In re: Britons travelling abroad for health care. UHC, or single payer, or whatever you want to call it, advocates are promising that we can have awesome health care at lower cost by switching to their model. No tradeoffs! Rationing is just a lie by conservative health care opponents who hate poor people! Look at Europe!
If this were actually true, the number of Europeans seeking health care abroad, other than cosmetic procedures, should be zero. If the health care is really every bit as good as what's available on the private market, they shouldn't turn to the private market. Americans seeking lower-cost health care abroad does not invalidate the market model; seeking lower cost alternatives through trade is a venerable free-market tradition. On the other hand, Europeans paying their own hard-earned cash in order to exit a system which allegedly provides exactly the same thing, for free, poses a problem for national health care advocates.
"If this were actually true, the number of Europeans seeking health care abroad, other than cosmetic procedures, should be zero."
Really? Are there actually serious folks arguing seriously that moving the US to single-payer would make absolutely EVERYONE better off? Examples?
This is quibbling. Where's the single payer advocate who admits that his system will involve hundreds of thousands of people paying into the system, and then paying again to seek timely medical care abroad?
WTF? You knock down the world's most brittle straw man, and when someone points out you are responding to an argument nobody has made, declare that fact as "quibbling"??????
Also, just to show how straw your strawman actually is - the same arguments you could make apply equally to a number of African nations that have, to one level or another, socialized their health care. Hey, all you would need to do to destroy the argument for universal health care, then, would be to find one wealthy guy in Nigeria who got his health care elsewhere, right?
http://en.wikipedia.org/wiki/Health_care_in_Nigeria
The two "Let me put this another way" posts can be tied together. The way that nationalized healthcare systems 'save' money is by holding workers' salaries down.
In France a MD with 10 years of experience can be paid as little as $60K. That is about what a US high school teacher with a PhD & 10 years of experience would paid in many districts - for 10 months of work.
We are constantly told that one of the biggest problems that we face in education is that the salaries paid are too low to attract high quality talent.
Would anyone what to go under the knife wielded by someone jealous of the high pay that public school teachers get?
Oh, I see . . . so what you're saying is that in your version of national health care, hundreds of thousands of Americans will seek treatment abroad? Because if not, that's not exactly a "straw man".
On the Africa thing . . . I'm puzzled how Africa got in here. But okay, I'll be the first to step up and say it: I don't want any African nation's healthcare system, and I don't want it even if not one single citizen of that country seeks healthcare abroad.
Really? Are there actually serious folks arguing seriously that moving the US to single-payer would make absolutely EVERYONE better off?
Good. So let's get started with figuring out WHO exactly will the proposed change make worse off. I've had a nagging suspicion it would be me and my family since I first heard the whole scheme mentioned.
Gee whiz, maybe you should go back to ranting about Comfort Inn. You gave that pages of discussion. However, the subject of national health care apparently merits only the flippant dissection of non-existent starw men opinions.
As has been discussed before, the issue on national health care strategies is NOT whether other factors, such as life style, can significantly affect health. It is NOT whether there is some other "perfect" system where everyone will live "forever" at no significant cost.
Those are stories for children --perhaps the type of children who spend pages ranting about their experiences at a hotel.
The REAL question is whether there is a national health care strategy that will produce better overall health benchmark results for the population at large than one that consumes around 24% of GDP while leaving 15% of the population to be treated in emergency rooms, all other factors being the same. Arguably, it would be fair to investigate whether earlier life style interventions associated with other strategies would, in fact, have overall positive impact on lifestyle choices.
Benchmark results would include whatever reasonable group of empirical measures could be agreed upon -- including infant mortality, life expectancy, days lost from work due to sickness, or whatever.
This issue is by no means completely "settled", and merits serious investigation. However, these hysterical rants of Megan's do nothing to resolve the issue.
