Universal Health Care

by Andrew

[In which I throw out ideas guaranteed to bring down the wrath of the ObWi comment horde down upon me.]

Health care is a growing problem in the United States. Ironically, the problem is a result of health care's great successes of the 20th century. Life expectancy and quality of life shot upwards in the 20th century as many common illnesses and other medical problems were either defeated or made at least controllable. But, since we've all got to die of something, that meant people started falling prey to other diseases attributable to longer life. Medicine has developed great ways to address many of these problems, but the cures are not cheap and the combination of increased life expectancy and a massive growth in the population of the United States has combined to send health care costs through the roof. Massive use of health insurance has helped to push the costs of health care up, as the costs are hidden behind 'insurance' plans. Conversely, health care costs are highly inelastic to begin with, as anyone with a serious illness will not care about cost if the alternative is death. All this leaves us with many upward pressures on medical costs with little corresponding downward pressure. In light of this, the demand for universal health care will continue to grow as people have greater difficulty getting the care they want or need. Indeed, I fully expect to see government-provided health care for everyone before I die. Still, I remain unconvinced universal coverage is a wise goal.

There is a limited supply of medicine available in the United States. That supply is sufficiently smaller than the available demand that the price of medicine is greater than what a lot of people can afford. So, the argument goes, we have the government take over the health care system and the problem is solved. Except that isn't quite so. Government taking over the system may change who gets access to health care, but it won't address the underlying problem that demand still outstrips supply. Indeed, demand will go up if we turn health care over to the government, since people will then see it as a basic right. And when demand goes up, so do prices.

But the government will keep prices down by negotiating directly with hospitals and drug companies and the like, so we don't have to worry about increased demand causing upward pressure on prices. That may be the case in terms of the dollar amounts expended to provide a particular drug or service, but prices are found beyond the sticker. If the government forces drug companies to sell their products for prices too low to cover the costs of research, the drug pipelines will dry up. If the government forces doctors to perform treatment for less than the cost of that treatment, the doctors will go into other lines of work or will simply refuse to treat patients who are covered by the government's health care program. We see this already with doctors who are refusing to serve Medicare patients, because what the government pays for a Medicare procedure doesn't cover their costs.

Ah, but the government can force the doctors to work for the lower prices. After all, the government has a monopoly on the use of force, so we'll just make it a law that everyone has to use the government program, so people won't be able to go outside it. Well, Canada tried that, and their court said it was a no-go. Further, even assuming the government will be able to enforce that kind of law (what's to stop people from slipping doctors cash for better treatment?), then we're back to watching the available pool of doctors drying up. Why would you do a job that you were losing money on, after all? And how many people are comfortable with using force against doctors to prevent them from using their skills to make money?

Well, maybe we can't fix that, but we'll fix the drug problem by pouring more money into research, right? That may work for you, but for me the idea that we'll fix a problem caused by government interference by...adding more government interference, well, that doesn't seem like the wisest course of action. Government research dollars are spent just like most government dollars: on areas where Congress thinks it will help get them reelected. There is no mechanism to make sure that government research is effective or efficient, because the only feedback mechanism is electoral. So big-name diseases get funding while less-well known problems are ignored or minimized. Drug companies have their own problems, I'm aware, as they're unlikely to research solutions to rare problems because they won't get their money back, but they do have feedback mechanisms that drive them to try to find solutions to big problems, as opposed to merely popular ones. The government's success at finding solutions to any problem is not nearly good enough for me to want to rely on government dollars to be the primary source of the many new drugs that will be required to continue our progress in finding better solutions to health problems.

Worst of all, if the government does put a universal health care plan in place, we'll never go back. If universal health care has problems, Congress won't kill it, they'll just 'fix' it, doubtless with the same degree of effectiveness they've had in addressing the looming entitlements crisis or in crafting Medicare's Plan D. Once we cross the Rubicon of universal health care, it won't matter if it works, we'll never get rid of it. Given that fact, and government's past record of stellar accomplishment, I'm very reluctant to allow the government to cross that Rubicon.

Comments

[Jesurgislac]

Good God, Andrew, you sound like a Conservative in 1948 explaining that the NHS just won't work.

Did you look at any universal health care systems before concluding that they just won't work for the US, though they do fine elsewhere? Or have you just swallowed whole the notion that they don't work anywhere, without bothering to do any research beyond the propaganda?

I was assuming you actually had some facts you were basing your ideas on, but it doesn't look as if you do.

[Anderson]

Jes is right; it's not like you're Hegel, sitting in your study and dialectically proving that the Real is the Rational.

This too struck me: "If the government forces drug companies to sell their products for prices too low to cover the costs of research, the drug pipelines will dry up."

And if the government replaces doctors with ponies, health care will deteriorate dramatically. But who said anything about that?

Aren't the drugcos actually making $$$ hand over fist? Well in excess of research costs?

And the bit about gov't-funded research being "more interference" is a little silly, as well as premised on the assumption that gov't involvement is axiomatically bad. I know you think that, but it's not something you can expect to be taken for granted.

[CharleyCarp]

Andrew, instead of a Canadian or British solution, what about more of a German solution: mandate that employers carry specific minimum in coverage (with tax credits); state subsidized coverage for unemployed (again with minimum standards); ability to buy supplemental insurance. Maybe one or two big insurance companies -- make it five to get competition on service -- and you'll be pooling risk across the population.

What do the Dutch do? Japanese?

[Jesurgislac]

FWIW, this was the kind of thing I was expecting Andrew to try to refute.

[hilzoy]

This is a complicated topic, and I won't even try to do it justice. However, just to start things off: one reason why I favor some system that guarantees universal coverage (whether a program of universal health insurance or of universal health care) is that health care really does not work like a normal market at all. Your post, I think, assumes that it does. For instance:

"Indeed, demand will go up if we turn health care over to the government, since people will then see it as a basic right. And when demand goes up, so do prices." -- This assumes (I think) that there are no other effects associated with having the government take over either health insurance or health care that would tend to bring prices down. I don't think this assumption is right.

