One of Megan McArdle's correspondents rants against the evils of the DC Department of Motor Vehicles before snarking " I can't wait for the government to take over our healthcare system."
A common enough sentiment. But look -- the government already runs a fleet of air craft carriers. Worse! The government's taken over our national monetary policy -- mistakes can plunge the country into recession or a destructive cycle of inflation. And as if that's not enough, they run a vast arsenal of nuclear warheads capable of destroying the entire planet. Which is just to say that if it's not conceivable that there could be a well-managed government agency, then we're all doomed irrespective of what happens with health care. But in fact if you look across the country or around the world, you see some highly effective public agencies and some highly dysfunctional ones. Obviously, you wouldn't want the health care system run like the worst of those agencies, but that's hardly to say that a highly effective government health care agency would be impossible to achieve.
This strikes me as odd because I wouldn't have thought it a particularly controversial proposition that the military is not a particularly effective organization. The US military is indisputably the most effective military in the world. But militaries are not very effective. At any of the tasks the military does which are comparable to a private organization, it performs worse than top-notch private organizations; it is not as good at logistics as Wal-Mart, as good at food service as McDonalds, etc. Military procurement is expensive and insanely inefficient. This is the nature of the beast; governments have all sorts of rules that are designed to achieve goals other than effectiveness.
Pointing out that the government does this very important job is not a "gotcha" to libertarians, who think that the government should run the military, and a few other things, because they're true "public goods": things that provide a large, and more importantly, non-excludable, public benefit. Healthcare spending, outside of a few categories such as vaccination, does not provide such a benefit; almost all of the benefit of modern healthcare spending is captured by the person to whom it is provided.
My quarrel with government-funded healthcare is not that I think that they are so incompetent that they will kill all the patients; it's that I think they will do a substantially worse job than the private sector at many important components of healthcare, particularly innovation. The nuclear analogy is a great soundbyte, but like most soundbytes, on closer examination it doesn't actually make much sense. Management can fail in lots of ways, only one of which results in the accidental release of all our nuclear warheads. The rest just incur other costs, like fiscal expense and slower innovation. On matters such as management of the nuclear arsenal, I'm not really lying awake at nights wondering whether we're spending too much or using too many personnel, or whether our warheads are really the very best they can be. But when something consumes 16% of our GDP and every innovation saves lives, you kind of have to start thinking about those things.
Tell me again where the US ranks in world health rankings... it's FIRST, right? It would have to be, what with how freaking EFFICIENT it is when compared to those idiotic systems in countries with nationalized health care.
Damn, I'm glad that's settled EMPIRICALLY once and for all! USA! USA! USA! FREE MARKET HOOBOY!
You betcha! Now I gotta find me a French poodle to kick.
At MoeLarryAndJesus:
Sarcasm is an ineffective and childish way to argue.
"almost all of the benefit of modern healthcare spending is captured by the person to whom it is provided"
How can you seriously make such a claim? Individuals capture only a fraction of their total economic output, even in the free market. Those of us who would outright die without expensive health care do try to contribute to society, you know.
I'd be more interested in where the various states rank. If California is three times as good (per capita, of course) as South Dakota, I'd be interested in why. (California would be equal to France or something at that point!)
Of course, if South Dakota is better than California, that might be interesting too.
Hollywood_Freaks says: "Sarcasm is an ineffective and childish way to argue."
Some positions are so old and tired they deserve sarcastic responses. Plugging the supposed "efficiency" of a system which leaves 40+ million people without real health care and has the "richest country in history" ranked 37th in health rankings (last I checked) is one of them.
Which former colleague would that be? Is there a link to the original post here which I am missing?
First, having spent nine years in the military, I can say without fear of condradiction that the military is hardly a model of efficiency. Further, the good things that it does accomplish are accomplish through strict order and dicipline and the utter dedication of its members. Would a national healthcare system look like the 82nd Airborne or the DMV? Would it be able to court martial its employees like the 82nd? Would it send its employees through months of rigorous training like the 82nd? Would it be able to dicipline its employees by docking their pay and confining them to their homes with little due process? If not, then a national healthcare system would look more like the DMV than the 82nd.
Also, as in all things, there are declining marginal returns to government activity. The fact that the government may do some things well (and this is, as Megan says, a debateable point) does not therefore mean that it should do everything because it could conceivably do them all just as well.
The fact that it does a lot of things -- some of them well, some of them not well -- suggests, to me anyway, that it might already be operating beyond its marginal efficiency and thus any new responsibilities added won't be done as well as the average of what it does already.
(Also, I'd like to second the complaint about a lack of a link. I think Megan, at times, gets excited to be responding to some or another post and forgets that not all of her readers are sitting next to her at the Starbucks surfing around the web so we might need a link to whatever prompted her comment...)
I would like somebody to explain why an insurance scheme like the one in Massachusetts would stifle innovation.
It is from Matt Yglesias.
I'd have to agree with Tim that the individual receiving the health care is not the only beneficiary of it. If health care was universal, people would be more likely to take preventative action, possibly preventing some of the major losses to society that occur in old age when the government picks up the tab.
"If health care was universal, people would be more likely to take preventative action, possibly preventing some of the major losses to society that occur in old age when the government picks up the tab."
They would also be just as likly to overuse a free system and over load it. Further, our healthcare spending is not driven by people who are worse for lack of preventative care. They are diven by the cost of treatment for the very ill near death and for preventable things like illness related to smoking, drug use and weight and our youths' bad habbit of shooting one another.
Want to save on healthcare? Turn out the old to die, force people to lose weight, stop people from using drugs, and figure out a way to keep gang members from shooting each other.
Megan,
You should really stop stepping in this accidentally (actually, your colleague should have avoided this mess).
The military gives a dreaded IQ test to every single one of its members. If you are below a certain cutoff, you don't get to join. Since the members of the military are all of a certain level of intelligence and are all dedicated to the mission, they can successfully operate even with bad bureaucratic practices. To a certain extent, there is also the fact that the military has a incentive that other government departments do not have; operate too badly and you die. DMV clerks don't face this. Walmart faces termination as an organization if it is too inefficient. This is clearly a stronger incentive.
Since the Carter administration, no other government department has been allowed to screen applicants for IQ. Just as soon as someone comes up with an IQ test that isn't "biased" in that it doesn't reflect racial differences, this policy will be reversed. Good luck with that.
"The US military is indisputably the most effective military in the world"
This word you use - effective - I do not think it means what you think it means.
"Plugging the supposed "efficiency" of a system which leaves 40+ million people without real health care and has the "richest country in history" ranked 37th in health rankings (last I checked) is one of them."
Wrong. That #37 ranking accounts for spending. We're ranked #16 in overall health by the WHO. And that WHO ranking is 62.5% based on "equality". In terms of health response, we rank #1. And the #2 country (Switzerland) is closer to #15 than to us. Moreover, a lot of the rankings don't compare apples to apples. Newborn under 500g aren't counted in European infant mortality stats, but are counted in ours. When you correct for lifestyle (i.e., drug use, obesity, car accidents, violence), we're ahead of the world. Oh, and the number of chronically uninsured Americans is probably closer to 10 million (by the governments own figures) than 40, as that 40 million includes people uninsured for very short period as well as immigrants. Oh, and those uninsured aren't denied care, which would be againt the law.
Apart from that, you make a great point.
I'm surprised Megan didn't jump all over Yglesias for bruting about the government's horrible record on monetary policy as some sign of government competence. Did he miss the 1970's? Has he never heard of the Great Depression?
"They would also be just as likly to overuse a free system and over load it. Further, our healthcare spending is not driven by people who are worse for lack of preventative care. They are diven by the cost of treatment for the very ill near death and for preventable things like illness related to smoking, drug use and weight and our youths' bad habbit of shooting one another. "
I didn't say "free," I said universal. And I would definitely argue that lack of preventative care plays a big role. Like you implied, obesity is a big problem, but if people were able to get health care before developing diabetes, or were able to see a doctor who could help them prevent it, it would likely be less of a problem. Not to imply causation from correlation, but diabetes is more prevalent in low-income communities--and I don't think that can be ignored, and I think it indicates that better access to health care for the poor would relieve the costs of care related to weight.
Anybody been following the ongoing series of nuke security scandals at Minot AFB over the last year or two?
If it were up to me I'd consider taking my planetary-annihilation business elsewhere, though in fairness, Minot seems to be in better shape than the NHS.
k,
Like what?
Most Americans already have health insurance, so the additional preventative medicine we will all supposedly benefit from must come from the newly covered, but what is this preventative care that saves big dollars?
Are Americans going to change their diets and stop smoking if we go to universal care? Are they going to start exercising more? Will they drive more safely? Will they stop shooting each other? No one has ever demonstrated the connection in a convincing way.