Good point, Megan. When you have the time, it would be fun to see you address Ezra's other post today related to this topic. It's a graph showing the inevitable rise of Medicare costs. Klein says that the way to stop the rise in costs is a single-payer plan. It seems to me that Medicare is already basically a single-payer plan. As Medicare already pays up to 70% less than private insurance for physicians, procedures and hospitalizations, I wonder where he thinks all these "savings" are going to come from.
(In my area, all of the hospitals are already non-profit operations, so I am also wondering how they can be further squeezed.)
Megan,
It's increasingly difficult to argue with someone who has no desire to engage in a good faith argument. Your original position is "there's this argument out there that says there will be no rationing or tradeoffs, at all, in a universal health care system! And it isn't true, because England has universal health care, and > 1 English person left England to get treatment!"
But that's absurd, because
a) nobody's arguing what you claim is the argument your entire post is set up to defeat
b) England has one of the less efficient, and least-funded UHC system in the world.
You might as well argue that Nigeria, a country with an even worse run, less funded system, should be held to the same requirements - if it doesn't work perfectly, it is a complete and crushing blow to efficiency arguments of universal health care It is a stupid argument, of course - but no stupider than your already stupid argument.
Now that this has been shown, you move goalposts, and make also easily-refuted arguments. You argue that perhaps hundreds of thousands of Americans will go abroad for health care if the system is made universal. This, of course, would still lead (as Ezra has shown) in a DROP of the number of people who go abroad. Whether it is true and to what extent depends on how efficient and how well funded the system is. But I don't WANT to get into a discussion over this with you, because YOU ARENT GOING TO RESPOND IN GOOD FAITH. Instead you are just going to do what you always do: move the goalposts, say something stupid, and try to cover it up by being haughty about it.
OK, Justin, I'll stipulate England is a lousy example. Please explain to me how Medicare costs will be successfully contained under a new universal single-payer arrangement.
Isn't the NHS a terrible example for these purposes?
The UK has both a tax-supported national health care system and a parallel private-sector system. In recent years the NHS has been encouraged to outsource services to private-sector companies. In many cases, this costs more than public-sector service, which means the same government budget is paying for less health care, leading to shortages.
Furthermore, since the UK has a combined system, they're basically acknowledging upfront that their government system won't be covering everything. UK medical tourists aren't "fleeing" national health care; they're choosing foreign private-sector health care over domestic private-sector health care.
Sigh. Britain is not the only country in Europe that sends medical tourists abroad, Justin; it's just the only country in Europe that writes about the phenomenon in English.
50,000 is a lot greater than one--and, by the way, since the survey was less than comprehensive, the true number is undoubtedly higher--it's the equivalent of 250,000 Americans going abroad for non-cosmetic treatment each year. Which, for all I know, may be the number of Americans who do so. But I don't want to pay high taxes for universal coverage, and then not have universal coverage.
My point is proven.
For those who care (ie not Megan) the number of Americans getting medical care abroad has been, afaict, most recently estimated at half a million per year as of last year.
http://www.usatoday.com/news/health/2006-11-02-health-overseas_x.htm
The key word being "estimated", Justin. It's a black number, thrown around by various groups with varying agendas on, at least as far as I can tell, extremely poor evidence.
Tim Connor,
As has been discussed before, the issue on national health care strategies is NOT whether other factors, such as life style, can significantly affect health.
It is most definitely an issue when people keep citing aggregate health stats like average life expectancy and infant mortality rate as evidence for the alleged superiority of other nations' health care systems. Proponents of "universal health care" and "single-payer health care" make this nonsensical argument all the time.
The REAL question is whether there is a national health care strategy that will produce better overall health benchmark results for the population at large than one that consumes around 24% of GDP ...
Good grief. Whose health care system consumes 24% of GDP?
Avram, every system is mixed except Canada and North Korea, where it's illegal to seek treatment outside the system. The degree of exit is a pretty good testimony to the quality of the care, but every system has some exit--except the US, where there's no comprehensive public system to exit.
you're right, you are acting about 12 today.