For starters, any program of (universal) government-provided health insurance would eliminate a lot of administrative costs off the bat -- all the different forms for different insurance companies, checking to see who's covered and for what, etc. In many markets, determining eligibility isn't a big burden -- if you can pay at the supermarket, fine; if not, not. In this market, it is, and eliminating it would eliminating a large chunk of the costs of delivering health care, without requiring compromises in health care or in the fees paid to doctors and hospitals.

Moreover, insurance works by pooling risk, and at present, insurers have a huge incentive to try to include as many healthy people as possible, while excluding those with huge medical costs. The effort to do this directly costs money, but also, to the extent that insurance companies are successful, they have an incentive not to invest in the kinds of prevention that would make economic sense if they knew that this person was someone they'd have to pay for eventually, but don't make sense if they think they can offload the person before the serious costs kick in.

Universal health insurance, by providing one big pool from which no citizen could be excluded, would both eliminate all the energy that now goes into trying to shuck off the people with very high costs, and also eliminate the possibility of lowering costs by ditching the sick, as opposed to preventing them from having expensive complications later. This would lower costs for the nation as a whole.

Moreover, since we are unwilling to let people die on the streets outside a hospital (as opposed to letting them die of unmanaged conditions), we require hospitals to provide emergency care. This has all sorts of adverse effects -- the use of emergency rooms for what ought to be clinic visits, incentives to site hospitals away from places like inner cities, where a lot of these emergencies might appear, etc. -- but it's also care that we all pay for indirectly, through higher costs for hospitals. Moreover, it's a very expensive way to get medical care to people -- under this system, you have to wait until your condition is "an emergency" before getting help, when it could have been managed much less expensively (and in a way that the patient would greatly prefer -- everyone would rather just take blood pressure medication than actually have a heart attack, for instance) in ways that are, unlike emergency care, not available for free.

The US government now pays more, per capita, for health care than the UK, despite the fact that the UK covers all its citizens while we do not. It's worth asking why. I think that while I am in general pro-markets, there are specific cases in which, for specific reasons, they don't work well. The army is one: who wants a bunch of private armies running around, bidding on contracts? or armies that are primarily motivated by profits? Health care is another: between the fact that it does not involve transactions between buyers and sellers, but between patient, doctor, insurance company, and (often) employer, all of whom have quite different sets of interests, and the fact that it's impossible to comparison-shop since there is very little publicly available information on pricing, it does not work the way a normal market would. Moreover, for the reasons I've sketched, there are costs directly associated with having a market-oriented system (e.g., the costs of having many manipulable risk pools, as opposed to one big non-manipulable one). Eliminating these costs would allow us to avoid your "demand up, prices up as well" conclusion.

[liberal japonicus]

I see you are taking on Jes in the other thread. It may feel like a horde, but it isn't really :^)

Your arguments center around the notion of a free market, but given that the US is paying a price globally for not having universal care, this seems a bit problematic. frex

Other countries (like here in Japan), by adopting universal care, make themselves more competitive because the health of their population is more robust. Here, there is a national health insurance, which is based upon income of the previous year, and a set of private insurers. Employers are mandated to get their employees into a health plan.

Other countries with centralized health care can also better deal with the potential of pandemics such as bird flu

Furthermore, health is one of those fields where an once of prevention does equal a pound of cure. At my university, written into our job contract, we have to get a physical checkup every year and it is paid for by the university, and the government has a large bus set up that drives to various employment places to do checkups, with the university paying the set fee (rather small, I think, because our health plan covers a set percentage of our health costs). I, because of an approved committment outside of the university, was not there during the 2 days for checkups. Last week, I got a note in my mailbox reminding me that I hadn't had my yearly checkup and telling me that the university would pay for whatever the cost was if I submitted the receipts, or if I went to the government health center, the bill would be sent to the uni. Thus, the government can hook into early prevention, which lowers health costs all around and contributes the a healthier populace which is what I thought governments were supposed to be working towards.

[Jesurgislacs]

see you are taking on Jes in the other thread. It may feel like a horde, but it isn't really :^)

I am vast, I contain multitudes! ;-) And I'll shut up now.

[hilzoy]

Andrew: here's a good article on the VA system. It's particularly useful in this context because in trying to figure out why the VA system consistently beats private systems in quality tests, it concludes that a lot of the reasons have to do with the different financial incentives that the VA and private systems have,

[Fraser]

Andrew, the US government already invests substantially in drug research, so it's not like that would be anything new. And your prediction that "big-name diseases get funding while less-well known problems are ignored or minimized" is pretty much the way the system works now: There's a lot more money poured into impotence--er, erectile dysfunction--than diseases such as malaria that affect the Third World because Americans can pay a hell of a lot more than Indonesian villagers. Or diseases that affect so few people there's no real profit in marketing to them (though I believe the government has an "orphan drug" policy for dealing with that). Government follows votes, but industry follows money, and I can't see that government-backed insurance would make things worse (just as predictions of people waiting years for treatment in a government-run system wouldn't differ that much from HMO's cost-cutting tactics).

[LizardBreath]

There's also a kind of peculiar assumption that consumer demand for health care will go up in a simple relationship to decreased cost. There are a bunch of problems with this.

First, healthy people have a very limited appetite for health care. I have good health insurance through my job, and I still go to the doctor very rarely. My demand for health care is very price-insensitive: I don't want any health care if I'm feeling all right, and I'll pay almost anything I've got if I'm feeling ill. (Now, I do get price-sensitive at the margin of 'anything I've got' -- all I'm saying is that my appetite for health care doesn't have nearly as direct a relationship to its price as my appetite for theatre tickets.)

Second, preventive care is going to have some effect on reducing future demand. A country with universal vaccination is going to spend less on treating measles than one without; a country with universal maintenance care for diabetics is going to spend less on amputations and dialysis than one without. (This is even ignoring the human profit in allowing more diabetics to retain their feet, etc.)

I'm not claiming to have shown here that UHC won't increase the total demand for health care, but I am claiming that you can't assume that it will. The confounding factors are significant enough that you have to look at the results empirically, rather than relying on Econ 101 'price down=demand up'. In the real world, ceteris rarely are paribus.

