A Question For Megan McArdle

by hilzoy

Megan McArdle responds to my last post:

"Surely the point of worry is that many millions of people will be forced into the public system, because its existence will encourage their employers to dump their health care plans.  Since private systems have so far found it virtually impossible to deny many treatments for long, this will mean that millions of budget constrained people will find themselves with less available treatment than before. (...)

This is not a crazy worry.  What America is best at is delivering a lot of complicated care in extremis, and "quality of life" treatments.  What European countries are best at is delivering a lot of ordinary care for the sorts of things that afflict people from 0-50, which is why most of the Europhile journalists writing about Europe genuinely have very good experiences to report.  I'd rather be here to have a hip replacement, but I might rather be in the Netherlands to have a baby.  Doing something moderately ordinary here is a hassle.  Doing something extraordinary there is often not possible for the overwhelming majority of citizens, though that depends on what, and in what system."

The main point I wanted to make in my last post was this: if by 'rationing' you mean making it impossible for people to get certain kinds of care, even if they're willing to pay for it themselves or buy supplemental insurance, then no one is proposing rationing. If, on the other hand, you mean 'making people have to buy it themselves or pay for supplemental insurance', then you have to count our current system as rationing care in such a way that 47 million people, plus all those who discover that their health insurance doesn't actually cover the care they need, are 'deprived' of care. 

What you don't get to do is act as though the fate that would befall a 99 year old who needs a pacemaker (in the imaginary world in which no one has Medicare) is a horrible new scourge that Obama's plan would introduce into the world. Or, in short: you don't get to ignore the existence of the uninsured. (Or the underinsured, or those whose private plans deny them care.)

With that in mind, consider this sentence from McArdle's piece:

"I'd rather be here to have a hip replacement, but I might rather be in the Netherlands to have a baby."

A question for Megan: would you really rather be here for a hip replacement, given that you'd have about a one in six chance of being uninsured? If you say 'yes', does your answer rely on the fact that most people who need hip replacements are covered by Medicare? Would you also say 'yes' for some treatment that people your age are more likely to need?

If not, you're relying on the assumption that the people you're imagining actually have health insurance. In this context, that's not a valid assumption.

***

UPDATE: Kevin Drum questions Megan's assumption that we do, in fact, do better at managing serious diseases:

"If by "extraordinary" Megan means the most extreme 0.001% of procedures, then maybe she's right.  Maybe.  But nothing I've read about Western European healthcare systems makes me believe that there's any substantial difference between the way they treat severe illnesses and the way we do it.  And no systematic difference in success rates for such treatment either.  Nor should this come as a surprise, since most extreme medicine is practiced on older patients, who are covered by a public plan both here and in Europe."

He's right. But even if we pretend, for the sake of argument, that there is such a difference, we'd still need to bear in mind the possibility of being uninsured here when asking: where would I rather be if I needed medical care?

Comments

[Russell Abbott]

Right as usual, hilzoy. Way to stay focused. I expect Ms. McArdle to respond with a rambling non sequitur shortly.

[JimV]

As one of the uninsured whom McArdle couldn't care less about, thank you.

[halop8]

that famous definition of a just law (can't remember who said it) -- one you'd support if you had no way of knowing what place you'd occupy in society -- seems apt here.

[KCinDC]

McArdle says "private systems have so far found it virtually impossible to deny many treatments for long". Is that true? I find it hard to believe. But if it is, why shouldn't we expect that the public option would also find it impossible?

[Dan]

Does Ms. McArdle's health insurance cover hip replacement? Has anyone asked her?

[Tony P.]

Hilzoy,

The first thing I'd say to Megan is that she, herself, would actually rather not have a hip replacement, period.

When my local supermarket puts 2-liter bottles of caffeine-free Diet Coke on sale for 99 cents, I stock up. If my local hospital ran a promotion (Hip replacements half off! This week only!!) my reaction as a "consumer" would be slightly different. Maybe I'm weird, but health care is not something I would buy more of just because it was cheaper. Or want less of just because it was more expensive. So I don't get how price rationing (i.e. The Market) is supposed to work for health care.

--TP

[DecidedFenceSitter]

Why is it important to have a public options?

Cause your getting sick can/will get you or your spouse fired

And from the same Illinois woman, What happens when the corporation is in charge of your health versus the state.

Saw both of these on Atrios, but linked to the blogger's home blog.

[PhoenixRising]

C'mon, Hilzoy, quit playing Pin the Tail on the Syllogism with Megan--and put that Rawlsian veil back where you found it, it's not a blindfold! Oh wait...

Since private systems have so far found it virtually impossible to deny many treatments for long...

I think we've found the locus of the problem. Megan lives in a country in which private insurers pay the claims of their customers without wailing, gnashing of teeth, or the hiring of lawyers.

In other words, like this country-- except for the uninsured (who private insurers largely don't want as customers) and those insured who have serious, expensive, curable or treatable illnesses (whose insurance companies will get rid of them somehow).

She should really think about meeting with, say, some cancer survivors. Because in this country where I live, private insurance companies are the people we pay to come onto the battlefield where Americans with serious illnesses are fighting for their lives...and http://www.progressivefox.com/?p=721>shoot the wounded.

[mattH]

Really? "Policy Wonkery"? I would think that you need a "Read What I Wrote" or "Common Sense" tag for this one.

[Marty]

"A question for Megan: would you really rather be here for a hip replacement, given that you'd have about a one in six chance of being uninsured? If you say 'yes', does your answer rely on the fact that most people who need hip replacements are covered by Medicare? Would you also say 'yes' for some treatment that people your age are more likely to need?"

As usual we are getting quality of care and availability confused. I would rather be in America for any care if I am insured or can afford it.

I would rather be anywhere I can get it if I can't pay for it.

I would rather have an acceptable baseline of care available to the uninsured and here.

