risks. Most of us can afford to pay something resembling our pro rata shares of the total cost of health care consumed in this country. Few of us could afford to pay the cost of a severe illness or injury out of pocket. Our current system does a pretty lousy job of spreading the costs and the risks. I have yet to see a plausible free-market alternative. That leaves the government.

Oops. It was long enough the first time. Sorry!

Oops. It was long enough the first time. Sorry!

But worth reading twice. Good post.

Re the thought experiment she would have the more recent treatments under her estranged husbands health care correct?

I thought you were postulating replacement of the current healthcare system with government-provided health coverage at a 10-20 year old standard of care, with anything newer than that to be provided by private payment. In that system, unless you're also assuming that private health insurance would be available to cover the newer treatments, she dies. And if you are assuming the availability of private insurance, I think we're into "assume a can opener" territory.

link to on topic Kevin Drum:
http://www.washingtonmonthly.com/archives/individual/2005_04/006096.php
I mean, jeez, a power sander?

Why would private insurance be unavailable? The only reason I can imagine it would be unavailable is if the government made it illegal. We are in more of an 'assume that the Earth has air' territory.

BTW did I make it clear that the standard wouldn't be permanently fixed in 1995? It would slide every year.

If we don't like that system, lets talk about another one. My main point is that rationing of health care has to happen somewhere. Making a 'public' system doesn't cause the problem to go away. If there was a cure for AIDS that cost $1,000,000,000 per person, the government could not and therefore would not pay for it. The expense scale has to stop somewhere, but when it is your life on the line of course you tend to think (and wrongly) that money is no object.

Sebastian: My main point is that rationing of health care has to happen somewhere. Making a 'public' system doesn't cause the problem to go away.

No. But it does mean that rationing of health care happens on a "who needs what" basis, rather than on the current system in the US, in which those who can afford to pay get the most profitable treatment for them to have (profitable to the sellers, not to the patients), and those who cannot afford to pay, get less than they need.

Any health care system dependent on the profit principle is going to be about an effective a health-care system as private toll roads were in 18th-century England: maximally profitable to the shareholders, maximally inefficient to the users.

You need to stop thinking that the health care system has to run at a profit. That really doesn't make sense if the primary purpose of a healthcare system is to take care of the people who use it.

Why would private insurance continue to cover someone who had a condition that guaranteed that claims would vastly exceed premiums for the remainder of her life? The only way a carrier won't do that is if government makes it illegal to drop sick people, and once you start down that road, we're headed right back into the same mess we have now.

I agree that the rationing of health care has to happen, but I think it's a bit of a red herring in the discussion of what health care finance ought to look like. Just to be clear on where I'm coming from, I don't necessarily have a problem with the cost of health care per se. Good health care is worth spending money on. The problem I see with the current system is not so much the cost as that it's just a crazy way of doing things. If I believed that a free-market fix was viable, I'd be for it, but I don't, so I'm not.

Washington Monthly had an article up a while back, now behind its firewall, about VA health care.

There are two critical points:

1. the VA is nonprofit, but has the power of the federal government in the financial markets. One important reason that hospitals, insurers and health care plans are for-profit is for access to capital. A public agency doesn't have that problem.

2. The VA serves its patients on the basis of a lifetime contract.

Result -- Alignment of important incentives. There are no investors to provide a return on their investment. A huge client base allows for deep discounts in purchasing drugs and other supplies. As a stand-alone agency it is (largely) immune from legislative pestering. The lifetime contract allows for long-term financial commitments to patient wellness. The large patient base allows for the development of a huge database of effective treatment and enforcement of professional standards.

I'll be blunt. I believe that rationing should apply only to end-of-life care. Those with chronic illnesses who are in the productive years of their life should receive professional caliber medical care, no matter what their income is. But huge sums of money are spent on people in the last six months of life. We should be at a point where trained clinicians should be able to say, with some accuracy, that a patient has six months to live. At that point, I'll pay for palliative care for the rest of that patient's life, but I'd rather not pay for extraordinary treatment.

One secondary market should, therefore, be insurance for extraordinary end-of-life care.

Under a single payer plan, a second secondary market should spring up spontaneously. Here in sunny Orange County, CA (just down the road from Kevin Drum) reside some of the most highly regarded doctors in the world. Some of them are promising, essentially, premium treatment. In addition to having acceptable insurance, patients must pay a certain montly sum. (I'm hearing numbers around $150 / month.) In return, the doctor promises same-day emergency consultation, next-day regular consultation and access to his (presumably premium) set of skills.