LM&J,
Once again, the relevant question is where the United States would rank in real health with universal care. A very solid case can be made that the US would rank in, at best, the same place as today- Americans just live more unhealthy lifestyles than the residents of just about every other OECD country.
I don't doubt for a second that a lot of the medical care the US consumes has little to no benefit. Of the cash my company lays out for my health insurance, I could certainly find more efficient ways to serve my own needs for quite a bit less, but I am not given the option to do so.
At any of the tasks the military does which are comparable to a private organization, it performs worse than top-notch private organizations; it is not as good at logistics as Wal-Mart, as good at food service as McDonalds, etc.
Your larger point is right, but no organization is going to be good at everything. Wal Mart is a great logistics company that's terrible at PR, etc. Food service and even logistics aren't the military's real mission, so it's unfair to compare the military to a company that's entirely dedicated to food service. The military can function well with shitty food, so it would be stupid of them to invest resources in it. Its logistics may not measure up to Wal-Mart's, but it probably deserves some credit for basically inventing the field during WWII
Nice to see someone managed to drag race into this.
You do get a bit sloppy - the lack of a link or at least a reference to the quoted material, as well as having "of the week" items that aren't even updated every month.
But you're one of my favorite blogs to read....and, hell, it's free.
Ok, bad analogy. Sure Wal-Mart is good at logistics in running stores but ask them to pick up the city of Madison WI and move every living person there to some third world country while letting someone shoot at their trucks and have it done in the next sixty days and my guess is they won’t be very efficient at it either. (and while they are at it- congress will help with new rules)
logistics [is]n't the military's real mission...
Good heavens, logistics is virtually everything for any military operation beyond stopping people at the base guardhouse. That's why we have an entire service branch dedicated almost entirely to it. It's one thing the military is well and truly GREAT at doing (although not cheaply. Multiple redundancy can get expensive).
Have none of you people ever seen one of the 10,000 History Channel specials devoted to the capture of the Ludendorf railway bridge at Remagen? Or even seen "Saving Private Ryan"?
Ok, bad analogy. Sure Wal-Mart is good at logistics in running stores but ask them to pick up the city of Madison WI and move every living person there to some third world country while letting someone shoot at their trucks and have it done in the next sixty days and my guess is they won’t be very efficient at it either. (and while they are at it- congress will help with new rules)
In the military there is a saying "Amateurs talk tactics, Professionals study logistics"
"Some positions are so old and tired they deserve sarcastic responses. Plugging the supposed "efficiency" of a system which leaves 40+ million people without real health care and has the "richest country in history" ranked 37th in health rankings (last I checked) is one of them.
Posted by MoeLarryAndJesus
__________________________________
And some statistics have been disproven so many times anyone using them should simply be ignored, which I urge everyone to do with this insufficiently informed commenter.
Also note two additional ignorance indicators: (1) the inability to distinguish between health care and health insurance, and (2) the use of tautological "rankings" which selectively score features such that US ranks as lowly as possible. So for example "financial fairness" (as defined by economic illiterates) is included, while the differences in emergency/EOL spend and the vastly superior innovation of the US industry are not.
I know you guys already had a back-and-forth after this, but I just *gotta* pile on:
Food service and even logistics aren't the military's real mission,
"Okay, we're 1,000 miles from base; who's replacing our rations?"
"Not me." "Not me." "Not me."
"I think that's someone else's department."
"Anyone know the number for Health and Human Services?"
"I think my dad worked for the Department of Agriculture, or maybe got a loan from them or something."
*****
Sadly, I've see a lot of passing the buck like that these days. Where I work, the cafeteria's trash cans are so full as to be unusable, and when I tell them, I get "Oh, that's [the role of the] Facilities [department]." (A different contractor runs the cafeteria.)
Hell no! If it's impeding the function of your cafeteria, you better GET Facilities to do their job.
Massachusetts requires everybody to have medical insurance, and subsidizes the cost for people who have to buy it on their own. I asked earlier how this stifles innovation. Nobody answered, and I think the reason is that Megan's argument is spurious. But I'm willing to listen if somebody comes up with an answer to my question.
The fact that the government runs the military reasonably well (certainly compared to other government functions) is not terribly surprising, given that it's just about the first thing any government ever did. It's the core "sine qua non" function of a national government. More than five thousand years of trial-and-error (and, recently, other methods) have made it possible for this relationship to work as well as it does.
The second thing most governments have done is run the currency. Again, they have gotten reasonably good at it -- again, for the most part, and still with the capacity for huge disasters when they screw it up.
The fact that it's really hard for governments to do these two things decently well, should make us cautious about loading more tasks on the government's shoulders. Or are we going to strip them of the DMV in order to permit more attention to healthcare?
Stan:
The issue is that universal health care means different things depending upon the speaker. The unstated, but implied, context here is single-payer.
The devil's in the details, but as I understand it, the Massachusetts plan seems a fairly reasonable approach to universal health care. How has the plan fared?
"almost all of the benefit of modern healthcare spending is captured by the person to whom it is provided"
A person's health is definitely a public good. When a person is healthy, they are a more productive worker, which in turn makes the people they work with more productive, which in turn makes the people they work with more productive, and so on. Similarly, a healthy worker cannot realistically charge their coworkers from benefiting from their improved productivity. Since the healthy worker cannot prevent this chain reaction of increased productivity from benefiting other people, nor charge people for it, health is non-rival and non-excludable, thus making it public good and necessitating government intervention.
Nathan,
With that reasoning, I could substitute just about any personal characteristic in place of "healthy", and reach the same need for government intervention. Now, if the government wants to intervene so that I can have sex with Jennifer Alba, it will make me happier, more productive, and thus benefit everyone else (except, of course, poor Jennifer Alba).
Nathan-
"A person's health is definitely a public good. When a person is healthy, they are a more productive worker...Since the healthy worker cannot prevent this chain reaction of increased productivity from benefiting other people, nor charge people for it..."
So, under that reasoning, what isn't a public good?
And if you think a worker can't charge people for being more productive I bet you're at a loss to explain why some people make more money than others for the same hours of labor.
afdasf - "Nice to see someone managed to drag race into this."
If you're going to talk about the military as an effective government run operation, you need to talk about the differences between the military and non-military arms of government. The military can fire it's employees for violating the rules that the military sets down (it can even jail them). Civilian government cannot fire employees under pretty much any circumstances. The military screens every applicant for IQ. Civilian government does not. This makes a big difference in how well the organizations work.
Now, if you want to leave race out of the discussion, I'll be happy to; let's talk about bringing back the civil service exam so we know that government employees are intelligent enough to do their jobs without mentioning race. Unfortunately, everyone knows that when you have tests for intelligence with a minimum cutoff not all races are represented in proportion to how many take the tests. I'd be happy to leave it at that. Hmm, that's odd, let's move on. Unfortunately, our society has chosen not to take that approach. Example, NYCFD. By every measure an effective government organization (huge understatement). Firefighters charge into burning buildings to save people's lives. On 9/11 many of them didn't survive because of their dedication to duty. To become a firefighter, you have to take a test; I'd think that given the results, the test works quite well in sorting out quality firefighters. The Justice Department noticed that the number of blacks and hispanics who passed that test were not in proportion to their population so - out with that bad racist test. I'd have been happy if they simply ignored the demographics of people who passed the screening because we have a very effective fire department. Oh well, guess there are some things more important than having high quality firefighters.
Ever wonder why government employees are mostly bad at their jobs? It's because you can't test for competence because there will be differences between the races on the test. The only government department that's exempt from this is the military. Not coincidentally, the military is by far the most competent government department.
I agree with Nathan's comments above, but thats only because Nate minds think alike.
I would say Libertarians are guilty of the same mental flaws as other ideological purists - belief that systems composed of human beings will somehow overcome human nature. Our health-care system really blows. Sorry. It's built on waste, over-billing and lazy-ass doctors pushing pharmo-drugs. If you think the private sector can do everything better because the market just magically corrects itself and does everything so efficiently and so privatize, privatize, privatize - Well then I've got some airline stocks I'd like to sell you.
Here is a link to the quoted Yglesias post.
Maybe Megan didn't include it to protect us from the idiotic comments over there.
the other Nathan,
But progressives make exactly that claim- that there is a way to organize things that overcomes human nature. Libertarians simply believe that if you can't satisfy the wants of enough freely acting customers, your business should be allowed to fail.
And your analogy about airlines is silly. The government has actively prevented the very thing that would allow profitable operations- consolidation and elimination of the non-productive factors- and all in the name of maximal competition. This is starting to change as the airlines have become less and less viable (fewer and fewer idiots are willing to loan them money, except for the government), but this was a process that should have been allowed to occur 20 years ago.