[Emma]

American health care never fails to amaze people from other countries. I'm Australian. We have a combination of government funded healthcare and optional private insurance. Yes, of course there is rationing in every system. Sometimes the doctors do it by refusing to do the risky surgery on the 99 year old. Sometimes it is in the form of delay -- my son had to wait 2 months for his free ingrown toenail surgery, my daughter had to wait 3 months for her free tonsils and adenoids removal. I had to wait an extra 3 hours for my free planned caesarean section because an emergency case took precedence. But sometimes it is on the basis of triage -- my sister's state of the art cancer treatment was immediate and free, my own ruptured appendix removal was immediate and free, my emergency caesarean delivery of premature twins and subsequent neonatal intensive care was immediate and free. I have never had private health insurance, although it is available in Australia, because it is a terrible product, expensive, playing on elitism and fear, and insurance companies try to get out of paying for what you need. I'm not interested in pretty decor in hospital rooms or slightly better food. I pay my taxes, plus an extra levy on people with good incomes and no private insurance. There are other ways to organise health care and, following the debate over there, it seems no-one is looking at all the options, only a very small subset. As Ezra, I think, pointed out -- the 6-month waiting time for that hip replacement in Australia or UK looks a lot better when contrasted with a waiting time that is effectively infinite because you are uninsured.

[kenB]

To some extent I think you and Megan are talking past each other, or at least disagreeing about the connotations of the term "rationing". If the "rationing" card is meant to scare Americans into thinking that some procedures will become *entirely unavailable* for everyone, then you're correct; but if it's simply meant to scare non-wealthy Americans into thinking that some procedures will become unaffordable for *them*, then Megan's response is more salient. For an average American, the fact that they can still get procedure X if they can come up with an extra $10,000 to pay for it might be cold comfort.

The majority of Americans may well be willing to make this sacrifice in order to extend coverage to more people, but as far as I can tell, the current political leadership is happy to leave the impression that no one will have to give up anything.

[john miller]

kenB, care to provide any evidence to back up what I see as an assertion that a public option would be more limiting than private insurance. It may be relevant to note that Medicare denies far less a percentage of claims tha private insurance, allows more bed days per hospital stay, and requires next to no precertification processes.

Additionally, since all we are talking about is a competitive public option, not single payor, many of the arguements against are somewhat irrelevant.

Finally, considering how horrible health care is in other countries, to hear people like McArdle tell it, why oh why haven't the populations of those countries risen up and demanded a better system? Oh, I forget, they aren't Americans so obviously they don't know any better.

[Barry]

Megan: "I'd rather be here to have a hip replacement, but I might rather be in the Netherlands to have a baby. "

I'm convinced by now that anybody who brings up hip replacements is frankly ignorant or lying.

I have some of the best coverage in the USA, IMHO. When I needed a hip replacement, it took 7 months. To give you an idea of how good my coverage is, I paid less than $500 out of pocket for the surgery, convalescence and physical therapy (which is nontrivial, for a hip replacement). I'm not really sure what the exact figure was, because it wasn't a big deal.

When my mother (age 81) fell and broke her hip, it took roughly 10-12 hours.

That's because my hip replacement was the normal arthritis-driven major elective surgery, for which the wait time is several months (unless you can be on stand-by, and be laid up for a month on 48hrs notice).

My mother's surgery was major non-elective emergency surgery, for which the wait time is hours.

[kenB]

John, it's unfortunate that political discussions so quickly become emotional and devolve into accusations of bad faith or heartlessness. Just as it was possible to believe that Saddam was a bad ruler but that perhaps invading Iraq and deposing him could make a bad situation worse, it's possible to acknowledge that the current health care situation in this country leaves much to be desired but still be skeptical of the various proposals to "fix" it.

Right now I see Obama marketing the health care plans just like Bush marketed the Iraq war -- lots of emphasis on best-case scenarios bordering on the unrealistic, and little or no talk about the real risks, costs, and potential sacrifices.

As far as the "competitive public option" is concerned, I'm waiting to see more details. So far, I really don't understand how it would simultaneously be both truly competitive and also significantly better than existing private plans.

[progenitor]

kenB, what color lipstick do you like on your pig?

[Chris Johnson]

Interesting discussion. There is another problem with Ms. McArdle's view of medical care besides ignoring the uninsured -- her assumption that American care for esoteric conditions or for delivering high-tech interventions is better than it is in most European countries is wrong. Many of our high-tech (and expensive) interventions have never been shown to give better outcomes than lower-tech (and cheaper) alternatives. So a bigger question is not where to have the hip replacement, but if you really need it at all. A system that denied procedures of unproven benefit would be good for American patients, not bad.

[ScentOfViolets]

John, it's unfortunate that political discussions so quickly become emotional and devolve into accusations of bad faith or heartlessness. Just as it was possible to believe that Saddam was a bad ruler but that perhaps invading Iraq and deposing him could make a bad situation worse, it's possible to acknowledge that the current health care situation in this country leaves much to be desired but still be skeptical of the various proposals to "fix" it.

Well, here's the deal: for me to believe that anyone is discussing the issue in good faith, they have to start with the premise that other countries do a better job of health care for more people and at a lower cost.

That's the starting point. I've found that people who talk about 'good faith' on this issue often really are just saying that American health care is the best health care overall for the American population. That is, they are arguing very much in bad faith, but are stalling on being called on it to get their talking points out there.

[Marty]

"Well, here's the deal: for me to believe that anyone is discussing the issue in good faith, they have to start with the premise that other countries do a better job of health care for more people and at a lower cost."

Other countries do a better job of providing healthcare to a larger percentage of their population. They don't provide better healthcare to those that have access to it. Can we start there instead?

[KCinDC]

I would rather be in America for any care if I am insured or can afford it.

I might go along with that if "insured" were changed to "insured and somehow guaranteed that the insurance company would actually pay for the treatment and not cancel my insurance and that being treated would not prevent me from getting insurance in the future if I ever want to leave my current job and, say, work for myself".

[Doctor Science]

Since private systems have so far found it virtually impossible to deny many treatments for long

... she lost me right there. She *cannot possibly* be arguing in good faith, or at least not in good brain.

[Marty]

"Just as it was possible to believe that Saddam was a bad ruler but that perhaps invading Iraq and deposing him could make a bad situation worse"

Is it worse?

[ScentOfViolets]

They don't provide better healthcare to those that have access to it. Can we start there instead?

Posted by: Marty

I don't know - do you have any data to support your claim? I can look up WHO statistics to support mine. On some level, your statement is just a tautology, depending on what you mean by 'having access'. That term is not at all clear.

[Marty]

"On some level, your statement is just a tautology, depending on what you mean by 'having access'. That term is not at all clear."

never mind.

[hilzoy]

Marty: "Other countries do a better job of providing healthcare to a larger percentage of their population. They don't provide better healthcare to those that have access to it. Can we start there instead?"