This is a perfect example of a secondary market functioning on top of standard insurance. I think this provides precisely the right result. Doctors who believe that they have premium skills can restrict access by levying a surcharge. If they're wrong, no one will go to them. There probably needs to be some regulation of this secondary market to prevent surcharges from being applied in historically underserved areas, but not much, especially if the single payer sets rates appropriately.

as to the current system, feh. Employer-based coverage has got to go. The quickest way to kill it, I imagine, is to eliminate the tax breaks.

"Making a 'public' system doesn't cause the problem to go away."

But experience does suggest that it helps control costs, which (somewhat) alleviates the problem of rationing. See the VA. (Incentive for innovation is another matter.)

Sebastian: Why would private insurance be unavailable? The only reason I can imagine it would be unavailable is if the government made it illegal.

Huh? I cited the report myself, a bit further up, but in any case I thought it well-known - private insurance is unavailable to 40+ million people in the US, because they can't afford it - and five million of those people are children, whose parents can't afford it. The government doesn't have to "make it illegal" for it to be made unavailable.

DaveL: yup, under my proposed thought experiment, if she hasn't got private insurance that pays for the new treatments, and she can't get charitable care, she dies. I'll bite that bullet honestly. I do believe that, if insurance for newer treatments were subject to an unregulated private market, it would probably be affordable to a lot more people than it is now. But probably is not certainly and more people is not everyone; I could make no promises.

The thing is, though, unless you believe that everyone is entitled to receive any medical treatment that might possibly extend their life, regardless of cost, there will always be someone about whom you can tell such a story. Are you defending that strong a positive entitlement? If not, what do you say to some other person, with different situational particulars, who tells the same sort of story about some treatment you think is too expensive to be worth covering?

"there will always be someone about whom you can tell such a story"

Sure, as an abstract debating point, but the real-world policy point of the argument is that under a single payer system such "rationing" decisionmaking will be made according to some principle other than individual wealth.

"I cited the report myself, a bit further up, but in any case I thought it well-known - private insurance is unavailable to 40+ million people in the US, because they can't afford it - and five million of those people are children, whose parents can't afford it. The government doesn't have to "make it illegal" for it to be made unavailable."

Yet the person in question does in fact have insurance and does in fact get treatment. And that is under the allegedly awful current system.

Once again, what do you do with a $1,000,000,000 cure for AIDS? Do you have the goverment pay for it for all HIV+ people? What about a person who needs a second liver transplant (to live) and refuses to stop drinking? Does the government pay for that?

The thing is, though, unless you believe that everyone is entitled to receive any medical treatment that might possibly extend their life, regardless of cost, there will always be someone about whom you can tell such a story.

Isn't the issue that a socialized healthcare system is cheaper? The whole "at what cost do you cut off service" is a bit of a red herring - that problem exists under all healthcare models. And you don't need thought experiments, most socialized medical systems have guidelines about what is and isn't appropriate care based on cost/benefit. The point is that socialized healthcare is cheaper. And more fair.

Nicholas, first of all, I have to admit that your willingness to "bite the bullet" with someone else's life impresses me not at all. In fact, it makes me think that you're sheltered, immature, and haven't bothered to think seriously about how the world works. So if I don't take you very seriously, that's why.

Remember that the person I'm talking about was employed and could pay for her own health insurance through her employment until she got too sick to work. The same thing could happen to you (which, I suspect, might change your attitude). You continue to assert that an unregulated private market would provide insurance that would work better than the current system. I've asked you to explain why I should believe that. You haven't bothered. So I ask again: in your libertarian utopia, why would a health insurer continue to cover someone who got cancer? Why wouldn't the economically rational course be to price policies for the vast majority of people who use moderate amounts of health care and cancel the policies of the seriously ill and seriously injured?

And a reminder: many of us have paid attention to the bankruptcy bill and have the example of the free market in consumer finance close at hand. You're going to need to explain how a population that does a lousy job of obtaining reasonable credit terms will do an outstanding job of protecting its own interests in the vastly more complex arena of health insurance.

Good luck.

"I hesitate to broach this since the discussion is being so civil, but I think that for Republicans the fact that the US offers terrible health care at high financial cost to poor and especially black people is a feature not a bug."

Frank, the implication that Republicans are interested in killing off black people is not appreciated. Further discussion along that vein will get you banned.

Hilzoy, thanks for correcting me about the initial obstacle to the Oregon plan; I'd thought it was a private lawsuit rather than an initial decision that had shut it down on ADA grounds.