Funny you should mention that, "not the other nathan". I was just wishing a few minutes ago that I loaded up on Delta stock today. Up nearly 6% in one day.
SG -
The Massachusetts plan costs more than anticipated because its planners underestimated the number of people without health insurance. However, the plan is popular with the Massachusetts public, and there is no chance that that it will be revoked any time soon.
I realize that many people here are talking about a single payer plan. I ascribe this in part to rhetorical slight of hand on our host's part. She knows that there's no really good argument against a Massachusetts type plan, so she prefers arguing against a straw man. It's unworthy of her.
With regard to the posts by Yancey and Steve Johnson, obviously we have to weigh the cost of any particular public service against its usefulness, and each of us will come to different conclusions based on our values. Yancey and Steve don't think universal medical insurance is worth the cost and I do. Each to his own.
Finally, regarding Steve Johnson's view that most government employees are bad at their jobs, I have to ask how he came to this conclusion.
"Obviously, you wouldn't want the health care system run like the worst of those agencies, but that's hardly to say that a highly effective government health care agency would be impossible to achieve."
Your former colleague, MM, might be correct, in the long run, but I believe a pretty respected economist (JMK) had a succinct response to that....."in the long run, we're all dead...."
"She knows that there's no really good argument against a Massachusetts type plan, so she prefers arguing against a straw man. It's unworthy of her."
Actually the Massachussetts plan is the strawman. The original post refers to government running healthcare, and Megan's comment is "government funded healthcare". It is you who changed the terms.
There are plenty of good arguments against the Massachussetts plan, although it is almost certainly less bad than government running healthcare.
The cost overruns were not caused by underestimating the number of uninsured. They were caused by refusing to accept the natural consequences of subsidies. In response to the plan people changed their behavior. And we all know why that possibility wasn't considered: because then the price would have been too steep and it wouldn't have passed. So instead the politicans lied and and are now acting surprised.
I'm shocked!
Jumping in:
I don't mean to go off topic, but as a free market person, I have a basic question: has anyone looked at insurance companies and their potential wrong doing here?
bear with me. Under a basic free market, the market expands as demand goes up. Right now, there is 100% (or close to it) demand for health insurance. Now, notably, the poorest will not receive the same quality goods as the richest in any market, but realistically, a company should be jumping in here to offer basic, if weak, health insurance to the poor. There should be several. The premiums would be just enough for the lowliest to handle, if not offering the best doctors or coverage.
The fact that this isn't happening makes me very suspicious. Certainly neither Democrats or Republicans have any philosophical fight on this: both would love to see 100% of the people insured (or able to afford health care) in America. They mostly disagree on how to do it, and degree.
The light must then turn to insurance companies. Are there lobbying tactics and reguluation decreasing competition? Are they creating monopolies that are untouchable for the poor, yet stifle competition?
Face it, when oil prices go up, Exxon is called before Congress and read the riot act. If food goes up, producers get investigated. Congressmen love getting their faces on TV when someone from a perceived price gouger is getting reamed.
So why no major Congressional hearings with insurance companies facing this? Why no free market competitors springing up? I'm no conspiracy theorist usually, but I smell a rat here.
Yancy:"With that reasoning, I could substitute just about any personal characteristic in place of "healthy", and reach the same need for government intervention."
If those characteristics exhibit the great amount of positive externalities that public health provides, then yes, the private sector will under produce the socially optimal level of the public good (in this case, public health), and society on whole would be better off with government intervention. It is easy to come up with ridiculous examples, but when you look at poor countries suffering health epidemics like AIDS and malaria, you see the huge toll that poor health levies on a country’s productivity.
Steve:"So, under that reasoning, what isn't a public good?
And if you think a worker can't charge people for being more productive I bet you're at a loss to explain why some people make more money than others for the same hours of labor."
Any good that you can both elicit and charge a price for, and prevent multiple people from enjoying simultaneously, is a public good. An apple is not a public good, because you can charge someone to consume it, and only one person can consume it at a time. A sunset is a public good, because you cannot charge someone to consume it, and many people can consume it at the same time. As for the worker and productivity aspect, I was a little vague in my phrasing. Clearly a person who is too sick to work full time will be paid much smaller wages than a healthy person with the same education, ect. What I meant was a healthy person cannot exclude other people from enjoying the benefits of her improved productivity (in a competitve labor environment. If you are a superstar worker, and can extract economic rents, then the rules change a little bit)
Jack M.,
In regard to "The premiums would be just enough for the lowliest to handle, if not offering the best doctors or coverage", government on both the state and local level hs in many instances prevented this from happening by mandating minimum levels of service that require that plans include birth control, psychiatric care, and other extras that drive up the price of minimum care.
Jack M.,
In regard to "The premiums would be just enough for the lowliest to handle, if not offering the best doctors or coverage", government on both the state and local level hs in many instances prevented this from happening by mandating minimum levels of service that require that plans include birth control, psychiatric care, and other extras that drive up the price of minimum care.
First nathan:
*What I meant was a healthy person cannot exclude other people from enjoying the benefits of her improved productivity (in a competitve labor environment.*
Sure they can: they can either work fewer hours or work less productively.
Bobar:
So birth control shouldn't be covered? Is it covered under the host's health care plan? I wonder what she has to say about that. What other extras do you mean? Usually those extras are priced in.
The US miliatry is extremely effective at killing people and breaking things - that is the core mission. In order to accomplish this, it has to undertake certain tasks, which include moving the breakers and their stuff to the location of the things to be broken. It does this extremely well, but there are always small details that fall through the cracks - unfortunately that is the nature of the thing. If the troops don't get their rations for 24 hours that will suck, but you know they have some candybars in their pockets in case of such an occurence. If your Aunt Millie doesn't get her IV changed for 24 hours, I will assume she will die.
"Access to a waiting list is not access to healthcare" - Chief Justice of the Supreme Court of Canada Beverly McLachlin, a Liberal appointee to the bench, writing in a decision on whether the Canada Health Act violates the human rights of Quebecers. Currently, many Americans lack health insurance (though a lot of those 37 million are either between plans or illegal aliens) - whether they lack healthcare is another question. Every single Canadian and permanent resident of Canada has health insurance, though many are routinely denied treatment due to rationing and waiting lists that are so long that a sizable portion of the waitees are projected to die before reaching care.
The US miliatry is extremely effective at killing people and breaking things - that is the core mission. In order to accomplish this, it has to undertake certain tasks, which include moving the breakers and their stuff to the location of the things to be broken. It does this extremely well, but there are always small details that fall through the cracks - unfortunately that is the nature of the thing. If the troops don't get their rations for 24 hours that will suck, but you know they have some candybars in their pockets in case of such an occurence. If your Aunt Millie doesn't get her IV changed for 24 hours, I will assume she will die.
"Access to a waiting list is not access to healthcare" - Chief Justice of the Supreme Court of Canada Beverly McLachlin, a Liberal appointee to the bench, writing in a decision on whether the Canada Health Act violates the human rights of Quebecers. Currently, many Americans lack health insurance (though a lot of those 37 million are either between plans or illegal aliens) - whether they lack healthcare is another question. Every single Canadian and permanent resident of Canada has health insurance, though many are routinely denied treatment due to rationing and waiting lists that are so long that a sizable portion of the waitees are projected to die before reaching care.
I think they will do a substantially worse job than the private sector at many important components of healthcare, particularly innovation.
And yet, in practice, that's not true.
I guess those little factual niceties don't bother libertarians, though.
They would also be just as likly to overuse a free system and over load it.
Because if there's one thing that people love to do, it's go to the doctor's office!
John, your position implies that the proportion of the American population that suffers from psychosomatic illnesses is substantially larger than any mental health professional believes it to be. What's your evidence for this implicit assertion?
Jack M.,
There are others of every possible political persuasion here who know a lot more about the subject than I do, but I do believe that Bobar is right in thinking that the most obvious "bare-bones" sort of plan -- one with a high deductible that would shelter you from the costs of catastrophically expensive illness or injury, but otherwise leave you basically paying for medical expenses out-of-pocket -- is illegal in at least some states.
Some retailers have noticed the demand for cheap, readily available, basic medical care and have started running clinics as a sideline. I don't really see the point of running small and fairly predictable costs under an insurance scheme, unless it's to move money from some people to others for your own purposes. Like:
Joe Klein's conscience, why should birth control be covered under medical insurance? (I mean, compulsorily covered; I don't see any problem with making it an option.) We're talking about a regular expense here, not the sort of thing one ordinarily "insures" against. Never mind for the moment that fertility isn't a disease, and that maybe medical insurance ought to be reserved for actual illnesses. The bigger question is: What would be the point?