-- Actuslly, though there are enough different bits of health care that there surely are things the US does best, it does not really do best for those who can afford it on a bunch of measures. See, for instance, this study, which shows that people with several chronic illnesses not only were a lot more likely to have problems accessing care in the US than in the other countries studied, but also that they were more likely to have medical errors and problems coordinating care.

[Witt]

would you really rather be here for a hip replacement, given that you'd have about a one in six chance of being uninsured?

That's the nub. I won't presume to speak for the pundit in question, but IME when people make this argument, they hear "you" not as the neutral "one" but as the specific "you, personally." And they interpret it as "Me with my current level of privileges."

So of course you get crazy answers. If you draw the circle narrowly enough to exclude the 47 million uninsured etc., and you just think of the "you" in question as "Would *I*, with my current good health and high-paying job and excellent social status..." then people are going to come up with radically different answers than if they are thinking "Would I, if the dice-roll came out differently..."

[mightygodking]

Other countries do a better job of providing healthcare to a larger percentage of their population. They don't provide better healthcare to those that have access to it. Can we start there instead?

If we're going to start discussing the health care systems of Fantasy Earth, where your claim is actually true, I think it only fair that we take into account the effect of dragon ravagings on the healthcare system of Australia Two, as well as the ongoing zombie mutation crisis.

[hilzoy]

This study has all sorts of useful data on international comparisons. Overall, we don't come out too well, even on things where lack of access isn't part of the problem. E.g., on p. 53, you can see that our rate of deaths due to surgical/medical mishaps per 100,000 population is nearly twice the OECD median.

[Nombrilisme Vide]

@Marty:

"Just as it was possible to believe that Saddam was a bad ruler but that perhaps invading Iraq and deposing him could make a bad situation worse"

Is it worse?

This depends entirely on how you judge something to be "worse". Personally, I'd look at the million plus dead, millions displaced as refugees, deteriorated civil rights and infrastructure, and ongoing sectarian violence... all of which forces me to conclude yes, it's worse. However, if you wish to dictate the standard of judgment to be limited to the number of purple thumbs after an election, then one might be justified in concluding "no".

However, this is more than a little bit of a digression... it smacks of a full-blown attempt at derailment. The only relevance the above has is that it provides another situation where ignoring the health and well-being of the majority of the population of the nation in question could lead one to different conclusions than considering it would.

[chris y]

But nothing I've read about Western European healthcare systems makes me believe that there's any substantial difference between the way they treat severe illnesses and the way we do it.

Agreed. My experience of a radical procedure in the British system, at age 43 was - serious cardiac condition identified: late November; angiogram: between Christmas and New Year; valve replacement: Early February. Given that arrangements had to be made, I'm not sure I'd have wanted it much quicker. I assume the response would have been much the same in any country with competent cardiac units, but I'm not bankrupt and I still have my house.

[Jesurgislac]

Marty: Other countries do a better job of providing healthcare to a larger percentage of their population. They don't provide better healthcare to those that have access to it. Can we start there instead?

Well, even if you were allowed to presume without data that the privileged group in the US who do have access to healthcare get better healthcare than anyone else in the world, that still means you're arguing that in order to assess how good the US is at providing healthcare, you want to leave out of the assessment the millions of people in the US whose sole access to healthcare is a long queue in the emergency room or a long wait while a health insurance company decides how best to deny your claim. In effect, you're arguing that a country should be judged by how well it treats its aristocracy, regardless of how badly it treats its peasants. Does that seem reasonable to you?

[ScentOfViolets]

"On some level, your statement is just a tautology, depending on what you mean by 'having access'. That term is not at all clear."

never mind.

Posted by: Marty

And this is what I mean by not arguing in good faith. If you have a problem with what I said, ask for clarifications or elaborations. It sounds an to me an awful lot like you do want to force the discussion to occur on grounds that are not, well, well-grounded in reality. And that you know it. If this isn't what you're trying to do, I think you have some 'splainin to do.

[Marty]

"And this is what I mean by not arguing in good faith. If you have a problem with what I said, ask for clarifications or elaborations. It sounds an to me an awful lot like you do want to force the discussion to occur on grounds that are not, well, well-grounded in reality. And that you know it. If this isn't what you're trying to do, I think you have some 'splainin to do."

I will put this as simply as I can.

The US healthcare providers provide exceptional care. I really don't care whether the quality of caree is slightly better or worse than anywhere else. It is not the problem that the legislation that is proposed is trying to solve.

So, at several points in this discussion I have tried to point out that we need to find a way to get all of those people to have access to the system at a level beyond critical care for emergencies.

I also believe that we shouldn't just copy someone else's system as those systems have their own flaws despite the points of reference that we are provided in this thread.

We should find a morally and financially realistic solution to the problem.

I really don't have to 'splain anything. There are several comments in this thread where I make it clear that I believe something needs to be done.

I would just like to discuss solving the problem without messing up what does work.

[liberal japonicus]

'exceptional' means, at least to me, a marked difference in quality to what is available in other countries, and, having experience in both the US and Japan, I don't think that the US is head and shoulders above the health care here. But that is anecdotal, so I wonder: What would you accept as proof that the US does not provide exceptional care?

[ScentOfViolets]

Right, the falsifiable hypothesis. I'd also like to know by what measure and data Marty thinks the U.S. provides 'exceptional' care.

[Marty]

"'exceptional' means, at least to me, a marked difference in quality to what is available in other countries, and, having experience in both the US and Japan, I don't think that the US is head and shoulders above the health care here. But that is anecdotal, so I wonder: What would you accept as proof that the US does not provide exceptional care?"

I believe that all countries noted above< Japan, US, Canada, UK provide exceptional care, or you can call it adequate care,

I don't need to provide a falsifiable hypothesis on quality of care when the point is:

" It is not the problem that the legislation that is proposed is trying to solve. "

Repeat, it's not the problem the legislation addresses. The legislation is about who gets to have access to the system.

[russell]

"The US healthcare providers provide exceptional care."

I think this statement needs some qualification.

Exceptional care is available in the US. Not everyone has access to it. Not even everyone who has health insurance has access to it.

Also, the places where American health care is exceptional are mostly in areas having to do with the application of sophisticated technology. In terms of plain old hands-on workaday health care, I'm not aware that US care is significantly better than anyone else.