[Andrew]

hilzoy,

I am not anything approaching a health care wonk; it's just not an area that particularly interests me. (Something the commentary thus far has done much to encourage.) I can see that there could be some reduction in costs via risk-pooling and the availability of preventive care as opposed to ER care. However, I'm curious if anyone has done any studies to see if that will counterbalance the increased demand for preventive services. I may well be wrong, but I don't believe that primary care physicians are going short of patients right now. That being the case, those we have are now going to be asked to take on more patients, which will probably mean rather extensive waiting lists to see one's doctor. That can be resolved in the longer term by increasing the number of primary care physicians we have, but doing that requires that we pay primary care physicians more, therefore encouraging more people to go into primary care. Further, assuming Jes's 18,000/year figure is accurate, that's another 18k a year who need to see the doctor...those numbers add up over time. And what about illegal immigrants? That's a lot more people who need to see doctors, who will now have the means under universal care.

So while I can see admin costs dropping and ER use going down, it seems to me that there will still be increased demand. I'm not sure if the reduced admin costs will cover that.

[Steve]

It's a given that the US will never adopt a system that attempts to eliminate the notion of private insurance. You'll always be able to go above and beyond the system if you want to.

[Anderson]

So while I can see admin costs dropping and ER use going down, it seems to me that there will still be increased demand. I'm not sure if the reduced admin costs will cover that.

That neglects the contention that increased delivery of preventive services will in fact prevent conditions that would cost much, much more to treat later.

At worst, you get a market tilt away from specialists towards primary care, which in an era of factories closing down & moving to Mexico, isn't breaking my heart for the medical community.

[Andrew]

LB,

I am trying to get all the way to Econ 102, so have a little patience with me. ;)

As I noted above, I think there are some reasons to believe demand will go up beyond the basic supply/demand curve.

Also, let's remember that we all die of something. And someone who drops dead of a heart attack produces a lot less stress on the medical system than someone who takes various BP meds for decades and then gets cancer of Alzheimer's (sp?) disease. (Please note this is not an argument for encouraging people to die cheaply, just a point in favor of increased demand.) While preventive medicine can stave off the point at which this occurs, at some point we all get damn pricey.

[hilzoy]

Andrew: there will certainly be increased demand for primary care, and probably this will outweigh the decreased demand for emergency rooms. (The latter a marvelous development, since we now have huge waiting lines, and some patients get stashed in corners for days waiting for a bed.) But my general point was: there are huge cost savings from administration. Moreover, it's not as though doctors don't spend their time on administration, negotiating with insurance plans for coverage for their patients, etc., etc. So this would free up doctors' time as well.

It's worth reading a little about this, just because it's a very interesting case study of an area in which there's a serious case to be made that markets do not provide the best solution, a case that in no way relies on assumptions about magic etc., and thus it's fun even if your primary interest is just in refining your views about when and why markets work best.

[Andrew]

hil,

There are so many things I would love to read about, it's physically impossible for me to hit them all. If you ever find your way to Colorado I'll show you my library; I own several thousand books, and I'm always buying more. (BTW, see if your book's rank jumped on Amazon. :) And I'm always behind in my reading. Nonetheless, I will see if I can fit some health care wonkery into the mix.

[socratic_me]

However, I'm curious if anyone has done any studies to see if that will counterbalance the increased demand for preventive services.

Isn't that what was meant to be presented by all the references to the fact that other countries, spending significantly less per capita than the U.S. still have consistently better health care?

[hilzoy]

The VA article is short and well-written. This (pdf) is a primer for journalists on health care proposals that one of the country's best health care economists wrote during the runup to the last elections; it's also short and well-written. (Health care wonkery made easy ;) )

[jaywalker]

Does anyone dispute one of the following propositions?

1. Two percent of patients account for more than fifty percent of total healthcare cost. Looking at average (ie your own) behaviour is misleading.

2. It is also said that in your last year of your life you spend 50 percent of your total lifetime healthcare cost.

3. Fixing healthcare means tackling unhealthy lifestyles, especially obesity. Prevention pays. Some people will not like the coming sticks and carrots.

4. Some countries do well with a public system, some don't. Some do well with private accounts, some don't. It is not a question about market or government, but one about efficient management and accountability.

5. All healthcare systems are extremely inefficient and wasteful. Better management, better administration, better IT, better purchasing and especially better communication and cooperation is necessary.

[jaywalker]

Andrew,
for managing your books, have a look at LibraryThing. I love it having entered more than a thousand of my prrecious books. You could show your virtual bookshelves (incl. covers) to hilzoy and anybody else. Highly recommended (and addictive).

[Andrew]

Fixing healthcare means tackling unhealthy lifestyles, especially obesity. Prevention pays. Some people will not like the coming sticks and carrots.

This is another good reason to oppose government interference, for me. The campaign against soda/fast food/sweets is already silly. I have no interest in giving government the ability to tell me what I can eat.

[hilzoy]

Andrew: no policy proposal that I'm aware of would give the government the power to tell you what to eat. Policies in which the pool of insured people is fixed would, however, have a greater incentive to cover things like smoking cessation programs, help from dieticians for those who want it, and other voluntary forms of help than is currently the case.

[Andrew]

hilzoy,

Not yet. But we already have mandatory seat belt laws, for example, and many states have mandatory helmet laws, both justified by the theory that since the public would have to pay for that person's medical care, the state has the right to force people to do what's good for them. And there are already people pressing for more hard paternalism when it comes to food choices. It's a second-order effect of government expansion.

[sujal]

Ugh, Andrew, that was just terrible. You didn't address any specific plan, but the straw man of the least palatable (to you) healthcare system possible.

Other people are taking you on in the specific generalizations you've made, but the simple fact that you're railing against some imaginary, made up solution without anything concrete is disappointing.

[Sebastian Holsclaw]

I don't have time to get into a point-by-point today (which is too bad because this is an interesting conversation), but I would just like to mention that insofar as pharmaceuticals and research costs, other countries can be so successful because they are free-riding off of the profit that can be made in the US market (and yes the includes foreign drug companies that make a large percentage of their profit in the US--which is to say nearly all of them).

Attempting to have the major payor also become a free rider is not generally a good way of tackling the free rider problem--it tends to destroy the good in question.