So far as I can see, the only benefit is to move money -- minus whatever fraction is lost to bureaucratic friction -- from insured people who don't use prescription birth control (not just people actively trying to become pregnant or people with religious objections, but people who rely on condoms, those who are infertile, those who are gay) to insured people who do. Remind me why we ought to mandate this?
NARAL (I think) is trying to use the fact that McCain voted against such a mandate as proof that he's a raving misogynist. It struck me as one of a handful of his votes I could wholeheartedly approve.
Jack M.,
There are others of every possible political persuasion here who know a lot more about the subject than I do, but I do believe that Bobar is right in thinking that the most obvious "bare-bones" sort of plan -- one with a high deductible that would shelter you from the costs of catastrophically expensive illness or injury, but otherwise leave you basically paying for medical expenses out-of-pocket -- is illegal in at least some states.
Some retailers have noticed the demand for cheap, readily available, basic medical care and have started running clinics as a sideline. I don't really see the point of running small and fairly predictable costs under an insurance scheme, unless it's to move money from some people to others for your own purposes. Like:
Joe Klein's conscience, why should birth control be covered under medical insurance? (I mean, compulsorily covered; I don't see any problem with making it an option.) We're talking about a regular expense here, not the sort of thing one ordinarily "insures" against. Never mind for the moment that fertility isn't a disease, and that maybe medical insurance ought to be reserved for actual illnesses. The bigger question is: What would be the point?
So far as I can see, the only benefit is to move money -- minus whatever fraction is lost to bureaucratic friction -- from insured people who don't use prescription birth control (not just people actively trying to become pregnant or people with religious objections, but people who rely on condoms, those who are infertile, those who are gay) to insured people who do. Remind me why we ought to mandate this?
NARAL (I think) is trying to use the fact that McCain voted against such a mandate as proof that he's a raving misogynist. It struck me as one of a handful of his votes I could wholeheartedly approve.
Oh, dear, I do apologize for the double-post. (Memo to self: Don't try to refresh the page; close browser & start over.) Sorry.
I'm mostly libertarian, and hate the idea of government intervention in most areas of life.
However, oddly enough, I'm absolutely fine with the government taking over health care. Contrary to what many Americans seem to believe, the fact is that the U.S. health care system utterly sucks, and is devoid of most market forces anyway.
Imagine a world in which the only cars that were avilable were Ferraris and Bentleys. The manufacturers of those two cars have convinced our government that no other cars should be allowed on the road, because they are inferior and our citizens deserve better.
If you can't afford a Ferrari or Bentley, well, you can always team up with a bunch of other people and buy one, and then share it. Of course, if you need to use the car a LOT then nobody wants to share with you, and you're back to having to buy a Ferrari or Bentley on your own.
Also, our helpful government does buy Ferraris and Bentleys for the very poor to share. But they aren't allowed to drive them to work, or do anything productive with them.
Oh, and the government forces the manufacturers of Ferraris and Bentleys to sell these cars to the the government for far below cost, to give to the poor. Thus forcing the manufacturers to sell their other Ferraris and Bentleys for EVEN HIGHER prices than they would otherwise charge to the rest of us.
That's basically our health care system today. Screw it. We deserve socialist health care, because we have utterly failed in allowing market forces to properly influence health care anyway.
your position implies that the proportion of the American population that suffers from psychosomatic illnesses is substantially larger than any mental health professional believes it to be. What's your evidence for this implicit assertion?
The tragedy of the commons doesn't result from a mental health disorder. It's a natural consequence of people acting in their perceived self-interest.
The high cost of health care (the root of the problem) is a signal that health care is already a relatively scarce good. The explicit argument being made is that there are people who don't receive health care because they can not afford it. The stated intent of any universal health care plan is to increase the number of people with access to health care. By definition, that will increase the load on the health care system.
Furthermore, there's been a stated desire to reduce the share of the economy going to health care. So, you're going to be both increasing the number of users of the health care system, insulating them from the true cost of their consumption, while decreasing the resources allocated to health care. How does that not result in overloading?
Agreed, in addition to the cost that mandated benefits add to insurance premiums, there’s another factor as well. Insurance is one of the few economic areas where regulation is primarily done at the State level and each State effectively creates a local oligopoly in the insurance market by only allowing their residents to buy a health insurance policy that covers those mandated benefits instead of being able to buy a cheaper policy from a company that’s licensed in a State that has fewer mandated benefits. So not only has government policy artificially increased the cost of insurance, they’ve artificially restricted the number of companies and types of policies that can be sold within a given market.
It's a natural consequence of people acting in their perceived self-interest.
Granted, but the only people who see it in their self-interest to go to the doctor's office when it doesn't appear medically necessary are psychosomatics.
So, again, I'm forced to ask why you think far, far more people suffer from that mental malady than any mental health professional seems to believe.
The high cost of health care (the root of the problem) is a signal that health care is already a relatively scarce good.
The scarcity may very well be artificial. The simple truth is that the medical care necessary to keep relatively healthy is not at all scarce.
By definition, that will increase the load on the health care system.
Indeed, in all likelihood, the load will increase to where it should be, the load necessary to support the health needs of our population.
It's not immediately clear why a small number of individuals should be given the government-granted benefit of enjoying an underloaded health care system at the expense of a much larger number of people completely hedged out of health care, entirely. Where's society's interest in that?
And the only reason that people would overload the system - that is, visit the doctor's office much more than is necessary - is if they were going there for treatment of illnesses they didn't actually have, and that's the definition of "psychosomatic." Why should we fear expanded access leading to an overload of the system, unless there are far more psychosomatics than anyone has reason to believe?
Michelle Dulak Thomson:
You do know that McCain cheated on his first wife with his present one, right? And that he's called his second wife a cunt and trollop, right?
Chet:
*Granted, but the only people who see it in their self-interest to go to the doctor's office when it doesn't appear medically necessary are psychosomatics.*
That's incorrect. Lots of medical care has benefits which don't outweigh the costs, and can actually be harmful. For example, prostate cancer screening is now believed to do more harm than good for men over 75 (http://blogs.wsj.com/health/2008/08/05/for-elderly-prostate-cancer-screening-may-harm-more-than-help/?mod=googlenews_wsj). Between 60 and 75, there is little evidence of any medical benefit.
However, many people would get a screening "just to be safe", and thus medical care is overused. If additional medical care has little marginal cost, then people are more likely to do this.
For other examples of overuse, think of the "my baby sneezed, I want antibiotics" crowd.
In fact, LOTS of medical care falls into this category. Robin Hansen wrote a good summary of the evidence of this:
http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-in-half/
The most important fact to get from this essay: in one experiment, some people got free health care, others had to pay for it. The "free health care" people got 30% more health care, but there was no statistically significant difference in health levels.
Ninja Zombie:
And we are supposed to take CATO's word for it? Right!!!
Every single Canadian and permanent resident of Canada has health insurance, though many are routinely denied treatment due to rationing and waiting lists that are so long that a sizable portion of the waitees are projected to die before reaching care.
Cite?
Re: many are routinely denied treatment due to rationing and waiting lists that are so long that a sizable portion of the waitees are projected to die before reaching care.
This is a huge exagaerration. Yes, there is rationing and waiting lists in Canada-- and yet, we yhavet hose in the US too (I assume you and yours are exceedingly healthy not to be aware of this fact). However dcritical care is NOT rationed in Canada nor are you put on a waiting list (beyond the expected) if you show up in the ER with dire symptoms. And if large numbers of people were dying in Canada for want of haelth care it would show up in the vital stats-- which it doesn't (canadian life expectancy is superior to that in the US).
Now on another topic Megan raised, why do we assume, without a shred of proof or argument, that governmment funding must necessarily mean an end to innovation? This has not been true in other areas where the government spends money. We do not fight wars with bows and swords still. And our roads and bridges have improved immensely since the government started spending on them in a big way.
Re: but I do believe that Bobar is right in thinking that the most obvious "bare-bones" sort of plan -- one with a high deductible that would shelter you from the costs of catastrophically expensive illness or injury, but otherwise leave you basically paying for medical expenses out-of-pocket -- is illegal in at least some states.