If you go to the doctor because you have the flu in the US vs any other OECD nation, do you think you'll get better treatment or a better outcome? If you step on a nail? Break your leg? Need tonsils removed?

If you need an MRI, Bob's your uncle. Otherwise I'm not sure how care here is any better.

In terms of outcomes, in most areas American health care is mediocre. Which is to say, the *actual health of the people who live in the United States* is at best fair to middling.

And, famously, it's not for lack of spending money on it.

As an aside, I'll also add that all of the debate on health policy in the US focuses on how to make health insurance available to everyone so they can go buy health care from private vendors. The possibilities for straight up public provision of health care is not even on the table.

Why is that?

[Anderson]

This exchange presents an interesting opportunity for me to test my working assumption that McArdle is devoid of any intellectual integrity.

Her response to Hilzoy will be an important confirmation or correction of my views.

[Nombrilisme Vide]

@Marty:
Repeat, it's not the problem the legislation addresses. The legislation is about who gets to have access to the system.

You're moving your goal posts. Upthread, you claimed that you'd unhesitatingly prefer to be treated in the US if you had assured access to care, based on superior quality of care, and that you'd not want to go to an, e.g., European access model because it would result in lowering said quality. Now you've done an about-face and started claiming that quality of care doesn't matter, but that instead we must "[solve] the problem without messing up what does work" in the US system. Um. What would that nebulous, undefined "what does work" be, if not quality of care? You've conceded access to care is markedly inferior under the US model, so if it's not quality... what is it?

[liberal japonicus]

I believe that all countries noted above< Japan, US, Canada, UK provide exceptional care, or you can call it adequate care

I'm sure that this article has been linked before, but the pdf inside the article, from the Organization for Economic Cooperation and Development is really worth a look. If our system is as good as Japan and the UK, why are USains paying twice as much for it?

You argue that this legislation has nothing to do with these imbalances, but if you don't see that this is a starting step in health care reform rather than a complete and total solution, we are going to just talk past each other, I fear.

[Jesurgislac]

Marty: Repeat, it's not the problem the legislation addresses. The legislation is about who gets to have access to the system.

But socialized / not-for-profit healthcare is definitively superior healthcare to for-profit healthcare. Sorry: that's just how it is. A system where the overriding goal is "How best can we keep the patients healthy and well?" is invariably going to provide superior healthcare to a system where the overriding goal is "How can we keep our profits high for the end of each quarter?" Hence Cuba doing better on most healthcare markers than the US, because despite having substantially lower resources, the healthcare system is run on superior lines.

Obama's legislation will not fix that problem, as far as I can see, because Obama's goal includes protecting the profits of the health insurance companies from the unfair competition of a superior health care system.

For-profit health care systems necessarily minimize access: some patients will simply never be profitable. So in order to solve the problem of the US's inferior health care system, the US must first resolve the lack of access ... by establishing an NHS.

But you still have a government that cares more for corporate persons that need profits than human persons who need health care, so it's not going to happen.

(Hm. Interestingly, Firefox 3 is suffering the greyed-out Typepad bug that won't let me post: but IE8 will let me post this.)

[Sebastian]

"I'm sure that this article has been linked before, but the pdf inside the article, from the Organization for Economic Cooperation and Development is really worth a look. If our system is as good as Japan and the UK, why are USains paying twice as much for it?"

And if the US government is better than insurance companies at saving money, why is already paying more than the UK or Japan, and as much as Canada, but only covering 27% of the population? Heck, Medicare + Medicaid alone is about as much as the UK spends to cover everyone.

Whatever is going on in the US, it isn't that the government fails to spend enough money on health care.

[Jesurgislac]

And if the US government is better than insurance companies at saving money, why is already paying more than the UK or Japan, and as much as Canada, but only covering 27% of the population?

Given that you ignored all the answers you were given last time you asked this question, what exactly is the point of your asking it again?

[nous]

Seb - "Whatever is going on in the US, it isn't that the government fails to spend enough money on health care."

True, but the US government is also only one player in a system that is optimized for getting doctors paid according to services billed through the intermediary of insurance companies. If the US government has to play in that paradigm, then it has to pay in it as well.

What we really need to do is change that paradigm, but the insurance industry and their lackeys in congress have gone to a lot of trouble framing the rhetoric of this paradigm in order to make the public associate European models with Soviet bread lines.

[liberal japonicus]

Actually, according to the pdf you link to, the public spending on healthcare is actually lower (as a proportion of GDP) than other countries, but when private spending is added, the total outstrips the other OECD countries. (figure 1 on your pdf, the text is here as a clickable link.)

Also, because of US public health expenditures are often a last resort, the cost is inflated. Your pdf notes:

A final point to take into account is that private charity exists, from hospitals and doctors as well as from individuals who support charitable organizations. It is estimated that two-thirds of the health care received by the uninsured costs them nothing.

While the pdf seems to take that as evidence that the US system works, I take it as indicative of a broken system, in that the charity that is going to keeping the indigent healthy (or at least, not sick) is not available for other purposes.

I was looking for a Malcolm Gladwell piece related to this, but I could only find this, which I think might be interesting for this discussion.

[Bernard Yomtov]

Sebastian,

You've raised this 27% issue often, and it's worth discussion, but let's look at it another way.

The relevant comparison is not with Canada, the UK, etc, but with the private coverage available in the US. We're not talking about moving away from the Canadian system. We're talking about moving away from the current US system. You yourself rais ethe question of whether the government is more efficient than insurance companies.

Since private health consumes about 8.1% of GDP, the implication is that government spends a little more than twice as much per covered person as the rest of the system. I've been unable to locate good comprehensive age-based statistics, but I'm guessing that's pretty efficient, taking into account the people covered by government programs.

For example, cancer incidence in 70-74 year olds is about eleven times that in 40-44 year olds. While the incidence of new cancers seems to be over 2% in Medicare eligible peopel, it dos not even reach 1% until you get to age 60 or so, and this is new cases, so many of those diagnosed between 60 and 64 will end up with treatment partly covered by Medicare.

[KCinDC]

Upthread, you claimed that you'd unhesitatingly prefer to be treated in the US if you had assured access to care

Actually what Marty wrote was "I would rather be in America for any care if I am insured or can afford it." Being insured is a completely different thing from having assured access to care, which is one reason we so desperately need reform.