"oooh, look! English people travel out of their country for medical service!" doesn't say much of anything except that England may be a poor model for developing a better system of delivering health care.
Note: may be. If English people are leaving largely for vanity treatments because their tax dollars deliver barely adequate care at very low cost, that doesn't necessarily sound like a bad system.
Here's something you virtually never talk about: cruelty.
How cruel is the US system? How many people suffer needless pain or are driven into financial disaster because of our system? How many people stay in jobs they loathe because they cannot afford to lose their coverage? How many kids are starting with a strike against them because their mothers aren't getting proper pre-natal and early post-natal care?
Let's stack up the cruelty of the US system against other countries before making snide remarks about the wealthy traveling for better service. No one disputes that the US is a great place to get sick if you've got lots of money; it's the rest of us that wonder about the system.
Francis, if your system classifies cataract surgery, dentistry, hip replacements, and heart bypasses as "vanity surgery", then I'm definitely not on board.
Okay, Francis, why don't you present your analysis of the comparative cruelty of different nations' health care systems showing that the U.S. system is more cruel.
Bear in mind that you'll need to factor in all the suffering people endure in, say, Canada and Britain while they're on a waiting list for hip replacement surgery or whatever else it might be.
How many people stay in jobs they loathe because they cannot afford to lose their coverage?
This has got to be a strawman. You leave your job, you have an 18-month COBRA coverage (yes you pay what your employer used to pay, so?). If you positively can't find a job equivalent to the one you loathed, in 18 months, you probably are not looking for one. You must have loathed your occupation rather than particular job. Tough cookies. I can think of quite a few things I'd rather do than write [boring, really] software. None of them pay nearly as much. Including writing other software that I don't find boring ;)
If the issue is that it is much harder to get health insurance as a free agent than as an employee, I'm with you. Ending the special tax status of employer-provided insurance has got to help with this, no?
Megan,
Do what Mankiw did and get rid of comments. These people are just rude. It's like you try to have an interesting cocktail party, but the same loud rude people keep coming in, being rude. That's why good parties have an invite list.
Do it. Get rid of comments. The rude end up monopolizing the comments and no good comes out of the discussion.
And I'll repeat my previous question: WHO will be worse off with the proposed universal healthcare system? Any rule of thumb? Age, income level, family size, familial health history, race maybe? Under "worse off" I include both having to pay more for the same level of service, directly or indirectly, and not being able to obtain the level of service available now.
Megan McArdle writes:
The survey was an industry-sponsored survey of the healthcare-tourism industry which almost certainly means that it exaggerates the size of the market - as Megan McArdle MBA should understand. Yet she claims the opposite is "undoubtedly" true without, of course, providing any evidence.
Sigh. Britain is not the only country in Europe that sends medical tourists abroad, Justin; it's just the only country in Europe that writes about the phenomenon in English.
Well, you read French. Where are the articles about French medical tourists? I suppose they exist, but I haven't actually encountered them, and my son was treated at Bumrungrad. I understand a fair number of Aussies go there, but the ones I've read about have gone for sex change operations and laser eye surgery.
On the "medical tourism should be zero" claim: you obviously recognize that even if major medical procedures were high-quality and easily available in systems providing universal insurance, there would still be SOME medical tourism by people who simply preferred care elsewhere. Bumrungrad attracts sex change candidates not just because it's cheap, but because it's one of the most experienced hospitals in the world at that operation. There's an OB/GYN at a hospital in Singapore who has the world's best record on CVS procedures. As long as these procedures are affordable, some people will seek them out, and obviously if they're paying out of pocket the price will be a factor sending them to South/East Asia or Eastern Europe. (Also, some people's health insurance plans may cover international treatment, and might themselves save money by sending clients abroad.)
I am all in favor in getting rid of comments. Since the free market is worshiped here, I am also entitled to be in favor of getting rid of Megan, since my subscription dollars, in tiny part, pay for this ad.