The typical way to deal with a free rider problem is to attempt to impose the costs on the free riders. This solution (agreements to enforce patents in other countries) is not typically favored around here.

[Andrew]

jaywalker,

Thanks, that looks interesting. I can see where it would get addictive quickly.

[Andrew]

sujal,

No need to thank me. All part of the service.

[Jesurgislac]

Andrew: I have no interest in giving government the ability to tell me what I can eat.

I know I said I'd shut up, but:

The federal government heavily subsidizes the corn industry.

Corn syrup is thus an extremely cheap sweetener.

When I visit the US, I read the ingredients-list on the side of packaged food, and it's astonishing to me how many processed foods contain corn syrup - processed foods that, in the UK, don't contain nearly as much sweetener, if any at all.

(Read the Accidental Hedonist on this topic.)

The people who really won't like government sticks-and-carrots to get people to eat more healthily are the people who profit from the US food industry -

One of the carrots (literally) to get people in my neighborhood to eat better is a government-subsidised fruit-and-vegetable co-op, that enables the locals to buy fresh fruit and vegetables far cheaper than from the supermarket, and in more variety. No one forces them to buy there: but for some years now there's been a systematic campaign encouraging people to eat a minimum of five portions of fruit and vegetables per day for better health. I shop there when I can, though it's actually there because there's a sink housing estate just across the road: funding for these fruit-and-veg co-ops is available nationwide, targetted at areas where people may not find it easy to follow government advice to buy fresh fruit and vegetables.

[Andrew]

Jes,

Thanks for the tip. I must have missed the post where I said I'm a big fan of federal subsidies for business; hopefully you can point it out to me.

You might also want to know that part of the reason corn syrup is used so extensively is government tariffs on imported sugar to protect our own sugar industry.

And it may shock you to realize that I'd be perfectly happy to tear all of that out root and branch. If we had no business subsidies whatsoever I would be ecstatic, because I'd like to get the government out of the business of choosing winners and losers.

[Francis]

"there is a limited supply of medicine in the US"

there's also a limited supply of chicken. And in both cases, as demand increases and costs rise, new suppliers enter the market.

We may need to drag an economist into this discussion as opposed to us amateurs acting like we know what we're talking about. But Andrew makes the classic fallacy of looking at the demand side only.

In the next ten years, lots of very good medications will go off-patent, allowing for generic manufacturers to make the medication at very low cost.

Having universal insurance, as opposed to universal care, does not eliminate the incentive to create new drugs. Patent protections will still exist, so as long as the new drug is measurably better than the existing ones doctors will prescribe the new one. The insurer and the drug company can then butt heads on pricing, much as they do now.

[Andrew]

Francis,

While admittedly an amateur economist, I addressed some of my concerns regarding why I don't know if supply will keep up with demand in the post.

And I'm not nearly as sanguine as you that universal insurance won't torpedo new drug research. One of the ways governments keep costs down, after all, is to trim the price of drugs by setting caps on drug prices. That may not yet be a goal of current plans, but I don't think it is unreasonable to expect that to become part of the plan as the government attempts to control costs.

[Doctor Science]

jaywalker:

Fixing healthcare means tackling unhealthy lifestyles, especially obesity.

No. We can fix the US healthcare system -- make it comparable to that of other developed nations, instead of *much worse* -- without "tackling unhealthy lifestyles". Unless by "unhealthy lifestyles" you mean povery and racism.

[Jesurgislac]

Andrew: I must have missed the post where I said I'm a big fan of federal subsidies for business; hopefully you can point it out to me.

You appeared to be arguing that universal health care would lead to the government telling you what to eat/drink. This hasn't happened in any other country with universal health care, but what has happened is government campaigns and subsidies directed towards getting people to eat more healthily. At present, the US has government campaigns and subsidies directed (as with federal subsidies for corn syrup, making it a universal ingredient) towards getting people to eat more unhealthily.

[Andrew]

Also, to increase demand, aren't we going to need to take on the AMA's ability to restrict the number of new doctors?

[Slartibartfast]

The federal government heavily subsidizes the corn industry.

Corn syrup is thus an extremely cheap sweetener.

Ditto, cane sugar. In spades. It's one of my favorite pet peeves. But this kind of subsidy isn't entirely contained within the United States, interestingly enough.

[Andrew]

Jes,

The U.S. may be four centuries separated from the Mayflower, but the Puritan ethic still is remarkably strong here. The U.S. is packed with people interested in using the power of the state to make people live 'right.' I see no reason to believe that will stop any time soon.

[Jesurgislac]

Andrew: The U.S. is packed with people interested in using the power of the state to make people live 'right.' I see no reason to believe that will stop any time soon.

Nor do I: but given that "making people live 'right'" at the moment means depriving them of access to basic health care, filling them up with ignorant misinformation about prophylactics, and campaigning against marriage, it has got to be an improvement if the federal government turns away from "make people live in a moral way" and turns to "encourage people to have a healthier lifestyle".

[Bruce Baugh]

Andrew, it bugs me to see this debate conducted in the abstract. The fact is that every other industrialized nation has some form of national health service, and gets better care for less money than we do. I would be much more impressed by an argument that deals with how this is.

[hilzoy]

Andrew: the state is also packed full of people who resist attempts by the state to make them live by someone else's conception of 'right'. In this particular case, I think that trying to get legislation passed that would use the health care system to force people's lifestyle choices would be very difficult, if only because of the conservative (in this sense) cast of the Congress.

Besides, as I said, there's a lot of progress waiting to be made by the much less intrusive means of providing people with the help they need and want in order to make lifestyle changes voluntarily. That doesn't involve forcing anyone to do anything, and it provides huge benefits.

(For analogous reasons, I have always wondered why we don't fund enough drug treatment to meet the demand. I mean, do we want people to stay addicted to drugs? Do we like being mugged by addicts?)

[Andrew]

it has got to be an improvement if the federal government turns away from "make people live in a moral way" and turns to "encourage people to have a healthier lifestyle".

You're agreeing that government has the right to tell people how to live, as long as you're the one whose principles are pushed by the government. I want the government out of the business of telling people how to live.