[mythago]

Public health insurance is also a subsidy to small businesses. BigCo can afford to get a decently-priced plan out of BigHealthInsurer, because BigCo has a larger pool of employees and has more financial clout. Mom and Pop, LLC has to pay exorbitant prices to cover its five full-time employees, and can't compete with BigCo. With a public plan, the small business would become much more competitive.

Maybe that's McArdle's real problem with the plan - anything that nicks BigCo and its ilk is evil in her book.

[Sebastian Dangerfield]

Megan's Ironclad McLogic:

1. If I were 88 years old and needed a baboon heart with special solar-operated valves in order to live for two months longer than I otherwise would, would I want to be:

(a) A wealthy person in the USA, with a gold-plated retiree health-care plan provided by my employer, which has inexplicably declined to dump that plan because its prpensity to pay for too many baboon hearts has made it very expensive to maintain; or

(b) A poor person in Sweden.

2. Because the answer to question 1 is obviously (a), public plans suck. QED.

[Chris Johnson]

It is well known that in the USA we do a large number of very dubious things to patients. These things have risks, and people suffer complications and bad outcomes from those risks. It is a sad thing to suffer a stroke during a needed cardiac procedure; it is tragic to have the same thing happen during an unneeded one. Fee-for-service medicine is the engine driving all this. Until we stop paying physicians and hospitals for doing things, instead of for thinking about it and often not doing things, there is no way to slow down the engine. It's useful to consider what we call Loeb's Laws, now 50 years old at least:
1.If what you are doing is doing good, keep doing it
2.If what you are doing is not doing good, stop doing it
3.If you don't know what to do, it's best to do nothing
4.Never make the treatment worse than the disease (alternate version: do whatever you can to keep your patient out of the operating room)

[Sebastian]

"Given that you ignored all the answers you were given last time you asked this question, what exactly is the point of your asking it again?"

Please link the EXACT comments you believe answer the question in ways that I did not deal with in that post. At least 80% of the responses were wildly off topic and/or grammar complaints.

The US government spends just as more per capita than Japan, the UK and as much as Canada. It covers 27% for what other countries do at 100%. Figuring out why that is so is crucial to any discussion of dramatically expanding US government health care involvement.

Bernard, "The relevant comparison is not with Canada, the UK, etc, but with the private coverage available in the US. We're not talking about moving away from the Canadian system. We're talking about moving away from the current US system. You yourself rais ethe question of whether the government is more efficient than insurance companies."

The most common response to nearly any question I raise on health care, especially from eric martin for example, is "other countries make it work". And yes, they do. With the amount of money the US government already spends. I'm not raising this as an obstacle to covering the uninsured. I'm raising it because if we keep doing whatever it is we are doing--which no one seems to understand well--we are going to end up with an even more hideously expensive system for no good reason.

So far as I can tell, both the US government and private insurers are spending vastly more than anyone else, and for very little actual health effect. Looked at another way, if we spent 150% of what everyone else did but spent it at only 75% effectiveness compared to everyone else, we could still cover 100% of the population. Instead we spend 200% of what everyone else spends and don't even cover the whole population. Our government spends 100% of what everyone else spends AND the private system spends 100% of what everyone else spends AND we don't cover all of the population. Something is really wrong there and it pretty much gets glossed over in "insurance companies are bad" rhetoric, or "governments suck" rhetoric without ever getting to the underlying issue.

[Eric Martin]

The most common response to nearly any question I raise on health care, especially from eric martin for example, is "other countries make it work".

Seb, that's BS. I've listed, numerous times, some of the factors that contribute. They include:

1. Administrative costs (larger because of the number of players in the game, whereas single payer cuts down on those).
2. High cost of drugs
3. Profits of insurance companies.
4. Advertising budgets for insurance companies.
5. Over medicating (I linked to the New Yorker article detailing this, don't know if you read it)
6. Money spent by insurers in denying claims, money spent litigating those denials

etc.

Speaking of admin costs, Krugman has a good post:

http://krugman.blogs.nytimes.com/2009/07/06/a-bit-more-on-administrative-costs/

[Jesurgislac]

Sebastian: Please link the EXACT comments you believe answer the question in ways that I did not deal with in that post.

What for, so you can ignore them all over again? *shrug* I just figured anyone who missed your original post and the thread that followed, ought to be aware that your question was answered, and pretty thoroughly, some weeks ago - but you didn't like the answers, so you ignored them and just keep repeating the question.

[Sebastian]

"Seb, that's BS. I've listed, numerous times, some of the factors that contribute. They include:

1. Administrative costs (larger because of the number of players in the game, whereas single payer cuts down on those).
2. High cost of drugs
3. Profits of insurance companies.
4. Advertising budgets for insurance companies.
5. Over medicating (I linked to the New Yorker article detailing this, don't know if you read it)
6. Money spent by insurers in denying claims, money spent litigating those denials"

And here you go illustrating my point. By definition the government doesn't have 3, 4, or 6 AT ALL. So they can't possibly be the reason why the government spends 100% of the amount that Canada does per capita while covering 28% of the people.

I've repeatedly addressed 2). Essentially drug costs represent about 10% of total expenditures. And the differences in drug costs between the US and other countries represent much less than that. That can't explain why the government spends 100% of the amount that Canada does per capita while covering 28% of the people.

So that leaves you with 1 and 5? 1 is highly speculative (does the mere existence of other payees substantially drive up Medicare costs that much? Why doesn't that happen in Germany, Japan or France then?)

So I guess that leaves 5? Are you talking about the article hilzoy linked in comments? My question there is: Medicare already has all the government incentives in the world to reduce overtreatment. But it doesn't. Or rather, just like private systems such as Kaiser (which does a very good job of holding down costs while providing good care) it does so in a very uneven manner.

Unanswered, is why you believe a much bigger government system would have a different outcome than Medicare. My question is, when the government already spends as much as Canada, it doesn't already have the efficiencies that you believe are available. How much bigger than "spends as much or more per person as Canada, the UK or Japan" do we need before the efficiencies materialize? Maybe they don't just 'materialize' and we should try to figure out where the government is going wrong before dramatically expanding it.