A multi-page rant on Comfort Inn, but only snide sentences on health care? Good grief.
At this time, only Fallows outweighs the presence of this drivel.
Update: doing a little Googling of "tourisme medical francais", but all I've come up with so far are stories about medical tourism TO France, and one piece which notes that the term "tourisme medical" is shocking to the French because it conjures the slogan "medical treatment is not a product" and the specter of the "Polish plumber". Apparently some French people go to Tunisia for complex orthodontal work that's not covered by French insurance, and a guy who went to Spain because a hospital there had greater expertise in his rare disease sued the French government in the EU court system when it refused to reimburse his treatment. He lost. None of this seems to speak to the issues at hand, and it all suggests there's little French medical tourism abroad. That may of course reflect greater French mistrust of foreign care and lower fluency in English, the international language of medicine, which would make one less comfortable seeking care in India or Thailand.
By the way, mixner is, unusually, absolutely right. Commonly accepted numbers for current health care spending are about 15%. Many projections suggest it will reach about 20% by 2016 --as things stand.
I still believe that rates more empiricism than snideness, and way more detail than M.M.'s travails in a hotel.
Oh, incidentally, this:
UHC, or single payer, or whatever you want to call it,
is not fair. Universal health care, a la the NHS, means docs all work for the government. Single payer, a la Canada, means there is no private health insurance. A different form of single payer, a la France, means there are private insurers, but they're obliged to join a single payment authority and aren't allowed to refuse to pay for treatment ordered by a doctor. And then there's non-single-payer universal health insurance, like the Netherlands, which includes a buyer mandate. These are all very different. If you want a single term that covers all of what universal health insurance advocates want, you have to say "universal health insurance". It's unfair to imply these are just semantic distinctions which are being imposed for PC reasons, like "differently abled" or whatever. You wouldn't accept it if I were to say "libertarians, or neocons, or whatever they want to call themselves".
It's increasingly difficult to argue with someone who has no desire to engage in a good faith argument.
Yes, and that's why there's no point in trying to engage the single-payer fanatics. The rational thing to do is just snark at them, because being snide is fun, while refuting the same bullshit day in and day out is mere drudgery.
For example, they might try to pretend death by violence has anything to do with whether a place has single-payer health care or not, by talking about life expectancy.
Or they could push forward the idea that Britons seeking basic dental care simply prefer Bulgarian dentists, by making an analogy to procedures where people seek out best-in-the-world specialists because of life-and-death risk, or risk of a complete loss of the ability to orgasm.
Or they could pretend that there is are such thing as reliable health care statistics when it comes to self-reporting from a totalitarian state.
You can point out the defects of the Canadian system or the VA system or Medicare or Medicaid or TennCare or the British NHS, and show how they're structural difficulties imposed by the very nature of economics. They'll go on demand you show the problems in the French system, because apparently there's some way to magically suspend the laws of economics in France, and anyway how things work out in France is a better predictor for how they'll work in the U.S. than partial plans in the U.S. and full plans in countries with more similarities to the U.S.
And eventually, you realize it's as pointless as trying to convince a Creationist about the merits of evolution. People have a belief that gives them comfort, and they won't let you shake it. Because, just as the idea that we're a random accident of blind natural forces is scary, so too is the idea that health should be left to lasseiz-faire, the blind workings of economic forces.
Lunatic,
The reason most universal health insurance plans proposed for the US are more similar to the French or Dutch systems than to the British or Canadian ones is that the British and Canadian systems have no place for private insurers. Because of the political might of the US insurance industry, and because Americans currently covered by private insurers are nervous about the implications of a shift to national care, the transition to a Canadian or British system would be impractical in the US. If you are unable to describe the problems with French or Dutch care, that probably has to do with one of two things: first, you haven't done much research on those systems and don't understand them; two, those systems actually don't have very many problems, and the problems they do have are similar to those in the US, because the systems themselves are similar to the American system, except for a few fixes which ensure universal coverage and seem to hold costs down dramatically.