That is not true. High deductible policies are legal everywhere I know of. The mandates Bobar refers make it illegal to exclude certain conditions or procedures from coverage, however they do not require the insurer to pay anything until the policy deductible is met. In other words, mental illness must be covered, but the insurer doesn't pay until the insured runs up high expenses, exactly as with any other condition. And while birth control would be covered in principle, in pratice a high deductible policy would not need to worry about paying anything at all, since no one would ever meet the deductible on that. The real reason high deductible policies are still terribly expensive is because the sorts of thing that are covered can be very, very expensive. A low deductible, low limit policy that stop paying at, say $5000 would be very affordable. No matter how many doctor visits you made: office visits are chump change for insurers. It's the catastrophic expenses that are well, catastrophic. And therein may lie the answer, or part of one: have the government set up some sort of entity like the SSA that would cover catastrophic costs and chronic long term illnesses (maybe indirectly, by reimbursing insurers) and the cost of even "gold plated, everything's covered" policies would be affordable for all but the poorest.
Joe Klein's Conscience:
You don't need to take Robin Hansen's word for it. He cites all his empirical sources, most importantly the seminal RAND study. His reasoning is spelled out in the article, you can follow it and point out where you think he is flawed.
Please, don't take his word for it. Read it skeptically.
Or, you could just ignore anything published by your ideological enemies. After all, they are just stupid, evil and dishonest, and can't possibly have any valid arguments. And any empirical studies they cite must be wrong.
Nathan - Since the healthy worker cannot prevent this chain reaction of increased productivity from benefiting other people, nor charge people for it, health is non-rival and non-excludable, thus making it public good and necessitating government intervention.
Well, that totally shoots the right to privacy, doesn't it? How people raise their kids also has a huge impact on the rest of us. So we should therefore allow forced sterilizations? Is there any aspect of my life the government wouldn't be allowed to control under that logic?
Of course, you still have to prove that nationalization of healthcare generates more productivity than it consumes. It'd be interesting if you could show that. Otherwise, your argument is just a hypothetical.
Also, we have to look at what healthcare does and does not fix. As it now stands, the US has better treatment and detection for, say, prostate cancer than countries with nationalized healthcare. That's one disease which responds well to increased treatment, unlike, say, obesity. (We have early detection for that condition, right? Hasn't done much good.)
It's entirely possible that nationalization of healthcare will produce less productivity than it consumes. Especially since the costs tend to be diffuse and the benefits tend to be highly centralized.
Based on the lifestyle differences between people using the same healthcare system and the impact on lifespan, I think the government would be better off giving every American a membership to a local gym rather than using the money for healthcare.
(If the offenders had gov't health worker union protection they'd still be on the job, of course.)
Also, the guys in the silos reportedly have figured out how just one on them can turn both keys at the same time using a spoon and a piece of string.
Maybe we've just been lucky. (When I think of the Russians I've known, I'm sure we've been lucky.)
The warning example that makes me think "don't let this government run our health care" isn't nearly so much its screw-ups running the military with $400 hammers and all, or any other things, nearly so much as the record it is compiling running health care right now.
I could refer to several other nice examples but the one link per comment anti-spam filter won't permit. ;-(
OK, one other warning example that does make me think "don't let these politicians run my health care!" is their inability to run a cafeteria.
Nationalizing health care would be rather more complicated than running a cafeteria, wouldn't it?
If so, that's some proverbial food for thought that should be on the menu.
Wait ... another example is how the new housing bill just enacted to help boost the depressed housing market provides more new subsidized below-market-cost housing to counter the housing glut ... while also containing special provisions to extend corporate tax breaks to Chrysler, which is no longer a corporation ... and designates a Canadian-owned railroad car manufacturing plant, located in Alabama a good 300 miles from the Gulf coast, as being part of the Gulf coast hurricane relief zone nonetheless, so it can get millions of dollars or tax-subsidized financing.
As "housing market relief" goes, that was all as carefully thought-through as the Senate cafeteria menu.
And another example is ... oh, that's enough.
I can't wait until these guys design national health care for us too! Our just desert!
Yes Bobar, I can see that.
The question is: are the states the ones in the pocket of insurance companies? after all, by setting those regulations, it effectively bars entry of start-up insurers; only insurers with major capital to cover those incidents the state won't allow them to not cover can come in. This insures (ha!) that only well-funded businesses come in and can't just pick off low lying fruit.
and that still doesn't explain why Congress isn't holding hearings. Congress holds hearings (largely meaningless) on things it has no power over, or are of very little importance. Major League Baseball, for example, has had its players reamed out. Insurers are a big fat target, and, more importantly, they're liked a lot less than most baseball players. To mix a metaphor, it would be slam dunk. So I think there must be some kind of payoff going on here. (yes, yes, I have my tinfoil hat).
There is no possibility whatsoever of a single payer system being enacted in the foreseeable future. Consequently, I can't understand Megan's wailings about the horrors of socialized medicine. The only three possibilities in the current political climate are some form of the Massachusetts system, the status quo, and McCain's plan to phase out employer-provided medical insurance and to encourage everybody to buy insurance privately. Why warn about something that nobody is proposing? If Megan dislikes the Massachusetts plan or the watered down version favored by Obama, why not say so? Why the continued kvetching about something that won't happen anyway?
When I was a junior officer in the Navy, my Supply Officer once told me a story about his Cold War training experience at the Naval Supply School in Athens, GA. As the instructor was passing out the dozens of manuals that outlined the Byzantine logistical system of the Navy, one student asked if any of it was confidential. The instructor replied, "Oh my no. If the Russians got their hands on these it would set them back ten years."
Lots of medical care has benefits which don't outweigh the costs, and can actually be harmful.
What doctors, in your view, are going to be performing medically unnecessary, harmful exams under single-payer health insurance? More specifically why do you believe the only thing preventing that from happening now are the roadblocks that, for many people, obstruct any kind of care whatsoever?
If you're so worried about people getting medically harmful exams, isn't this a little bit overkill? Can't we prevent such harmful wastes without simply selecting a portion of the population to receive no care at all, which is the current system?
For other examples of overuse, think of the "my baby sneezed, I want antibiotics" crowd.
Again, those people aren't the people not getting care under the current system. Those people are the people whose wallets ensure they get whatever care they want, even wasteful unnecessary care. Those are the people who would benefit from a little care-rationing, don't you think? Don't you think those people are less likely to get whatever antibiotic scrips they want, in a system where doctors don't have to prostitute their prescription pads just to keep a private practice above water?
Chet says, Granted, but the only people who see it in their self-interest to go to the doctor's office when it doesn't appear medically necessary are psychosomatics. I'd be willing to wager he's never lived in a country with national health insurance. I don't know if it's typical - it's my only experience - but in Japan, it's certainly the case that low-cost health care increases dramatically the public's use of medical resources. My doctor friends who have their own primary care (generally internal medicine) clinics generally "see" between 80 and 250 patients in a six-hour examination day, depending on the time of year. Because of government price controls and subsidies, it's cheaper (or at least it was a few years ago when I still lived there) to visit the doctor when you've got a cold than it is to pick up some cold medicine at the pharmacy - and that's precisely what people do.
And the phenomenon is even more marked among the elderly, who used to receive completely free care at the hospital of their choice. The running joke throughout Japan - one that I heard from several physician friends in various parts of the country - involved the nurses and/or other patients in the waiting room noting that Saito-san must be "out sick" today . . . after all, he's not here for his daily visit.
I'm not sure why, when it comes to health care and taxes, it's so hard for folks like Chet to concede that the basic laws of economics still hold true: Prices affect behavior. It's really not that hard a concept to grasp.
I'd be willing to wager he's never lived in a country with national health insurance.
I lived in England for all of 1996, where I was a student. Mostly London, but I did get the chance to get out into the countryside fairly frequently.
I didn't observe that the English found going to the doctor any more pleasant than Americans typically do. This idea that our doctors offices are going to be swamped by thrill-seekers looking for nothing but a good time is lunacy. But I guess you have to be crazy to think we've got the health care system we need.
Because of government price controls and subsidies, it's cheaper (or at least it was a few years ago when I still lived there) to visit the doctor when you've got a cold than it is to pick up some cold medicine at the pharmacy
In England pharmacies are part of the NHS system.
I'm not sure why, when it comes to health care and taxes, it's so hard for folks like Chet to concede that the basic laws of economics still hold true: Prices affect behavior.
There's no such thing as the "basic laws of economics." The entire field of economics is a joke (especially to real scientists, like sociologists) where the whole exercise is predicated on fundamentally false ideas of human behavior.
Like the idea that people would go to the doctor for anything but medically-necessary services.
"The entire field of economics is a joke (especially to real scientists, like sociologists) where the whole exercise is predicated on fundamentally false ideas of human behavior."
I'm confused. Did you just assert that sociologists are real scientists and economists are not? I thought sociology was generally acknowledged to be a joke, but I could just be confused about what you are saying.
People who argue that the political dynamic of the United States has resulted in excessive military spending, some say by as much as a few hundred billion dollars, while also saying that the Department of Defense demonstrates that government can effectively employ capital, are pretty funny, if unintentionally so.