[Andrew]

Bruce,

As I noted above, I'm not a health care wonk. It would therefore be difficult or impossible for me to discuss specific plans intelligently. I wrote this piece based on Francis' comment yesterday about convincing me that universal health care is a good thing to lay out some of the reasons I'm leery of a government universal health care plan.

hilzoy,

I'd like to believe you're right, but Congress has shown itself a dismal guardian of civil liberties over the past 30 years, and the courts aren't much better, if at all. I would prefer to avoid giving the federal government any more excuses for expanding its already excessive powers.

[Jeff Eaton]

Andrew,

I have to agree with a couple of the earlier posters who noted that you're approaching this as a sort of abstract philosophical exercise rather than studying the actual information about real and proposed insurance and health care systems.

Even barring real-world data on real-world health care programs, there's one presupposition that strikes me as odd. Health Care is not a commodity good, like oranges or plasma televisions or paperback novels. If the price of getting a cornea transplant drops to $0, that doesn't mean that everyone is going to scramble over and scoop up all the corneas they can carry.

There will always be a difference between discretionary and non-discretionary medical procedures, as well. No one's talking about having breast enlargement paid for by the government, or something like that.

[dutchmarbel]

The latest Dutch system (we changed last year) works with no-claim as an incentive. Everybody gets the same basic insurance for the same price - and insurers cannot refuse people. If you do not use healthcare, you get approximately 300 dollars back that year (everytime you use healthcare you get a nice letter stating how much no-claim you have left for the year).

Having health insurance is obligatory, and your employer can bargain for better deals or pay part of your premium, but YOU have the contract with the insurance company.

GP's are crucial to our system: they guard the road to specialists. GP visits are not part of the no-claim, since that might jeopardize prevention.

The basic package is rather basic. You can extend via "extension" insurance packages. Appliers for those packages *can* be refused by the insurance companies.

Kids have a more extensive package anyway, till they are 18, since that is investing in your capital of the future (to use Andrews argument pro militairy healthcare). Prevention and information both lower the need for extensive healthcare.

Insurance companies compete with additional survices, better packages, faster services, faster repayments if you have chosen the non-natura system (you choose, you pay, they repay versus they pay directly but your choice of doctors is limited).

I'll come back with figures later, dinnertime now :)

[Jesurgislac]

Andrew: You're agreeing that government has the right to tell people how to live, as long as you're the one whose principles are pushed by the government.

Er, the principle of "eat five portions of fresh fruit and veg a day" isn't my principle - it's generally agreed to be a damned good idea.

I would, however, be opposed to an Act of Parliment or an attempt to amend the US Constitution to require people to eat 5 portions of fruit-and-veg each day or else. That would be silly. Again, as I said at the start of the thread and as others have said further down, this would be a far more interesting discussion if you weren't consistently setting up straw men - your imaginary consequences of universal health care systems - and were instead referring to actual universal health care systems, of which there are 28 around the world to look at.

I'm in favor of federal funding for safe sex education, too. Generally speaking, I suppose you could say that "my principles" are that if the government's going to pay for information to be distributed to citizens, it should be useful and accurate information - as useful and accurate as present-day knowledge can make it. You may feel that the government shouldn't be in the business of giving any information to citizens, but I fear that you are on a losing course there. (And it's an odd stance to take, too: it means you're against the Highway Code, among other useful things.)

[hilzoy]

Andrew: I really don't agree that universal health insurance is even remotely likely to lead to the government telling us what to eat, etc. It has not done so in any of the current government programs -- medicare, medicaid, VA, etc. Why on earth would it start now?

[Sebastian Holsclaw]

"The insurer and the drug company can then butt heads on pricing, much as they do now."

Unless the insurer is the government, in which case it can dictate pricing on various non-business threats (like breaking your patent or various other slightly less threatening things).

[Andrew]

hilzoy,

Maybe I'm wrong. I certainly hope so, since I expect the government to take over health care in my lifetime. But fifteen years ago the idea of suing a fast food company because you got fat eating their food would have been laughed out of court. The drive to relieve people of any responsibility for their choices has come a long ways since then, and the train shows few signs of stopping. I am decidedly leery of providing ammunition to those who would run our lives.

[Jesurgislac]

The drive to relieve people of any responsibility for their choices has come a long ways since then

Or, put another way: the drive to force people to take responsibility for their choices has come a long way since then. Or don't you regard the people who make decisions about the quality and marketing of fast food as, well, people?

[hilzoy]

Andrew: surely in that case the problem is with the tort system. (Assuming for the moment that you're talking about suing just because you got fat, and not because of some ingredient that posed more specific health risks that the company suppressed information about, a la tobacco companies. In the tobacco case, I think it makes sense to sue if one happens to be a person who took up smoking at a time when the tobacco companies knew about the risks, and were blocking the information, and one has suffered damage -- just as it would if a toy company painted its toys with paint they knew to be toxic and suppressed the evidence for that.)

[Andrew]

Or don't you regard the people who make decisions about the quality and marketing of fast food as, well, people?

An excellent example of what I'm talking about. If people eat too much, the fact McDonald's advertised their food isn't an excuse. The idea that McDonald's or RJR or any other company should pay damages because someone did something stupid is the height of stupidity.

[Jesurgislac]

Though I have to admit, Andrew, that supersize me was a far better and more effective indictment of the fast food industry than any government-subsidized information campaign would be. *throws you tiny sop*

[Farberesque]

Could someone please correct the spelling of the first word of this post? Thank you.

[hilzoy]

Can any lawyer chime in on the likelihood that someone would actually win a case of the sort Andrew is describing, absent a completely flukey jury?

[Slartibartfast]

No one could have predicted that eating too many burgers and fries would make you fat. No one.

[Farberesque]

That is to say, the first word of the title of this post . . .

[Andrew]

hilzoy,

I concur with your examples, and the tort system is certainly part of the problem. But given what we've seen with cigarette smoking and seat belts, I don't think it's unreasonable to think that what they can't get through the courts, activists may attempt to get via legislation.

[Jesurgislac]

Andrew: If people eat too much, the fact McDonald's advertised their food isn't an excuse. The idea that McDonald's or RJR or any other company should pay damages because someone did something stupid is the height of stupidity.