On the current disposition of the plan, there's this article:

http://www.memag.com/memag/article/articleDetail.jsp?id=127172&pageID=1

which says that the cost-controlling purpose of the plan has been basically destroyed by the feds, who have been unwilling to allow it to cut back services when budgets get tighter. Which is an example of the political problems with cost controls that I'm talking about.

And of course kenB is correct that a 10/20-year limitation would face the same obstacles. That's also part of my point: cost control in the real American political environment, as opposed to the fantasy one where everybody suddenly morphs into a French person, is harder than the proponents of single-payer are willing to acknowledge.

DaveL: I don't care if you're impressed or not; I frankly am not impressed by the idea that some people have an unlimited claim on other people's resources. I note that with all your ad hominems you didn't answer my question about the limits of positive entitlements.

On your substantive point, one reason I think that health insurance would be easier to obtain on a free market is that it wouldn't be coupled to employment. The association of insurance with employment is, I think we all agree, one of the very worst things about the US health care system. This association is not a result of market dynamics, but of dumb government tax policies instituted during WWII.

And if an insurer specifically offers coverage for treatment of a chronic illness, and then refuses to cover the very illness they've contracted to treat in return for premium payments, that's breach of contract. A free market does include contract enforcement.

I think D-P-U's point is the correct one. All this talk about who to cut off and how isn't the issue. These issues will always exist regardless of the implementation scheme. Arguing about them is good, but is a complete smokescreen intending to hid the rather large blue whale in the middle of the room which is that we have a really crappy health care system.

Worse, we have a really crappy health care system that is supposed to be fantastic because it's based on the market.

Our neighbors to the north have far better results (actual measurable facts) at a far cheaper cost.

Why?

And even better, why aren't we following suit?

We can argue about the other issues but it seems more like arguing about angels, the head of the pin, and how many will get health care when they are perched on said pin.

Which isn't really the issue at all.

NW, as has been suggested, your question about the limits of positive entitlements is a red herring: a single payer system would have to have limits, just like the current system has limits. The point is that under a hypothetical single payer system, more of those limits would be determined on the basis of relative incidence in the population and relative cost, resulting in a more efficient and rational allocation of resources than a system in which limits are largely set by ability to pay.

However, this leads directly into your point about the implications of political pressure on setting limits as a policy matter, which I grant you is a good point.

The association of insurance with employment is, I think we all agree, one of the very worst things about the US health care system.

Possibly from a soley ideological point of view. I'd be more concerned that 31% of US healthcare costs are on an administration nightmare, compared with 17% in Canada. Further to that are the carrier overhead costs which are practically non-existent in the Canadian system.

The administration overhead costs in the US alone would be enough to provide healthcare coverage to the millions of uninsured Americans. I'm sorry to be this blunt, but it's an idiotic system.

However, this leads directly into your point about the implications of political pressure on setting limits as a policy matter, which I grant you is a good point.

It is a valid point, but the same issue exists in the current system when states impose mandates on what health insurance policies must cover. Which is to say that it's pretty much another red herring, since the issue will exist in any plausible health care delivery system. (No, I don't think libertarian utopia is plausible.)

DaveL: I don't care if you're impressed or not; I frankly am not impressed by the idea that some people have an unlimited claim on other people's resources. I note that with all your ad hominems you didn't answer my question about the limits of positive entitlements.

I should know better than to try to argue with a resident of Libertarian Fantasyland, but again, I simply don't conceptualize the issue the way that you do. To me, it's not a question of "unlimited claims on other people's resources," it's a question of how we, as a society, can best distribute the risks of illness and injury. For largely empirical reasons, I don't think private health insurance is capable of doing that risk distribution in a reasonable. For, as nearly as I can tell, purely ideological reasons, you disagree. I don't think we're going to get very far.

Looking at the proposal Sebastian quotes, several things come to mind--

1) It essentially reduces the incentive to develop new treatments. A large amount of demand is re-directed to old products, and money spent on those won't necessarily be directed into new medical research. Why bother with risky new treatments which may never work and require huge R&D budgets when you can sell generics and much more of your sale is immediately profit? Sure, some companies will still develop new products, but ultimately, it de-incentivises creation of new products and methods.

Especially since likely most companies would cut back or dump their health care plans once there was a minimal level of protection guaranteed by the government, the same way pension plans are going into decline. Unless we postulate increased affordability of private insurance, that basically means less money to be spent on anything experimental.


I had other points, but I'm tired and now can't remember them. ^^;;

Play nice, guys. I'm dead certain that it's possible to discuss these issues without getting personal.

