One way to think about health care

Tyler Cowen suggests a number of ways to think about health care spending; more on that later. But here's a metric we might use to compare our various policy options. According to a study that even the New Republic's Jon Cohn admitted he thought was probably exaggerated, being uninsured killed 18,000 people a year this decade. Methicillin-resistant Staphylococcus aureus, on the other hand, apparently kills 19,000 a year.

MRSA is the result of inadequate hygiene in hospitals, and indiscriminate use of antibiotics. Doctors and other medical workers have gotten lazier about hygiene since the invention of antibiotics, in line with other sorts of risk-taking behavior (more than one wag has suggested that the best way to eliminate auto accidents would be to mount a spear on the steering wheel pointed straight at the driver's heart.) They also prescribe antibiotics even when they are not clearly indicated, "just in case" . . . or worse, when they know they won't do any good, but want to get an ignorant and demanding patient out of their office. Third place for blame must, of course, go to the patients who do not finish taking their drug courses, which allows partially resistant bugs to survive and eventually breed highly resistant bugs . . . and what with my awful memory, you can put me in the dock along with almost everyone else.

MRSA is just one of the infections that are thriving in this environment. What would be the cost of a war on infection in hospitals? One suspects it would be a lot less than insuring 44 million people.

This might be one of the items that Tyler suggests libertarians should think about. There's a clear public health cause here, as with vaccines; doctors who prescribe indiscriminately, or people who don't take all their pills, are in fact placing a substantial burden on the rest of the public.

Non libertarians can, of course, go along wishing that we would have national health care and a War on Infection. But it's worth asking yourself: in a world of scarce resources, where you could only have one, which would you choose? And by what principle?

Comments

Defining the costs of the lack of health care for 49 million Americans, and the underinsured status of countless more, soley by an estimate of deaths directly attributed to that lack is deeply unsatisfactory.

Posted by Freddie | October 16, 2007 7:42 PM

Wow, yet another utterly disconnected health care post.

Battling MRSA requires (a) an active program of getting health care workers to wash their hands; and (b) reminding physicians to stop overprescribing antibiotics. (There's probably some work to do in regulating feedlots as well.)

More generally, battling MRSA belongs in a much larger category of reducing medical errors. Much as airline pilots, over great resistance, were forced to develop cockpit management systems, so does the hospital industry.

Total cost: Financially, probably relatively minimal. Bureaucratically, quite high.

Providing access to primary care to those who are currently only getting emergency care is almost, but not quite, entirely unlike the problem of reducing medical error. (hat tip to the first person to get the reference.) While there may be a reduction in the rate of increase in costs after several years, there will need to be an immense effort made to train an army of primary doctors and get them into the communities where they're needed.

Please, stop reading Lomborg. Malaria and global warming are both serious problems. There is simply no reason whatsoever to pit them off against each other. This is even more the case where the solutions to the two problems require different commitments.

Posted by Francis | October 16, 2007 8:03 PM

The Dutch already fight a war on MRSA with the term "search and destroy", basically searching for and isolating MRSA patients. The US would do well to follow suit, however difficult it may be.

Posted by Klug | October 16, 2007 8:08 PM

What is strange about MRSA is that this is actually a really good example of where regulation is probably needed as it is a classic commons dilemma (or at least the overuse of antibiotics is). It is to my personal benefit to be treated with the most effective possible drug -- my contribution to antibiotic resistance due to a single course of drugs is unmeasurable and I derive benefit from fewer sick days and feeling better.

However, if everyone acts this way then the collective effect of our actions is to make these drugs eventually stop working for anyone. This is a drop in overall utility for everyone and not a happy scenario.

Antibiotic resistance appears to grow fastest with the freest markets in strong antibiotics.

Posted by Joseph Delaney | October 16, 2007 8:25 PM

Providing access to primary care to those who are currently only getting emergency care is almost, but not quite, entirely unlike the problem of reducing medical error. (hat tip to the first person to get the reference.)

Douglas Adams, The Hitchhiker's Guide to the Galaxy, regarding the tea substitute dispensed by the Nutrimatic aboard the Heart of Gold.

However, I think you're missing the point, which is not that one must always make tradeoffs. Your comment that two things "require different commitments" is almost entirely irrelevant. The idea that since two things are quite different, they automatically are not opposed to each other is a fallacy. Every single choice is opposed to each other. TANSTAAFL. Now, of course one may believe that both of these, in the universe of options, are both sufficiently superior to other ones as to be taken.