Chet: The entire field of economics is a joke (especially to real scientists, like sociologists)
That has got to be the funniest thing I've read all day.
Mcardle - libertarians, who think that the government should run the military, and a few other things, because they're true "public goods": things that provide a large, and more importantly, non-excludable, public benefit. Healthcare spending, outside of a few categories such as vaccination, does not provide such a benefit; almost all of the benefit of modern healthcare spending is captured by the person to whom it is provided.
No, almost all the financial benefit of healthcare spending goes to the people in insurance, Big Pharma, healthcare workers and professional, hospital and nursing home administrators and investors. Yes, the service benefit of America's "lead the world in per capita costs" goes to the patient, be they a full contributor, a welfare parasite, or illegal.....but you also have to look at the costs and the belief by most people that American health care is 40% more expensive than the patient service benefit or salaries of those in the biz - merit.
The out of control costs, inefficiencies, and knowledge that the bulk of people are better off under Universal Care are what is driving the sensible debate we are having on why we should have "American exceptionalism" that so clearly hurts our country.
1. America has become uncompetitive with most countries on exports because our trade deals force us to add our employer health care costs to the price of the goods or service we sell. Other countries get a direct VAT tax break and health care costs exempt from export costs. At one point, when the world was wrecked by WWII, such exceptionalism could be sustained. No more.
2. Jingoists who proudly proclaim how Commie Europe and Asia are financially screwed by their welfare state costs ignore that the US is in even deeper long-term financial jeopardy from government medicare that costs 40-70% more than our advanced nation trade rivals.
3. It is simply morally wrong to subject 1/7th of America's population to being outside health care insurance, despite being hard, law-abiding contributors to society while illegals, criminals, and welfare parasites get free medical and dental.
It's even worse for them because certain health care systems, notoriously hospitals, drugs, and rehab facilities will charge up to 90% more for an uninsured citizen than their "negotiated discounts" with patients insurers.
It encourages welfare people not to want to get a low-skill 1st rung on the ladder job because they lose health benefits. It encourages all those no health benefit ChinaMart workers and others without insurance to believe in the stupidity of saving anything, of buying assets or investing - because whatever pittance they put away can be wiped out by hospital bill collectors. And it encourages employers to scale back benefits and foist the cost of their most profitable part-time and law wage workers health onto taxpayers instead of paying "so we can beat the competition that is saddled with worker health care costs."
So given our health system is horrifically inefficient, discourages work, is near financial ruin, and cripples our ability to compete - we have to change the system. Best would be the Japanese or German/French systems that offer universal health care, but with a vigorous private enterprise system competing to raise quality of care and lower costs to taxpayers.
Tell me again where the US ranks in world health rankings... it's FIRST, right? It would have to be, what with how freaking EFFICIENT it is when compared to those idiotic systems in countries with nationalized health care.
There is no such thing as "world health rankings." It's a silly phrase masking an underlying conceptual incoherency.
"They would also be just as likly to overuse a free system and over load it.
Because if there's one thing that people love to do, it's go to the doctor's office!"
I live in Taiwan, where we have state-ruin healthcare and yes, people DO like to go to the doctor's offices, especially the elderly who are lonely, those who enjoy doctor shopping, etc. In fact, our child sees the doctor for EVERY single cold, and has to return every 2-3 days for additional medicine.
Of course since it costs "only US$ 5" for visit, people over use the doctor. Actual cost to the companies paying the remainder of the fee is about US$ 36 / visit. Keep in mind the doctor sees the cold victim for about 5 minutes and prescribes cold medicines from the state-approved list.
So birth control shouldn't be covered? Is it covered under the host's health care plan? I wonder what she has to say about that. What other extras do you mean? Usually those extras are priced in.
Of course birth control shouldn't be covered. The notion that it should is based on either ideological dishonesty or complete confusion as to what insurance is. Insurance is for spreading risk, not for spreading cost. Liberals want to create confusion about it being the latter, but the latter is just welfare, not insurance.
As for extras being priced in, that's the point. You can't offer a cheap plan, because you're required to provide extras by the government, and required to charge for them by economics.
Granted, but the only people who see it in their self-interest to go to the doctor's office when it doesn't appear medically necessary are psychosomatics.
False. You fail to consider the situation in which the illness or injury is real, but the doctor's office is not. (Either because the situation will resolve itself on its own or because it isn't treatable.)
More importantly, you also fail to consider that much medical treatment is not "necessary," but is done for quality of life purposes. I'm not talking about purely cosmetic treatment, which won't be covered, but for example, a joint replacement (knee, hip, etc.). It may make one's life better, but one will not die without it. If it's free (to the patient), the patient will get it. Why not? If not, he or she won't.
Re: Because of government price controls and subsidies, it's cheaper (or at least it was a few years ago when I still lived there) to visit the doctor when you've got a cold than it is to pick up some cold medicine at the pharmacy
No it’s not cheaper and never could be. Even if the doctor charges you nothing at all, you’re still going to spend more time at a doctor’s office than at a quick pharmacy visit—generally a lot more time. “Time is money” as they say, and even if you don’t miss work for a doctor visit, most people would prefer a ten minute trip to Walgreens to a two hour (or longer) doctor visit.
Re: It may make one's life better, but one will not die without it.
Are you some sort of neo-medieval ascetic? According to your way of thinking people whould simply accept pain and disability and perhaps praise God for it rather than going to a doctor and getting it taken care of when treatment exists.
I don't know... comparing government versus private is like comparing an immortal person to a mortal.
The immortal guy can be alive during your time, be a drunk, a total screwup, wrecking buildings, crashing cars. You compare him to the mortal people and say, "Wow he is really bad at living." But you are not seeing the full picture. (Sorry, just got around to seeing Hancock tonight).
Thus it is when we compare the government to the private sector. Invariably we are comparing the always existing government against a private sector filled with companies that failed at their tasks and cease to exist. The government cannot do that.
So for any task, you have to ask how ALL the players (existing and failed) stack up against the government. And this takes us into the theoretical.
In most cases we are comparing the successes (Walmart) against the government for a task (logistics), instead of comparing all people engaged in logistics (which include a huge number of failing companies in the private sector).
It's all very appley, orangey.
I share the astonishment, not to mention the sense of comedy, expressed by other commenters at Chet's apparent belief that sociology somehow more closely approximates a science than economics. Perhaps that bit of delusion explains his complete inability to respond to the point of my post: He stated that changing incentives in health care would not appreciably increase demand for same; I responded with one particular example where incentives - low or nonexistent fees and high costs of self-treatment - produced exactly that effect. I also cited in support of this view a few facts to support my position, facts gathered from conversations with a few dozen Japanese physicians, actual observation over a decade of living in Japan, and close attention to the issue in Japanese media.
Chet's response? (1) That Brits, whose health system creates different incentives (e.g., one seldom hears about waiting lists in Japan, which has a curious hybrid of public financing and private market which encourages overuse), don't seem to enjoy going to the doctor, as if I ever argued that "enjoyment" was an issue: Believe me, I've plenty of experience with sitting in the waiting room of one's primary care provider for four hours while waiting to be see for one's cold (because one arrived at the clinic at 9:00 am but was still number 130 in line) to know that one doesn't have to enjoy the experience to overconsume medical services.
(2) That the NHS runs pharmacies in the UK. That's beautiful, but I'm not sure what relevance it has to my argument, though I should also have noted that Japanese prescription pharmacies are generally attached to medical clinics, which together with government subsidies, leads to overprescription of drugs: Doctors are compensated so little per visit (between $7 and $20, last I heard) that they tend to overprescribe drugs and medical tests, most of which are conducted in their clinic, to capture other, more lucrative revenue streams. In my first year in Japan, I received many more - and more intrusive - medical tests for minor complaints than I had received in the previous twenty-two years in the U.S. Another example of how incentives skew the demand for medical services.
(3) That my assertions are based not, in fact, on observation but on an ideological commitment to a bizarre belief that people might consume unnecessary medical services if that cost of said services was subsidized. Whatever, dude: If Chet truly believes that after my post, which grounds my conclusion in my observations formed from observations during a decade in Japan, in conversations with dozens of doctors, and hundreds of hours spent in clinic waiting rooms, I don't see the point of carrying on the argument. Somebody's ideological blinders are standing in the way of dialogue, and they aren't mine. (I, unlike Chet, am ambivalent about the relative merits of different health care alternatives, though I prefer a more libertarian solution; observation has taught me, though, that incentives matter, even in health care, and they need to be taken into account in any attempt to restructure the industry.)