Until Supersize Me came out, one of McDonalds' marketing campaigns was the claim that you could eat every meal, every day at McDonalds - that's the claim that inspired Supersize Me.

McDonalds provides about the least healthy/most expensive food-for-kids imaginable: and targets kids specifically with marketing campaigns.

You can argue that people ought not to be stupid enough to believe the lies McDonald told about their food being healthy and nourishing, of course: and that McDonalds has no responsibility to sell nourishing/healthy food, not even if their marketing campaign says that's what they sell.

[Andrew]

Title fixed. Sorry about that. I haven't slept well lately; probably should have left this topic for another day.

[Andrew]

Jes,

Every McDonald's I've ever been to offers salads and lower calorie offerings. If people choose to purchase the higher calorie offerings, that's on them, as far as I'm concerned. Tort law ought to be restricted to negligence and misconduct.

[Enrak]

Just a couple of points I'd like to throw out there.

Everyone seems to think that we have a capitalistic health care system right now but we most certainly do not. The AMA limits the supply of doctors and more importantly state regulations (imposed to satisfy the AMA) limit the supply of health insurance. I know of (*important qualifier) no state in the union where you can get simple catastrophic health insurance. States require that you offer a certain amount of benefits and cover a certain number of services. Most young people do not need the health insurance that is offered.

Also, I see people making the claim that both the demand for health insurance won't rise and that people will modify their use of healthcare because of implementation of some form of universal coverage. I don't think we can assume that people will suddenly start taking advantage of preventative services just because we have universal health coverage. Most people WITH health insurance don't take enough advantage of preventative services.

Also, do not bet against government intervention in people's lifestyle choices. I work for a company that does health care research for the federal government and I've been involved in two conversations with people much higher up in the food chain than me who have suggested that laws should be made that target obesity. Both times when I asked why the government should get involved in that they said because the government pays for Medicare. If the government was the primary player I don't think they could resist the urge to try and reduce outlays be trying to force us to eat better and exercise more.

Also, the United States performs poorly against other industrialized nations on standard health measures for a variety of reasons. It is important not to overlook the fact that we have one of the highest rates of immigration in the world. And most immigrants come from poorer nations. There are various barriers to good health care service for immigrants (all). These would be the same in Europe and Japan if they had to face the same percentage. Similarly, measuring standards are not. The United States, just as an example, tries harder to save neonates than most other industrialized nations and counts all those 24 week neos that don't make it in the total. Most other countries do not include those in the total.

Administrative costs in the United States are much higher. There ain't much getting around that. But there are a lot of problems in other countries with national health insurance that aren't being discussed here, including queueing and outright denial of services for the elderly.

All that said, I am not diametrically opposed to some of the systems currently being implemented. I think the French and German systems both hold promise. An NHS style healthcare system a la Canada or UK fills me with dread.

[Jesurgislac]

Andrew: Every McDonald's I've ever been to offers salads and lower calorie offerings.

Yes; apparently the cheeseburgers are the "lower calorie offerings", since the salads on average contain more fat.

As you phrase it, "Every McDonald's I've ever been to" would suggest that you never went into a McDonalds before 2003, since it's only then that they started offering salads. (I may be wrong about the exact year, but I know it was a recent development.)

As I said *throwing you a sop* (made of wholemeal organic bread and organic fair trade wine) this change was undoubtedly due to Supersize Me, rather than any government action or tort prosecution.

[Slartibartfast]

Try 1985, J.

[Jesurgislac]

Frank: The United States, just as an example, tries harder to save neonates than most other industrialized nations and counts all those 24 week neos that don't make it in the total. Most other countries do not include those in the total.

I've often seen this claimed by anti-choicers, but I've never seen any links to actual data.

I see no reason to suppose it's true: certainly in the UK, to the best of my knowledge and belief, if a baby is born alive (even as early as 22 weeks) the baby must then be registered (it's a legal obligation on the parents to register the birth within 6 weeks) and I can't see why the GRO would make an exception, or why the parents would want to make an exception, just because the baby then died because s/he was too premature to live.

[Jesurgislac]

Slarti: Try 1985, J.

Really? Ah well. Come to that, the last time I went into a McDonalds for any other reason than to get out of the rain was, um... 1987, probably. (When I was an innocent teenager, I tried their fries, their apple pies, and their milkshakes, and concluded they were all vile. When I tried their coffee - as the price of getting to stay dry - that was so vile I'd actually rather be rained on.)

[Andrew]

I tried their fries, their apple pies, and their milkshakes, and concluded they were all vile.

Hey, you can insult me all you want, but I'll not have McDonald's fries impugned.

[LizardBreath]

But fifteen years ago the idea of suing a fast food company because you got fat eating their food would have been laughed out of court.

I haven't googled it yet, but I'm pretty darn certain that it was laughed out of court. Or, rather, dismissed. Let me go check.

[Andrew]

LB,

That would be good news. Thank you.

[Slartibartfast]

Ah, well. Wiki says 1985; this says 1987. I think mid- to late- 1980s is a safe bet, but I'd lean heavily in the 1987 direction.

I used to work at McDonald's, and I never ate there unless I was at work and had no other choice. I don't think I've eaten McDonald's food more than a half-dozen times since. That's in over two decades.

[LizardBreath]

Yep. I don't know that no other similar suits have been brought, but I don't believe they have.

[Jesurgislac]

Andrew: Hey, you can insult me all you want, but I'll not have McDonald's fries impugned.

Chacun à son goût.

I like fries to look like this.

[Enrak]

http://www.oecd.org/dataoecd/7/41/35530083.xls
footnote b

"In the US, Canada and some Nordic countries, very premature babies with a low chance of survival are registered as live births"

Guess who is right above the U.S - Canada. It's not that they are not reporting live births, it's that they don't have the same technology to try and save a premature baby as is available in the United States.

[LizardBreath]

The linked article above was to a dismissal with permission to replead -- here's the final dismissal.

[Slartibartfast]

And just as no one could possibly have predicted that eating twice the recommended daily caloric intake, and that consisting entirely of fast food, could possibly make one gain weight, no one who's ever taken a sip of McDonald's coffee within the first hour or so of its exit from the spigot could possibly have predicted that McDonald's coffee was hot.