The "belief that gives comfort" to advocates of universal health care is that every other advanced economy in the world has it, and it is in every case dramatically cheaper. This belief is hard to dislodge because, like the evidence for the theory of evolution, it is true.
because Americans currently covered by private insurers are nervous about the implications of a shift to national care
And I posit that the nervousness is well founded: many of them are liable to suffer increased costs, degradation of service quality or both. Are you going to engage this topic?
There's an article in the Oct. 30 New York Times about the Dutch and Swiss national health systems. According to the article, Secretary Leavitt is interested in learning more about them, but only for informational purposes. The system currently in effect in Massachusetts and Arnold Schwarznegger's health care proposal in California are similar to the Dutch and Swiss systems. So are the plans proposed by Senators Clinton, Edwards, and Obama. These are not single player systems, and they allow workers and retirees who get medical insurance through their employers to keep it.
I imagine Megan is opposed to a national health care plan of this type. I wonder if anybody in her camp can explain why.
These are not single player systems, and they allow workers and retirees who get medical insurance through their employers to keep it.
Without a change in cost of their coverage and level of taxation?
And that doesn't even begin to address the potential reductions in R&D spending by the industry.
Until someone tells me what they're going abroad *for*, I don't care.
"Rationing" is one of those words people use to stack the deck. It's rationing if done by the government, but something else (that doesn't even have a word, because it's considered natural, like the weather) if done by differential access to money. Anyone advocate of single-payer who engages the argument on those unfavorable terms will be trounced.
It's rationing if done by the government, but something else (that doesn't even have a word, because it's considered natural, like the weather) if done by differential access to money.
Everything else works the same way. If these terms are unvaforable, you must be a socialist.
Max, I don't see why a Massachusetts type health plan would affect the coverage offered by employers. Employers provide medical benefits as a recruiting tool, and they will continue to do so if it is in their interest. If they feel it isn't, they'll discontinue medical benefits whether or not the US adopts a universal coverage plan. Regarding the other part of your post, obviously insuring the uninsured will cost money, and this money will have to come from some combination of private and corporate taxes. If this is your objection to the type of plan I'm talking about, I understand it and to some extent I share it. On balance, I think insuring as many people as possible is worth the cost if people with good insurance through their employers can keep it.
So short version is: I will be paying more taxes and maybe (or maybe not: value of the employer-provided policy is sure to go down in the new environment and the cost may well stay the same or even increase with contraction of the pool) will be able to keep my current coverage. Thank you.
Max, despite what you say, I can't see why your existing coverage would be affected. Business executives don't make their decisions about employee benefits on altruistic grounds. They'll keep their insurance benefits if doing so is in their interest. Re taxes, you're right. I'm sure they'd go up if a Massachusetts type plan is enacted. If that's how you decide public policy, I can't argue with you.
brooksfoe,
If you are unable to describe the problems with French or Dutch care, that probably has to do with one of two things: first, you haven't done much research on those systems and don't understand them; two, those systems actually don't have very many problems,
Er, the French health care system is going bankrupt.
Tell us about the Dutch system. Is this now your proposed model for the U.S.? It keeps changing. First, it was Canada and Britain. Then France and Germany. Is it now the Netherlands? And when we find serious problems in that system, will it change to something else?
How do you remove the profit from the medical industry without strangling innovation?
I worked for a medical device company. They were developing an innovative product that improved quality of life, but was not life saving. The only market that justified this product was the US market. This doesn't mean the Europeans wouldn't get access to it (and get it earlier. CE Mark is substantially easier to obtain than FDA approval). But the nature of European health care funding meant that there was insufficient profitability in those markets alone to justify the development effort, only the US market did.
And the nature of technology is such that while the product surely starts out expensive, it should become cheaper and better in time. So sure, only the rich can afford it initially, but in 10-15 years, the goal was to become generally accessible.