JohnF,
Well, yes and no. For elderly retired people who would otherwise be sitting at home watching TV, the opportunity cost of going to the doctor is pretty darn low. When I was a struggling English teacher with expat insurance that covered 100% of my treatment and making $18/hr or so, paying nothing and waiting for three hours seemed like a better deal than paying between $35 or $40 for cold medicine at the pharmacy, particularly as I worked afternoons and evenings and could generally get to the clinic in the morning - the waiting room is a wonderful place to get some reading done. For students and housewives, the situation is similar.
*What doctors, in your view, are going to be performing medically unnecessary, harmful exams under single-payer health insurance?*
Most of them. Doctors and patients both have a well known bias towards doing *something*. "No evidence it works, but can't hurt to try, right?" Prostate cancer screening is now known to hurt people over 75, and there is no evidence at all that it is useful in the 60-75 crowd. This has been known for a long time, yet doctors continue to do the screenings.
One thing which reduces this is the cost of medical care. If it doesn't work, and it costs money, people will be less willing to buy it.
*Can't we prevent such harmful wastes without simply selecting a portion of the population to receive no care at all, which is the current system?*
Which portion of the population gets no care at all?
*Those people are the people whose wallets ensure they get whatever care they want, even wasteful unnecessary care.*
This is your mistake. *Currently*, those people are the ones who's can afford whatever care they want. You propose making nervous parenting affordable for everyone. You think being a nervous parent is a personality trait unique to the upper middle class?
The doctor may or may not give out antibiotics unnecessarily, that's a completely separate issue. Either way, he is still wasting time on patients who are overconsuming health care.
This isn't a minor phenomenon, confined to prostate cancer and upper middle class sneezing babies. The RAND study (note: a randomized trial, so we can infer causality) shows that with zero marginal cost health care ("free health care") increases spending by 30% with no increase in health.
*Those are the people who would benefit from a little care-rationing, don't you think?*
I agree very much. So what I would propose is something different: lets tweak the health care tax credit so that only high deductible health care with high copays is covered.
The 7:01 comment above signed "JonF" is, of course, actually my own. Apologies for the mistake.
As for what people "should" do, I think people "should" pay for their own care. If they don't want to "accept" pain or disability, they "should" save up their money and get treatment, rather than holding out their hands for a handout while spending their own money on vacations.
NZ: That same RAND study IIRC also pointed out that as costs increased, consumers cut back spending, but they cut back on useful and useless procedures equally. This suggests that there are also major information problems with a free market in health care.
Those information problems are one of the main reasons competition does not work as well in health care. In some areas (plastic surgery, LASIK, etc), where the procedures are optional and the patient has time to shop around, competition has reduced prices. On the other hand, while you are in the ambulance after suffering a heart attack, you really don’t have the time or ability to review and pick the best hospital.
As for how well the government can run a system, the VA was doing a pretty good job in the late 90s. It was the best large scale system in the US (I am not sure if it has been affected by the administration). See Longman:
http://www.washingtonmonthly.com/features/2005/0501.longman.html
Longman also points out that private providers tend to have major problems with short term thinking. Since the average customer stays with an private insurer about 7 years, the insurer has no incentive to invest in procedures with long term benefits. For example, if spending $1,000 now to save $20,000 20 years down the road for a diabetic is a possibility, it is one the private insurer has no interest in. After all “Why should I decrease my competitor’s costs” as one insurance executive said. The VA has the incentive to think in the long term because their patients generally stay with them until they die.
Another big problem is that the incentives are wrong. Individuals with insurance do not have much incentive to look for the lowest cost treatment options, because insurance picks up much of the cost. The employers that pay for the insurance don’t look for long term solutions, because most employees don’t stay that long (why should we pay for a health plan that will keep them healthier 15 years from now when they are working for someone else), and because employees tend to prefer lots of choice and low out of costs over long term health.
Also, there are 8 to 9 American nuclear warheads unaccounted for (one off the coast of Georgia), quite a few crashes of nuclear-equipped aircraft, and then the accidental shipping of missile equipment to Taiwan a few years back.
The general concept that our nuclear arsenal is some kind of great success is pretty laughable. The entire joke of the arms race was that we each have enough to blow each other up many times over -- the typical cost overruns of a government project. It's also kind of funny to say "government can run healthcare -- look at how they run that nuke arsenal -- they haven't killed us all with it yet!"
I concede the point, sir. Nationalized health care may in fact not kill us all and/or lead to an extremely fascinating post-apocalyptic Mad Max scenario. You win this round.
It's a simple fact that free health care causes Ameicans (can't speak for other nations) to drastically overuse health care. The question is how many do this.
Strangely enough, every one of the low income friends or family members I have, that get free health care for their kids and free maternity care for themselves have at least 4 kids, and anytime one of them gets so much as a sniffle they go to the doctor.
Meanwhile, the parents, who don't have free health care, never go.
Meanwhile, my kids, who I pay for their insurance (and also pay for the poor kids free health care I might add through my taxes and premiums) only go when they've been sick for 2 weeks and at that point it's clear they're not going to get over it in a few days.
Interesting dichotomy, and I'm guessing I'm not the only one to notice it.
NZ: That same RAND study IIRC also pointed out that as costs increased, consumers cut back spending, but they cut back on useful and useless procedures equally. This suggests that there are also major information problems with a free market in health care.
Those information problems are one of the main reasons competition does not work as well in health care. In some areas (plastic surgery, LASIK, etc), where the procedures are optional and the patient has time to shop around, competition has reduced prices. On the other hand, while you are in the ambulance after suffering a heart attack, you really don’t have the time or ability to review and pick the best hospital.
As for how well the government can run a system, the VA was doing a pretty good job in the late 90s. It was the best large scale system in the US (I am not sure if it has been affected by the administration). See Longman:
http://www.washingtonmonthly.com/features/2005/0501.longman.html
Longman also points out that private providers tend to have major problems with short term thinking. Since the average customer stays with an private insurer about 7 years, the insurer has no incentive to invest in procedures with long term benefits. For example, if spending $1,000 now to save $20,000 20 years down the road for a diabetic is a possibility, it is one the private insurer has no interest in. After all “Why should I decrease my competitor’s costs” as one insurance executive said. The VA has the incentive to think in the long term because their patients generally stay with them until they die.
Another big problem is that the incentives are wrong. Individuals with insurance do not have much incentive to look for the lowest cost treatment options, because insurance picks up much of the cost. The employers that pay for the insurance don’t look for long term solutions, because most employees don’t stay that long (why should we pay for a health plan that will keep them healthier 15 years from now when they are working for someone else), and because employees tend to prefer lots of choice and low out of costs over long term health.
NZ: That same RAND study IIRC also pointed out that as costs increased, consumers cut back spending, but they cut back on useful and useless procedures equally. This suggests that there are also major information problems with a free market in health care.
Those information problems are one of the main reasons competition does not work as well in health care. In some areas (plastic surgery, LASIK, etc), where the procedures are optional and the patient has time to shop around, competition has reduced prices. On the other hand, while you are in the ambulance after suffering a heart attack, you really don’t have the time or ability to review and pick the best hospital.
As for how well the government can run a system, the VA was doing a pretty good job in the late 90s. It was the best large scale system in the US (I am not sure if it has been affected by the administration). See Longman:
http://www.washingtonmonthly.com/features/2005/0501.longman.html
Longman also points out that private providers tend to have major problems with short term thinking. Since the average customer stays with an private insurer about 7 years, the insurer has no incentive to invest in procedures with long term benefits. For example, if spending $1,000 now to save $20,000 20 years down the road for a diabetic is a possibility, it is one the private insurer has no interest in. After all “Why should I decrease my competitor’s costs” as one insurance executive said. The VA has the incentive to think in the long term because their patients generally stay with them until they die.
Another big problem is that the incentives are wrong. Individuals with insurance do not have much incentive to look for the lowest cost treatment options, because insurance picks up much of the cost. The employers that pay for the insurance don’t look for long term solutions, because most employees don’t stay that long (why should we pay for a health plan that will keep them healthier 15 years from now when they are working for someone else), and because employees tend to prefer lots of choice and low out of costs over long term health.
*That same RAND study IIRC also pointed out that as costs increased, consumers cut back spending, but they cut back on useful and useless procedures equally.*
I'm not sure how you measure "useful" and "useless". A cost induced 30% drop in health care did not reduce health levels, so I don't see how you can say useful procedures were cut back on.
*On the other hand, while you are in the ambulance after suffering a heart attack, you really don’t have the time or ability to review and pick the best hospital.*
True, but trauma care accounts for a small fraction of total health care. If the inability to comparison shop is the argument for socialized medicine, then one should argue only for socialized trauma care. I'd actually have little problem with that (ignoring slippery slopes).