Sebastian: the implication that Republicans are interested in killing off black people is not appreciated.

Certainly not Republicans in general. But aren't Bush & Co using the argument that black people die early as a feature, not a bug?

You may not appreciate that argument, Sebastian - but you should tell George W. Bush that you don't.

Um, the 17% vs 31% administration cost overhead?

Hello?

That means we're wasting almost 2% of our GDP on nothing more than health care administrative costs. I think that works out to something like 220 billion dollars.

While I'm sure that arguments about old technologies and such are interesting, I severely doubt that we're going to save anywhere in the neighborhood of 2% of our GDP by doing so.

As they say, one robs banks because that's where the money is. There's clearly a sh*t load of low hanging fruit staring us in the face. Why the heck would we even postulate theoretical savings when we could garner real live actual savings?

But I guess that's the ideological barrier. That 2% of GDP is the cost of an "efficient" market.

Yet the person in question does in fact have insurance and does in fact get treatment.

...by having to stay married to the husband from whom she is separated. Her husband has the health insurance, not her - she gets it, but at the price of neither herself nor her husband being able to move on and get married to someone else. Not an ideal situation to be in, surely you'd admit?

Once again, what do you do with a $1,000,000,000 cure for AIDS? Do you have the goverment pay for it for all HIV+ people?

Some treatments won't be affordable. Some treatments will. It's the same now in the US - except that instead of treatments being rationed by need, they're rationed by who has most ability to pay. What happens now if there's a $1B cure for AIDS - who could afford to pay for it?

What about a person who needs a second liver transplant (to live) and refuses to stop drinking? Does the government pay for that?

The transplant system in the UK works on points. I have a friend who got a heart transplant a few years ago, without which he would have died, and the system was explained to me (via him and his partner, not directly to me, of course) that as and when donor organs become available, people on the register who need a heart or a liver or a kidney will have their need evaluated. First, who can receive the donor organ - for a liver transplant, that means you all but have to hope for a miracle, since there needs to be a very exact genetic match. (For a heart transplant, apparently, same blood type and right size is more important.)

Then, all the people on the list who could receive the donor organ have their points reckoned up, and the winner gets the donor organ. Being a habitual smoker will lose you points: so will being a heavy drinker: so will age/quality of life - I don't know what all the categories are. But ability to pay gets you nowhere.

Another friend lost her mother, not very long ago, to a massive cerebral hemorrhage. She and her sister were asked if they were willing to have her mother's organs donated to people who needed them, and my friend said that it was something that really helped: to know that thirteen people would live, would have better lives, because her mother's organs had gone to help them.

No payment either side. Sometimes you really can just give something freely, without thinking about monetary profit, and - believe it or not, O free marketeers - I think that's one of those times.

Under a single payer plan, a second secondary market should spring up spontaneously.

I could be wrong here, but it is my impression that any doctor who accepts Medicare is barred by law from performing "premium procedures" on other patients who have different payment methods. Can anybody give the facts on this?

Sometimes you really can just give something freely, without thinking about monetary profit, and - believe it or not, O free marketeers - I think that's one of those times.

Damn, and up until just now, I had the "auction my organs off on Ebay" box checked on my license.

one reason I think that health insurance would be easier to obtain on a free market is that it wouldn't be coupled to employment.

But lots of people don't get it through their employers today, and individual policies are expensive and hard to come by. Why will this miraculously change?

that's breach of contract. A free market does include contract enforcement.

Have you ever actually tried to enforce a contract in court? Perhaps some of the lawyers here can comment on how efficient the process is, especially when one sick and financially strapped individual is suing an insurance company.

In general insurance, and especially health insurance, is not a good example of an item in which free markets work well. They are plagued by problems of adverse selection, and in some circumstances will function badly or not at all.

I think a claim that the free market will solve our problems is based more on faith than on reason and evidence.

Slarti: Damn, and up until just now, I had the "auction my organs off on Ebay" box checked on my license.

Good heavens, you shameless hypocrite. Were you guilty of a lapse into socialism? You were planning to give your organs away, rather than sell them at a profit to the richest person who needed them? Tut, tut.

Bernard Y: I think a claim that the free market will solve our problems is based more on faith than on reason and evidence.

Ideology trumps facts every time. The belief that the free market just naturally creates a better health service is right-wing ideology, in the service of which 18 000 people a year die in the US, to the profit of health insurance companies.

What other ideology could kill so many people a year and not be condemned right and left?

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Whatnot


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