I still think that the point of merely observing the relative seriousness of the two cases is interesting, merely because it's a case where the public attention and rhetoric tends to be badly mistaken on relative risks. In particular, resistant diseases have a much greater chance of getting catastrophically worse than the deaths causes currently by lack of insurance (a property shared with things like global warming.)

Posted by John Thacker | October 16, 2007 8:49 PM

Since single payer healthcare costs less than the US healthcare system, we can use the savings to battle mrsa.

Posted by joeo | October 16, 2007 9:10 PM

The Dutch screen all high risk patients admitted to hospital. High risk includes the elderly, HIV, people on immunosuppressive drugs and AMERICANS. The last catgory should shame us.

Posted by pshrink | October 16, 2007 9:12 PM

see:
http://clusty.com/search?input-form=clusty-simple&v%3Asources=webplus&query=MRSA+Hydrogen+Peroxide

simple Hydrogen Peroxide vapor is showing highly positive results in battling MRSA in Hospital settings.

note, H2O2 goes for ~1 U$D/Quart (retail)

Certainly this aspect does not necessarily address Dr. Goodbar and his scrip pad, nor his impatient Patients.

Posted by Mark E Hoffer | October 16, 2007 10:08 PM

There are two problems with this argument:

1) While I haven't seen the study, I doubt that anyone can credibly estimate the "death toll" of being uninsured. This is probably some weird extrapolation off the RAND Health Insurance Experiment, or something, and probably doesn't have sufficient out of sample validity to demonstrate a system-wide effect.

2) The benefits of a different health care system are not confined to deaths. Not least, we should probably be using something like quality adjusted years -- which proponents of changes to the health care system would argue would result from a different system.

Posted by Isaac | October 16, 2007 10:13 PM

Megan,

Would it be too much to ask you to refrain from references to the cost of "not being insured" - at least without the scare quotes? The relevant fact is the presence or absence of the ability to pay the medical bill or to get someone else to pay it, not the presence or absence of "insurance," especially since almost all of what we call "health insurance" isn't really insurance at all.

Insurance = voluntary risk pool to convert expected losses from unlikely but catastrophically large to certain but manageably small.

Ken

Posted by Kenneth A. Regas | October 16, 2007 11:41 PM

Defining the costs of the lack of health care for 49 million Americans, and the underinsured status of countless more, soley by an estimate of deaths directly attributed to that lack is deeply unsatisfactory.

Can we stop including illegal immigrants in the category of "Americans" already? It might make for a more honest discussion of what sort of people's medical expenses actual Americans would be expected to pick up the tab for under socialized health care.

Posted by tommy | October 17, 2007 2:32 AM

"Can we stop including illegal immigrants in the category of "Americans" already?"

Absolutely! I also suggest we reduce that number by the count of those who can afford insurance, but choose not to carry it.

The real number appears tp be closer to 15-20 Million.

Posted by Tom | October 17, 2007 10:48 AM

Megan: it makes no sense to compare deaths due to lack of insurance to deaths due to MRSA. The reason is simple. It is within the US's power to reduce the number of deaths due to lack of insurance to 0 -- simply adopt universal health insurance, like any other advanced economy. By contrast, we do not have the power to reduce the number of deaths due to MRSA to 0. We can probably make a significant dent, with drastic measures like a major centralization of the US's public health system. (You know, the sort of thing you'd get if you had universal health insurance.) But ultimately, resistant disease strains are an inevitable result of the use of antibiotics; they can be minimized by not eliminated. Lack of health insurance, by contrast, is not an inevitable result of anything but corporate greed.

Posted by brooksfoe | October 17, 2007 12:04 PM

"Can we stop including illegal immigrants in the category of "Americans" already?"

Absolutely! I also suggest we reduce that number by the count of those who can afford insurance, but choose not to carry it.

The real number appears tp be closer to 15-20 Million.

I’d be curious to see how many of the “uninsured” are eligible for Medicaid but just haven’t enrolled yet.

Posted by Thorley Winston | October 17, 2007 12:15 PM

Two bigger problems than docs prescribing antibiotics (though I agree its a problem).

1. Antibacterial soaps. They serve no purpose. Use ethanol based disinfectants. When everything out there has an antibiotic (they can embed in plastics now), resistance is sure to follow.

2. Prophylactic use of antibiotics in agriculture. They just dump it in the food. Half of antibiotic use in the US is in agriculture. Its illegal in Europe, and they still manage to grow food. Bacteria that become resistant to antibiotics in people can transfer that resistance to human strains or infect humans directly.

Posted by Alejandro Gonzalez | October 17, 2007 12:24 PM

How about some real information on the "causes" of MRSA?