[Sebastian]

"What for, so you can ignore them all over again? *shrug* I just figured anyone who missed your original post and the thread that followed, ought to be aware that your question was answered, and pretty thoroughly, some weeks ago "

And I figured that if your intent was actually to inform such a person, they might want to know where in the long thread you thought such questions were answered so they can judge the validity of the answers. Of course if you had other intents, your response makes much more sense.

[Tony P.]

Our government spends 100% of what everyone else spends AND the private system spends 100% of what everyone else spends AND we don't cover all of the population.

Well, that means we "spend" on things other than actual health care, doesn't it? We have 2.3 physicians per 100,000 population compared to Canada's 2.1, so we have 10% more physicians per capita. Health care is prescribed by physicians. We have 10% more health care available per capita. We just don't distribute it as well, so many people go without. Our "system" -- by which I mean our financial system, not our medical one -- is not "efficient". But it does employ a lot of people, so that's a plus, I suppose.

--TP

[Eric Martin]

Seb, I'm not sure about the 10% figure, because I've seen higher quotes. I'd need to see the link.

When you're looking at the government, you're also dealing with the eldery and poor, and the costs are higher for those demos.

Admin costs and medicare: yes, the amount of paperwork in the entire system is augmented by the number of players.

And let me ask you, then: Why is it that we're spending so much more? What's your guess? If you can answer me that, we can decide on the solution.

PS: Is this the actual breakdown?

"...the government spends 100% of the amount that Canada does per capita while covering 28% of the people."

[Sebastian]

"PS: Is this the actual breakdown?

"...the government spends 100% of the amount that Canada does per capita while covering 28% of the people.""

Actually it is 27% of the population here I don't know why I improved the performance in my head.

[Note that the numbers are per capita which is the correct measure, and are as a percentage of GDP. Since the US has a much larger GDP per capita, the US government is actually spending more per capita than Canada does while covering only 27% of the population. But I didn't want to confuse things and there are some arguments for not correcting for that so I didn't].

The post which Jesurgislac linked has some tentative suggestions about what is going on. I'm more frustrated by the general lack of policy interest in the question, than that I'm certain I have then answer. Although I'm fairly certain that some of the bugaboos usually raised aren't the answer--much like cutting earmarks sounds good but isn't substantivally important. (See espeically drug prices).

[Slartibartfast]

Jesurgislac would apparently just tell you to shut UP, girl! than to actually attempt, or even just link to, an argument.

[Bernard Yomtov]

Something is really wrong there and it pretty much gets glossed over in "insurance companies are bad" rhetoric, or "governments suck" rhetoric without ever getting to the underlying issue.

Sebastian,

So long as you include the insurance companies in your indictment, and can recognize that they seem to be even less efficient than government, I agree with you. Except you dropped the 's' off the last word.

I think we have a lot of issues. One that hasn't been mentioned is that our current system leaves people less healthy when they go into government programs than other systems do. If you take all those uninsured folks, and suddenly cover them under Medicare when they reach 65, you are going to find the effects of a lot of deferred maintenance. That's going to make covering the 65+ population more expensive, per capita, in the US than other places. (I've tried to find some numbers for comparison. If anyone knows of any, I'd appreciate a link)

I also suspect that administrative costs do drive up Medicare costs. Doctors' offices are staffed to deal with insurance companies. That affects their costs and, inevitably, Medicare. Is the overhead load so big in Germany or France? (Hartmut, Novakant - can you help us?)

[liberal japonicus]

It is definitely not the case in Japan, you never see a person working solely on paperwork, or having a receptionist/clerk position.

Also, when you have a nationalized system, savings are found in preventative medicine. For example, when certain diseases are found to be effecting certain segments of the population, targeting those segments is accomplished simply by adding components to the annual checkup. For example, Japan has a high rate of stomach cancer, so a barium meal x-ray was added to the annual checkup for those over 40. This allows for early detection and intervention.

[Jesurgislac]

Slarti: [Sebastian] would apparently just tell you to shut UP, girl! than to actually attempt, or even just link to, an argument.

Fixed that for you.

I wish Sebastian would attempt an argument, or even a response to the people who keep responding patiently/politely to his 27%! thing.

Given Sebastian's reaction to having this pointed out is just "Shut up, girl!", well: it's only fair to point out to the patient people responding that Sebastian is not going to pay any attention to them.

[Slartibartfast]

Fixed that for you.

Fail

[Bernard Yomtov]

lj,

Thanks.

My doctor's office seems to have about one clerical employee per physician. This is just from casual observation, so it could be off. Still, add rent, supplies, insurance, etc., and you have a pretty heavy load. What is the ratio elsewhere?

[Hartmut]

Bernard, I am no expert on that but to my knowledge the doctors I know don't typically have a designated paperpusher employed (or that person works in an undiclosed location).
What on the other hand is quite common are shared practices, i.e. 2 or more doctors joining forces (obvious advantages: shared rent, nurses, there is at least one doctor present at most times even if one has to be absent...). The procedures to deal with the numerous insurance companies are, I presume, highly standardized, so it does not matter that much which one you are dealing with. As far as the insurance companies are concerned, they try to keep costs low, so they can lower the premiums as a means of competition. In typical German fashion the less efficient ones try (successfully) to hamper that. The companies have to 'pool' part of their revenue and the less fortunate are compensated out of that pot.
There is a bit of 'rationing' in that some procedures cannot be refunded by the insurance companies even if they wanted to. The offical reason is that it would give an unfair advantage (!) to some companies.

[Hartmut]

I just asked my mom and she said that to her knowledge the majority of the paperwork (of doctors) is outsourced to specialised firms that do it for a large number of doctor's offices, so a 1:1 ratio of paperpushers to physicians seems unlikely.

[liberal japonicus]

As it turns out, we just had to take a sick child to the hospital. Because she is under 6, all we have to do is present her insurance card as she was covered 100%. After the age of 6, it is 30%, and when we took my older daughter, who had the flu, we got a bill upon leaving for about 3000 yen ($30) and no other bills. Checking about what happens when people with no money have to pay these kinds of bills, there is a possibility of a no-interest loan, up to about 800$ dollars to cover this.

On the other hand, my older daughter broke her arm when we were in the States the last time, and even though we had insurance, we had to pay 4 different bills, which had to be paid before the travel insurance would reimburse us. The charges were
1)emergency room
2)emergency room doctor
3)radiologist (the xray was sent to a centralized radiology clinic which charged us separately)
4)Orthopedic clinic that we went to after the emergency room doctor misdiagnosed is as a hyperextended elbow rather than a fracture

That difference might be part of the difference between 27% and 100%

[Bernard Yomtov]

Hartmut, lj,

Thanks for the information.