Any system that kills the goose laying the golden egg (and France definitely qualifies) ought to be a non-starter. I support providing some basic level of universal health care for people who can't afford it, but I'm still hoping for devices, drugs and therapies unimaginable today to be commonplace when I'm elderly; all of the UHC plans I hear would kill innovation. They would also increase human suffering on an inter-generational timescale.
The effect on businesses and individuals is more complicated in mechanism, but quite simple in ultimate effect. As Max points out, if their insured pool shrinks, corporate costs per insured may rise. This will be passed on, in one way or another.
In my case part of this is explicit. Employees at my firm pay a portion of their insurance expense based on a progressive schedule. My premium will be up 7% in 2008. Currently I'm paying a few hundred per paycheck for my package of health and disability (family of 5, NYC). If it goes up, my deductions increase.
When and if the firm absorbs it without a payroll deduction, it is ultimately passed on in higher prices, so the consumer pays it (as with a tax increase). If the firm stops providing it, the taxpayers will take it on (under universal insurance). The only thing you can be sure of is that enterprise will not step up and accept a lower return on capital because universal insurance exists.
So, any increased costs, or savings, are passed on to taxpayers/consumers, no matter how you slice it.
This is a long-winded way of saying Max is on the right track. Any realized savings or costs of additional insureds will almost entirely arise within the following (especially to the extent this is a Baumol's cost situation):
Of the above, it seems services provided and provider pay are the dominant uses of funds and taxpayer/consumer funding is the dominant source of funds in a more universal model.
It is possible some productivity and preventive care savings will be netted against the above, but I wonder if those will even be significant. As Stan concedes, there probably is no free lunch here.
Dare I say, there is no Laffer Curve of healthcare efficiency with government involvement on one axis and taxpayer costs on the other?
If that's how you decide public policy, I can't argue with you.
Now make the results of this discussion part of the poll question and see how many Americans will support the universal coverage. Yes, I decide public policy on the basis of cost vs. benefit analysis. Hopefully the majority of the people are rational and do that too. It is just that many of them do not get a chance to continue the inference chain all the way to the voting booth... if they did, the two major parties would cease to be major, I imagine.
P.S. It seems like it's difficult for some commenters to understand the difference between -
1) Someone who has healthcare available at zero incremental cost going somewhere else to obtain it at a substantial incremental cost
and
2) Someone who will bear the incremental cost either way is shopping around internationally.
The other thing you have to take into account either way is the possibility that regulations/laws/legal liability may favor one sort of procedure over another in different countries (e.g. sex change, euthanasia, conception, non-traditional medicine).
Either way, someone abandoning a zero-cost option for a high cost option is revealing much stronger preferences than someone who is comparison shopping among costly options.
Max, I learned during my stay in the Netherlands that the majority of Dutch citizens below retirement age read and speak English and are reasonably familiar with political developments in the United States. Despite this, I see no political party in the Netherlands in favor of scrapping their universal coverage plan and going over to a purely private system. The same is true of the residents of Singapore, of Great Britain, Canada, Israel, and you name it. If our system is so great, why don't these countries like it? Are they brainwashed? Is there some socialist bug that affects everybody except the few Americans who agree with you? Please advise.
Mixner,
I support both the French and Dutch systems. You have in the main been above the sort of lamebrained "the French system is going bankrupt" attack you launch here. This is a tedious and inaccurate conservative talking point, distributed en masse through right-wing websites. It is based in misuse of some political rhetoric surrounding a conflict over funding of the French system which occurred in 2004. The funding problems were resolved. One measure which was taken was to introduce a copay for doctors' visits, which had been entirely free. The copay introduced was about 1 euro. The fixes needed to keep the French system from going bankrupt are piddling compared to those needed to keep the US's system from going bankrupt.
The French will not allow their system to go bankrupt; if problems are encountered, funding will be reformed or increased. French health spending consumes about 11% of GNP, compared to the US's 15% and rising. If there is anyone who needs to worry about bankruptcy, it is us.