[Doctor Science]

enrac:

It is important not to overlook the fact that we have one of the highest rates of immigration in the world.

It is important not to overlook the fact that the two groups with the worst health records in the US, Native Americans and blacks, are the people who have been here *longest*.

I say the black population has been here longest because it is made up of people most of whose ancestors were here by 1860 -- if not 1820 -- which is not the case for the "white" population. None of my (Irish, German, Swedish) ancestors were here before the Civil War, for instance.

[Ugh]

IIRC, the case filed against McDonalds for making people fat was dismissed, though the court left open the door for a future suit. I think the plaintiffs tried again and that case was dismissed too.

Don't spill the coffee on yourself.

[LizardBreath]

And certainly, after having been repeatedly notified that their coffee had caused third-degree burns on multiple occasions, McDonalds had no way of knowing that it might be a good idea to serve it at a temperature more typical of restaurant coffee. But we won't convince each other on this one.

[Slartibartfast]

No, I think you've convinced me that McDonald's is capable of stupidity. But I already knew that, so don't celebrate too much.

[Enrak]

Dr. Science,

I'm not going to argue with you there, as you have the benefit of evidence on your side. But many of the people that get the worst service already have health insurance (unless they are male) through Medicaid. How is extrapolating that to the rest of the population going to help?

Also, I belive that your points had already been raised, while mine had not. I don't think your point disputes mine.

[LizardBreath]

(Recorks champagne, finding it surprisingly difficult. On second thought, finding it unsurprisingly difficult.)

[Ugh]

I go back & forth on the McDonalds coffee case™. On the one hand, its coffee, its hot! And it's meant to be poured down your throat, no over your skin (IIRC, you mouth is capable of handling hotter liquids than your skin).

OTOH, multiple warnings of burns, and knowledge that the lids didn't fit well (especially when you're giving it to people who are driving) kinda meant they should have done something about both things.

Though I think the solution they came up with was to keep serving the coffee at the same temperature and just put warnings on the cups (I could be wrong about this).

[Francis]

on tort reform:

Leave it alone. If you don't trust the govt now, why {expelitive deleted} would you trust it to act as a gatekeeper to determine meritorious vs. non-meritorious lawsuits? Frex, last I read about the McDonald's made-me-fat case, it went nowhere. The plaintiff, stymied by the fact that he was served food, argued that the food was adulterated.

now wait a moment! Let's assume that the plaintiff could prove to a jury that McD deliberately added an addictive chemical with no nutrient/flavor value to its fries, and concealed that conduct. McD liable? I certainly hope so.

but since there was no such evidence, the case went nowhere.

re: health care. It seems to me that the thrust of the post is that we Americans cannot be trusted to leave us alone. Certainly Radley Balko's posts about Chicago add legitimacy to that concern.

but the current system is, essentially, dysfunctional and more expensive than any other industrialized country's system. we should not be paralyzed by the counsel of our fears to try to do better.

(note: health care insurance is already incredibly highly regulated by states. the notion that a single federally-chartered insurer will somehow be substantially more intrusive seems unlikely. but if we insist on maintaining our federal system, there's no reason why we cannot charter 50 separate joint federal-state insurers, each with its own coverage. of course, you'd have a real problem with people traveling to high-coverage states for elective procedures, but it would inject some competition into the system.)

[hilzoy]

OK, so in support of the idea that if we got universal health care the government would start telling us what we could and could not eat, we now have a suit that was dismissed, plus suspicions about what activists might do. Against it, we have the fact that the government has done nothing of the kind since it got into the health insurance business, plus the claim (by me) that if the government tried to e.g. ban McDonald's, the party that suggested that would be drummed out of office.

Meanwhile, I continue to say that it is a good thing if people who want to lose weight or quit smoking or stop drinking or give up crack get the help they need to do so voluntarily -- good for them, good for the rest of us (increased productivity, decreased emergency costs, etc.), good for whoever pays for their health care. Insurance companies do not now do enough of this because they can always hope that by the time the relevant habits start costing money, the patient in question will be covered by someone else. All insurance companies would be better off if all insurance companies covered this, but since there is no decision-making body called "all insurance companies", and since it's rational for each individual company not to do it and to free-ride on anyone who does, it doesn't get covered. Why this is supposed to be a good idea, I cannot imagine.

[Slartibartfast]

I thought I heard that they'd dialed the temperature back. One thing that irked me about that whole thing was the suggestion (actually, it was an assertion) that there is in fact an "industry standard" for coffee temperature. To me, the words industry standard imply some sort of agreement, normally written, and I'd be shocked to discover that there was such a thing in effect among fast-food restaurants. I'd be only slightly more shocked do discover that coffee temperature was regulated in law by international treaty.

[Jesurgislac]

Enrak, I can't access the link.

As I said, as far as I know if a premature baby is born alive, there's a legal obligation on the parents (or, failing the parents, ) to register the baby. If you can find me evidence that this is not the case...?

It's true that the legal distinction between a miscarriage and a stillbirth is at 24 weeks: but this is a legal distinction between a dead fetus and a dead baby. A live baby has to be registered - and as far as I know that obligation exists no matter if the infant then dies.

[Enrak]

The truth is that all insurance companies are already free-riding on Medicare. They know that by the time most of the benes will get really sick, they'll be able to pass the problem on to Medicare. That is why they underinvest in preventative services. There is zero incentive to invest. That's one of the reasons disease management doesn't work. Most of the benefits of disease management accrue over at least a 5-10 year timeframe. What incentive does that leave a health insurance company to enter a 60 year-old in their disease management program? Or really anyone else seeing as most people will change employers within 5 years.

[Enrak]

Jes,

There's a legal obligation, but what is your definition of alive? Not breathing, no heartbeat? In one country that would be recorded as a nonlive birth. Here in the United States there is a significant chance that they could get the baby to survive long enough to record it as a live birth.

If it's the same across all countries than why the footnote.

P.S. Just go to OECD, follow the Health links to infant mortality rates if you don't believe me.

[Andrew]

Why not allow the states to try their own solutions, rather than trying to impose a federal one-size-fits-all solution?