Re: triclosan soap

"Antibacterial product use did not lead to a significant increase in antimicrobial drug resistance after 1 year... nor did it have an effect on bacterial susceptibility to triclosan"
-Aiello, et al. Emerg Infect Dis. 2005 Oct 11.(10):1565-70

Re: feedlot antibiotics

"Researchers believe that MRSA initially arose because of selection pressure resulting from antibiotic use and misuse in hospitals. Issues with continuing antibacterial stewardship, poor infection control, and the increasing severity of illness in hospitalized patients have contributed to the recent explosion in the prevalence of MRSA. Similar selection pressures due to physician behavior (e.g., inappropriate use of antibiotics and failure to follow hospital infection control policies) have contributed to the emergence and spread of community-associated MRSA (CA-MRSA)"
-Moran, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006; 355:666–74.

Posted by Mark Mogler | October 17, 2007 1:41 PM

Point 1:
Triclosan attacks the same targets as Diazaborine and Isoniazid. If you are selecting for bacteria with Triclosan resistance (which you with antibacterial soaps), bacteria may also become resistant to others that target that disease.

Plus, there's no demonstrable benefit to using just regular soap (or ethanol based washes). The American Medical Association has opposed the routine use of antibacterial soaps since 2002.

Point 2:
I'm not disputing that MRSA arose in hospitals. I was making a more general point.

The AMA has supported restrictions on antibiotic use in agriculture since 2001.

Posted by Alejandro Gonzalez | October 17, 2007 2:19 PM

I should not have used the word bigger in my original post. I should have used "other potential."

Posted by Alejandro Gonzalez | October 17, 2007 2:21 PM

If there ever was a reason to give only doctors the power to allow use of non-lethal drugs (instead of having everything over the counter) it was about antibiotics because of the tragedy of the commons problem.

It didn't work.

**

MSRA is, for once, a real public health problem and not a private health issue that affects a lot of people. Thus, the mandate of the state is much clearer here.

Posted by luis | October 17, 2007 2:43 PM

Actually, one of the major culprits in MRSA is the union movement and the Left in general. By capturing large swaths of the healthcare sector and immorally pushing up wages and work rules for little to moderate skill positions (janitors, clerks, admins, even nurses), health care unions are directly responsible for thousands of deaths due to resistant bacteria.

Doctors have little overall impact, given their relatively low population in a hospital and low level of patient contact, though following infection protocol would help greatly.

This is but one of many examplkes of how the left is giulty of mass killings thanks to their policy and shold be held account for their crimes against humanity. Abolish unions and you will have gone very far in eliminating MRSA.

Posted by Hey | October 17, 2007 4:14 PM

Alejandro,

I agree that antibacterial soap is pointless.

However, there has been no evidence of triclosan soap usage creating triclosan resistance in the field. (see Aiello, et al)

The contribution of feedlots and triclosan soap to MRSA prevalence is so small that it has not been reported in scientific literature. Doctor/patient behavior, hospital management practices, and community hygiene are the main culprits.

I suppose that there "could" be a causal relationship demonstrated in the futrue, but there is not sufficient evidence at the present time for your claims about soap and feedlots.

FYI: The American Veterinary Medical Association supports prophylactic antibiotic usage, last I checked.

Re: Hey
Are you suggesting that unions create drug resistance? Please describe that mechanism! *rolls eyes*

Posted by Mark Mogler | October 17, 2007 5:27 PM

To Hey,
What the heck are you talking about? I have to figure that's sarcasm, since you didn't even provide any poor "justification" or evidence for your argument.

Posted by Eric | October 18, 2007 10:30 AM

Estonia’s health care is one of the best in the word for getting your money’s worth. So why not take what works and apply it to U.S health care. It was only 16 years ago when Estonia was under Russian control, and through the Singing Revolution gained their independence (http://singingrevolution.com; this film is quite inspirational). They’ve come a long way.

Posted by Tanvir | October 18, 2007 12:20 PM

brooksfoe:

That would change the deaths from "deaths due to lack of insurance" to "due to government health plan". My father and my father-in-law both got colon cancer. My father was scheduled for surgery with a couple of weeks. My father-in-law, on the other hand, had to wait because Finland had a doctor's strike underway.

The central problem with health care costs is that if the decision maker does not have to pay the demand is unlimited. It's like college tuition. The people making the decisions don't have to pay, at least, not upfront. Naturally we get ferocious inflation.

Posted by Bob | October 18, 2007 4:26 PM

That is a pretty insanely stupid non-point.

Posted by Lawrence Tureaud | October 20, 2007 12:13 PM