[Sebastian]

"What on the other hand is quite common are shared practices, i.e. 2 or more doctors joining forces (obvious advantages: shared rent, nurses, there is at least one doctor present at most times even if one has to be absent...)."

I know it is anecdotal, but this has been my experience with most US doctors. They aren't necessarily closely affiliated, but share an office with often shared nurses and usually one dedicated billing person across 3-4 doctors and 2-4 nurses--often they seem to come in once or twice a week (which I found out when trying to process an insurance snafu). Are you mistaking nurses filling out treatment paperwork for billing people?

[liberal japonicus]

Are you mistaking nurses filling out treatment paperwork for billing people?

I'm not sure if this was addressed specifically to Hartmut, so apologies for stepping in, but I don't think this is correct. My mother worked in a doctor's office and she was a trained nurse, but MS prevented her from being a full time nurse, so she worked primarily filling out paperwork, but could do nurse-y stuff in a pinch.

That billing is an art unto itself in the US is demonstrated by the existence of companies that specialize in providing billing services to doctors. Frex, here is one which states CPS assumes the responsibility and liability for the business of employment such as personnel management, labor law compliance, benefit management, human resource compliance, state and federal payroll taxes, workers' compensation and unemployment insurance and other employee-related issues. That seems like a lot of overhead.

There are certifications in medical coding and billing (apparently salaries range from 26 to 54k, with the average salary around 35k) Having certification and that kind of salary points to it being a major part of the costs.

At the interface between doctor and insurance company, there are a lot of potentials for miscommunication. Here is an example, that of billing codes.

From the wikipedia page on Medical billing procedures is this

In order to be clear on the payment of a medical billing claim, the health care provider or medical biller must have complete knowledge of different insurance plans that insurance companies are offering, and the laws and regulations that preside over them. Large insurance companies can have up to 15 different plans contracted with one provider. When providers agree to accept an insurance company’s plan, the contractual agreement includes many details including fee schedules which dictate what the insurance company will pay the provider for covered procedures and other rules such as timely filing guidelines.

Providers typically charge more for services than what has been negotiated by the doctor and the insurance company, so the expected payment from the insurance company for services is reduced. The amount that is paid by the insurance is known as an allowable amount. For example, although a psychiatrist may charge $80.00 for a medication management session, the insurance may only allow $50.00, so a $30 reduction would be assessed. This is called a "provider write off" or "contractual adjustment." After payment has been made a provider will typically receive an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) along with the payment from the insurance company that outlines these transactions.

The insurance payment is further reduced if the patient has a copay, deductible, or a coinsurance. If the patient in the previous example had a $5.00 copay, the doctor would be paid $45 by the insurance. The doctor is then responsible for collecting the out-of-pocket expense from the patient. If the patient had a $500.00 deductible, the contracted amount of $50 would not be paid by the insurance company. Instead, this amount would be the patient's responsibility to pay, and subsequent charges would also be the patient's responsibility, until his expenses totaled $500. At that point, the deductible is met, and the insurance would issue payment for future services.

A coinsurance is a percentage of the allowed amount that the patient must pay. It is most often applied to surgical and/or diagnostic procedures. Using the above example, a coinsurance of 20% would have the patient owing $10 and the insurance company owing $40.

In Medicare the physician can either be 'Participating' in which he will receive 80% of the allowable Medicare fee and 20% will be sent to the patient or can be 'Nonparticipating' in which the physician will receive 80% of the fee, and may bill patients for 15% or more on the scheduled amount. (emphasis mine)

I think this only scratches the surface of the problems with billing. Because large hospitals often write off uncollected bills, there is a desire to charge uninsured patients more, creating a win-win, in that if the patient does pay something, profit is taken, but if they don't thru bankruptcy, the hospital can claim that it is charity care, which is one reason why the majority of hospitals in the US are nonprofit (62% versus 18%).

I'd argue that this provides some reasons why the US is only covering 27% of the population with the same 6% of the GDP that gets 100% coverage in any other country.

[Bernard Yomtov]

Are you mistaking nurses filling out treatment paperwork for billing people?

If this is addressed to me, I don't think so.

My doctor's arrangement is complex, so I may have it wrong, but he is part of a 15-20 physician practice, who work in smaller groups of three. His small group has two receptionists who handle appointments, deal with referrals, pull the files of waiting patients, and pass billing information to a central accounting office. They probably do some other stuff as well, but are not nurses, technicians, or PA's.

[liberal japonicus]

Sorry, in my earlier post, I made a mistake when I said

After the age of 6, it is 30%

Actually, it is 70% that is paid by insurance, so the person is responsible for 30% of the bill.

[Bernard Yomtov]

Incidentally, the main point of my comment was not the administrative cost issue, but rather an attempt to suggest that the comparatively high cost of US government health programs, principally Medicare, may be due in part to the poor structure of the pre-Medicare system.

If your health care is spotty or nonexistent earlier in life, then it's going to cost more to take of you at age 65+ than if you had had decent care all along.

[kenB]

If your health care is spotty or nonexistent earlier in life, then it's going to cost more to take of you at age 65+ than if you had had decent care all along.

I wonder how true that is -- mightn't it be that good health just delays the big medical bills rather than avoiding them? Most people are going to get sick and die eventually, and there's no upper bound on age for Medicare coverage. Presumably the sooner you die, the less you cost the Medicare system.

[liberal japonicus]

Well, my benchmark is the Japanese system and Japan has the highest life expectancy.

Since I'm commenting, I thought I would pass on this article that discusses the Netherlands and France. It addresses the precise point of MM's claimed preference (albeit anecdotally, which is at least preferable to being solely inside of MM's head) with this

But in the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.

[Tony P.]

Presumably the sooner you die, the less you cost the Medicare system.

Maybe. But some things are counterintuitive. For instance:

Emergency-rooms are the most expensive way to deliver routine medical care, we are told. Presumably then, if people stop getting routine care in emergency rooms, "health care spending" will go down. But look: equipping and staffing an emergency room costs money whether it's constantly crowded or whether it mostly sits idle in between honest-to-god emergencies.