[Michael Cain]

Ditto Bruce's position. Every industrialized country that starts with universal medical care as a requirement spends less than the US does. Many of them have better measured outcomes, and none of them are worse overall. The organization of the health care system in those countries cover a wide range: from the NHS in the UK to Japan's system of private providers and insurers. This would seem to put the onus clearly on the other camp: exactly which benefits do you claim we are realizing by intentionally excluding universal care from our system?

Taiwan revamped their system in 1995, and included universal coverage. http://content.healthaffairs.org/cgi/content/full/22/3/77>This article provides some summary information about their experience. The evidence seems to support the argument that reduced overhead offset the costs of insuring those who were previously not covered. Once the program was well established, public approval has been in the 65-70% range, making it the most-approved government program.

[Andrew]

Jes,

Re: french fries, I prefer steak fries myself, but it's hard to find good ones.

[Francis]

Andrew: because the poor large Midwestern and Southern states hold disproportionate power in the Senate.

[Andrew]

Francis,

By that, I assume you mean that they are demanding federal intrusion because they don't have the money (or don't want to spend the money) for their own programs?

[dutchmarbel]

I'd like to link to a graph that shows how much the OECD countries spend on health care and how much of that is actually paid by the government.

It makes it very clear that under the current system the US government allready pays more than quite a number of countries pay *in total* (public and private spending combined).

Enrak: the immigrants usually are a lot younger too. Europa has on average a far older population, which had an impact on health costs.
The neonatal death figures are hard to compare anyway I find. Our average mother giving birth for the first time is 29, so we have more complications due to age. In the US you have more quadruplets due to commercializing of fertility treatments...

Problem with helping all those new born babies is that quite a percentage of them will be handicapped - and will thus suffer from the inadequate health insurance situation in the States.

About the sueing: that is also a culture thing. It does not happen that much here, and the ones that do happen are settled with smaller amounts. Amongst others because health costs are a lot less here...

[Michael Cain]

Andrew: "Why not allow the states to try their own solutions, rather than trying to impose a federal one-size-fits-all solution?"

Given open borders, the obvious free-rider problem as people with serious illnesses move in for the purpose of obtaining treatment they could not otherwise get. Given the interstate nature of big insurance, big hospitals, and big pharma, the inability of an individual state to impose meaningful coercion on the behavior of those companies (and yes, I acknowledge that universal coverage will require some degree of coercion). The inability of the states to make large experimental changes in how Medicare and Medicaid dollars -- roughly 40% of the total health care spending in a given state -- are spent. The probable inability of the states to conduct all of the possible experiments; I don't believe a state would be able to require that all doctors be employees of the state a la the NHS.

[hilzoy]

Andrew: if your concern is that universal health insurance would involve too much government intrusion, it's hard to see how state efforts would help that. What they would do is undermine some of the considerations in favor of having a federal policy, namely: having one risk pool, and also avoiding problems like: states being worried that generous health care provisions would serve as a magnet for the poor, etc.

[Brian Palmer]

Ugh, in addition to the warnings, they also went to a somewhat sturdier coffee cup. (And, the particular McDonalds where the case was at significantly lowered the serving temperature of the coffee).

[Andrew]

hilzoy,

I have many concerns, not least of which is that I still cling to an antiquated interpretation of the Constitution. I'd feel a lot better about what the federal government does if it did it by actually amending the Constitution as opposed to getting the Supremes to redefine the Constitution.

Further, I have a sneaking suspicion that when the day comes that universal coverage is imposed, the system Congress comes up with will be a bad one. At least by letting the states try their own solutions, the odds seem much better someone will come up with a good plan. With the federal government, if they shoot a brick we're stuck with it for some time to come. Yes, it can be fixed over time, but how many bad federal programs get fixed? What's the over-under on when we get serious about Social Security?

[hilzoy]

Andrew: I foresee an interesting argument about Social Security in our future. Personally, I think it's fine as is; certainly there's nothing that a bit of tweaking won't cure. I also bet that if the Dems take over Congress, the prescription drug bill will be vastly improved; if (as seems a lot more likely) they only take one house, the chances for serious improvement go up, but not nearly as much. So the length of time we're stuck with the worst of that, I think, depends a lot on the '06 vote.

Universal health insurance is complicated, but it's not that hard to come up with at least a decent solution, especially if we look at the experience of other countries.

[Jesurgislac]

I don't believe a state would be able to require that all doctors be employees of the state a la the NHS.

The UK does not require that all doctors shall be employees of the NHS. Doctors are free to work in private practice or for the NHS or both.

[Andrew]

hilzoy,

I certainly hope you're right about the Democrats and Plan D, since I would prefer an effective plan to an ineffective one. Juts as I don't subscribe the whole 'starve the beast' theory, I'm not a fan of trying to roll back government by making it as poor as possible.

As for Social Security, I'd have to look at the numbers again, as it has been some time, but as I recall, in 2017 the bills are going to start coming due, and I'd rather do something about that now than wait.

[Jesurgislac]

Enrak, as I thought I'd made clear: I can't follow your link. Not won't: can't. It doesn't work for me.

There's a legal obligation, but what is your definition of alive? Not breathing, no heartbeat? In one country that would be recorded as a nonlive birth. Here in the United States there is a significant chance that they could get the baby to survive long enough to record it as a live birth.

I'm sitting here going "what's the point?" I mean, assuming you're right, and American doctors do spend significantly more amounts of time trying to get a miscarried fetus that isn't breathing and has no heartbeat to achieve a heartbeat for long enough that the miscarriage is then recorded as a baby born alive that then dies? I mean, if that's the case, it's not "trying to save the life of a neonate" - it's giving a woman who suffered a late-term miscarriage the recognition and respect that she lost a child, which of course, she did. And of course, miscarriage/stillbirth/premature birth rates being so much higher in the US than in other industrialized countries - the result, I think, of the US's poor maternity health care provisions - I would guess that American doctors would be more motivated to give their patients at least that recognition/respect.

Though again, it would seem better just to improve the miscarriage/stillbirth/premature birth rates by improving maternal health care and health care generally... which is to say, by instituting universal health care.