The firemen in my town spend most of their time getting paid to sit around and wait for fires. We can save money by closing down a firehouse, but not by having fewer fires. Likewise, emergency rooms are expensive because people and equipment have to be paid for, whether over-used or under-used.

The one time I've received care in an emergency room this millenium was a Sunday afternoon a couple of summers ago. It was for a horrendous case of poison ivy. My own doctor's weekend fill-in ordered me to go, over the phone. I would gladly (though perhaps unwisely) have waited til Monday morning to go to my doctor's office instead. But I went. The ER was empty. I was seen immediately, given a prescription, and sent on my way. The staff went back to doing whatever they had been doing to pass the time. For all I know three trauma cases came in simultaneously five minutes after I left; but also, for all I know, the place remained mostly idle the rest of the shift, and the only money that came into the place all afternoon was my co-pay and whatever my insurance kicked in.

If we were trying to score that episode in terms of "health care spending", what would be the correct accounting? The staff, the rent, the lights would have been part of that year's "health care spending" whether I'd come down with poison ivy or not. The money to pay for those things would have come out of my (and my neighbors') pockets in the form of insurance premiums and taxes anyway. At the margin, my co-pay reduced those costs a tiny bit for everyone else, next year.

So the intuitive proposition that using the ER necessarily and/or always raises cost for eveybody else seems a bit less intuitive on closer scrutiny.

Likewise, I hesitate at least a little to agree with kenB's "presumably".

--TP

[Hartmut]

The persons in the doctor's office that are neither the doctor(s) nor the patients tend in my experience to do everything, drawing lab samples, administer vaccinations, do the reception, type the prescriptions and the reports (although most is done now by using specialised software instead of ye olde typewriter). That those persons do not do at least some reception work even if they are e.g x-ray (equipment) specialists is in my experience a rarity (even at the hospital level).

[Bernard Yomtov]

KenB,

Well, the way to find out is to do some reasonable comparisons, across countries, or maybe groups in the US.

Still, I'm dubious. For one thing, just having information helps. You have a better chance of avoiding diabetes, for example, if you know you're at risk.

Also, early detection is generally a good thing, and makes some treatments much more effective. If you have a number of mysterious symptoms you might feel that they are likely harmless, until you're under Medicare.

Finally, if, at age 60, you have a non-life-threatening condition that still needs treatment you might well decide to wait to take care of it, whereas you wouldn't if you had good private insurance.

[kenB]

Yes, I can see arguments on both sides. A study would be interesting, at least within the US -- I think the different health care arrangements and cultures across countries would make cost comparisons problematic.

But it does occur to me that Medicare is absolutely affected by the commercial market here in that Medicare reimbursement rates are based on market costs. A big question with single payer in the US is how pricing would be handled after you've eliminated the biggest commercial market.

[Anarch]

First, billing is an incredibly, incredibly difficult task in the US. I work for a major HIT firm and I'd guesstimate that around between a third and a quarter of our company works on billing-related issues, depending on how broadly you define them.

Second, to Tony P above: while there's certainly a measure of sunk cost in the existence of ER treatments, that's not where the real expense comes in. The real expense is for things like emergency MRIs, "crisis medications" -- I forget the actual term, but it's things you give the patient if they need to be stabilized stat -- monitoring equipment and the like. IIRC, a heavily trafficked ER is going to generate tens to hundreds of thousands more dollars per day in medical costs/revenue than a nearly empty one.

[Gary Farber]

"the ER was empty."

This is extremely unusual in any urban area. I've been to ERs quite a few times, and the only times I ever had to wait under four to six hours was once in NYC when I had a kidney stone, and once Boulder, CO for pneumonia. Broken bones and a concussion took about five hours in NYC, and two experience here in Raleigh, once for a foot with a bone chip break, and once for a mere severe toothache, took about five-plus hours.

And there was once in Seattle in 1986, but one of my symptoms at the time was lack of time sense, so my testimony on that would be unreliable.

Raleigh's WakeMed, the largest hospital and ER in the region, has a huge waiting room, and signs all over explaining that you may need to wait several hours due to the urgency of care, and how you're triaged, etc.

[Gary Farber]

Oh, and if you're in NYC and have a choice, although my experience was decades ago, I do not recommend the Bellevue ER unless you want to see a lot of extreme drama while waiting your many hours.

[Gary Farber]

Actual facts: it helps to be in a non-big city; it also depends on what time you come in.

Summary:

[...] The annual number of emergency department visits jumped from 90.3 million in 1996 to more than 119 million in 2006, a 32 percent increase. At the same time, the percentage of nonobstetric hospital admissions that came through emergency departments climbed from 36 percent in 1996 to 50 percent in 2006, according to the study, which is based on various components of the CDC's National Center for Health Statistics' National Health Care Survey.

[...]

The study does not address reasons for the increases in ER use, but the findings strongly suggest that the growing use of emergency departments is directly related to the shortage of primary care physicians.

[...]

The study also reached the following conclusions.

* Patients with Medicaid use the emergency department more frequently than patients with private insurance -- 82 per 100 persons for Medicaid compared with 21 per 100 for private insurance. Medicaid patients have a harder time finding physicians who will treat them than do patients with private insurance, which accounts for the disparities in ER visits, Pitts said.
* The average waiting time to see a physician in the emergency department was 56 minutes.
* The rate of visits per 100 persons was about 36 percent for whites compared with nearly 80 percent for blacks, a fact that Pitts attributed to many blacks' lower socioeconomic status and, consequently, their decreased access to physicians outside of ERs. Cultural factors also could play a role in discouraging blacks from seeking care from places other than ERs, Pitts said.
* The rate of visits per 100 persons for Hispanics was about 35 percent, lower than the rate for whites. Pitts said this statistic could be a result of language and cultural barriers that make Hispanics less likely to report their visits to ERs.
* Most ER visits occurred after normal business hours -- 8 a.m. to 5 p.m. on weekdays -- when 63 percent of adults and 73 percent of children younger than 15 came in.

[Crissa]

The whole point of there not being a market is so that there isn't a profit motive to steal.

Ugh.

Cadaver parts should be labeled, unlabeled parts should be destroyed, and they should never be sold, just transported.

At no point would an open market alleviate the problem of people stealing bribing or otherwise scheming to get theirs now while others have to wait.