*if spending $1,000 now to save $20,000 20 years down the road for a diabetic is a possibility, it is one the private insurer has no interest in.*
What sorts of medical conditions have treatments with that type of cost profile over time? Note: I'm not claiming they don't exist, I just don't know of any (or how much money such treatments could save).
The only medical *procedures* I'm aware of that offer such benefits are routine disease screenings, vaccinations, and similar things. But these are all routine care, and should not be covered by insurance.
It's a simple fact that free health care causes Ameicans (can't speak for other nations) to drastically overuse health care. The question is how many do this.
I can't believe anyone even considers it controversial that the demand for a good or service is in part a function of its cost. In other news, people tend to eat more at all-you-can-eat buffets than they would when dining a la carte and people have been cutting back on driving since gas has gone above $4/gallon. And yes, if you reduce the direct cost of health care to the consumer, more of it will be consumed. Not necessarily every person, but in the aggregate consumption will increase.
None of this is intended to be an argument for the current health care system (as it is flawed in many, many ways), only as an argument against the notion that making health care "free" will be cheap or easy. It still may be worth doing, but it ought to have the negative aspects honestly evaluated. Denying the obvious hazards makes one doubt the good-faith of the person proposing it.
The only medical *procedures* I'm aware of that offer such benefits are routine disease screenings, vaccinations, and similar things. But these are all routine care, and should not be covered by insurance.
This is second-hand, but I once worked with someone from the Netherlands, and they said that dental care was "free" (to the patient), but only if you received regular checkups. If you skipped going to the dentist for an extended period of time and then needed major work, you were charged for it.
While I don't think it would work in general for medicine (dentistry is much more amenable to preventative care than medicine in general), I did think it was an interesting approach.
I believe it was John Edwards during the primaries, realizing this problem, who wanted to mandate regular checkups as part of his health care plan. (Not just dental; medical as well.)
JonF - either you are uninformed or are being wilfully dishonest. It is routine in BC (my home province) for people to wait in chronic pain for a hip replacement for 2 years. The side effects include addiction to pain meds and loss of productivity. These folks already pay a huge portion of their income in taxes and "premiums" for their "free" healthcare, so unless they are quite weathy they are not going to have the $$ to go to the US to pay for the procedure so they can obtain it in a timely manner.
If you are hauled into the ER on death's door, you will be treated in a timely manner, just like an uninsured person who comes into an ER in the 'States. That is not the argument. Canada does very well on things like routine Drs. visits (though this is abused by hypochondreacs) and fine when it comes to massive trauma. The Canadian system falls down badly when it comes to expensive treatments for things that are very serious but not immediate - cancer treatment, joint replacement and neurological conditions. Anything that requires expesive diagnostic equipment (MRIs, PETs etc) is problematic.
If your have cancer or a neurological disorder, you will wait a long time for an appointment with the specialist, and even longer for an MRI. Nobody with any kind of insurance waits that long in the 'States, and if your insurance denies it to you, you are free to spend your own cash to get it. I spent the first 28 years of my life in Canada, and have seen how badly my mother and some of my parents' have been treated - frankly it makes me sick.
I have spend most of the last decade in NY, and while the US system is (or systems are) far from perfect, it is a hell of a lot better than the state-sponsored chop-shop up north.
Apologies for the multiple posts. I have no idea how one at 1103 spawned two copies over the next hour.
Re: When I was a struggling English teacher with expat insurance that covered 100% of my treatment and making $18/hr or so, paying nothing and waiting for three hours seemed like a better deal than paying between $35 or $40 for cold medicine at the pharmacy
Wow, what do you use for cold medicine? Single malt imported scotch? Excuse the sarcasm, but that does seem like an incredible amount to pay for a cold. Last time I had a cold I bought a $5.99 bottle of Nyquil, an extra box of Kleenix, a can of chicken noodle soup and a jug of juice-- about $12. Which I would have spent anyway even if I had gone to the doctor. Which I did not do, since I hate wasting time, and therein lies the truth about my comment about doctor visits costing you something even if those costs are not monetary: monetary transactions are at least reversible (in principle); time is not. You can always make more money, but time lost or wasted can never be regained.
And yes, I know, and have mentioned before, the fact that some lonely old folks use doctor visits as social occasions. But they are already covered under Medicare an their expenses are already in the system.
Now for a long-ish post about the real issues here. Doctor visits are not what drives up the cost of healthcare at all. Most doctor visits are compensated by insurance at around $25-$40 (I used to work in health insurance; I know these things). And if the patient is under a capitated plan, then the office visit is paid at $0, because the doctor (assuming he's the PCP) receives a flat monthly amount per patient whether he sees the patient every day or not at all.
In fact, it isn't patients who produce overconsumption, to the extent that it exists at all. Rather, it's the providers. They are the one who prescribe tests and treatments. They control the demand side of healthcare as well as the supply side (neat trick there, not to be found anywhere else in the economy). Patients lack the knowldge to make informed choices and so generally go along with whatever their doctor recommends, and no amount of tinkering with the financial side of healthcare will change that. Most of us are simply not going to go to medical school and gain the acumen we would need. Health plans have tried to deal with this fact of life by instituting a gatekeeper system, requiring pre-authorizaion for the more expensive treatments (decisions which are made by medical personal on staff by the way, not by accountants as silly people sometimes allege). This is not a bad idea in principle, but doctors hate to be second guessed, even by other medical personnel, and there are enough mistakes made that public outrage has been easy to stoke. The result is that all but the most egregious treatments are authorized.
But even ordinary treatments and tests are not really driving up the cost of healthcare. Your average mostly healthy Joe Ciztien is in fact guiltless in this matter. Trying to cut healthcare spending by denying healthcare to people of modest means (which is what the libertarian types are really talking about when you part the clouds of highflown cant) will not bring down the nation's healthcare tab. It isn't the cost of treating ordinary people that's the problem: it's the cost of treating the very sick and the dying. So what would you folks propose to do about that issue? Suggest that we just dump these people (who someday will be us) in a squalid charnel house until the die will not fly. Human nature demands that the sick be cared for. We will not be abandoning that basic imperative of being human any more than we will be growing wings or breathing under water or developing a taste for raw sewage in our cuisine.
How do you propose to pay for the very sick and the dying? They will be paid for, no escaping that. "There's no such thing as an unpaid bill" Let's hear the ideas from those of you who hate caring for the sick. And if you don't have any ideas on the subject then for crying out loud get out of the way and let people who do have solutions in mind try them out!
Re: JonF - either you are uninformed or are being wilfully dishonest.
You should re-read what I wrote. My point was not that there are no wait lists in Canada, but that we also have wait lists in the US. It took my dental insurer six months once to approve a crown over a broken tooth. A cousin of mine was on a wait list for disk (back) surgery for months, and was in a great deal of pain during that time. My step-sister was caught in a catch-22 between her HMO, her auto policy and workers comp and never was able to get knee surgery after an accident in her workplace parking lot-- she limps to this day. American healthcare is as big a mess as Canadian healthcare albeit we may do better on some things and worse on others. Oh, and we spend more money for no better results. As for only the Canadian rich being able to afford to come to America for healthcare, only those rich could afford to pay out of pocket anyway, no matter what side of the border they are on. After all, most Canadians live within 100 miles of the US border. Even at today's gas prices the trip itself is unlikely to bankrupt anyone, though Canadians running afoul of our new paranoid border regulations have my sympathy and apologies.
You fail to consider the situation in which the illness or injury is real, but the doctor's office is not.
You're right that I absolutely had not considered the economic impact of people with real illnesses going to imaginary doctor's offices.
Is this really the best you guys have to offer?
He stated that changing incentives in health care would not appreciably increase demand for same;
That's actually not what I stated at all, but thanks for proving that the only weapon in the privatized-medicine arsenal is dishonest.
The question was whether or not single-payer healthcare would result in an overconsumption of medical benefits, and there's absolutely no evidence that would be the case, since there's absolutely no incentive for people to get more healthcare than they need - because getting healthcare is such a generally unpleasant experience, traditionally, that only the mentally ill seek it out when they don't perceive a need for it.
So there would be no overcomsumption. Consumption would simply rise to the natural level - the exact amount of consumption necessary to support the health of our nation. The question for privatized-healthcare's defenders is, why should we support the system that artificially holds consumption below that natural level? Where's society's interest in privileging a few with an undercapacity healthcare system at the expense of many who get no healthcare at all?
While correctly pointing out the many shortcomings of Canada's socialized medical system, Holdfast says: "Canada does very well on things like routine Drs. visits ...".
Of course, even that is incorrect: millions of Canadians cannot even get a family doctor because there are not enough doctors available. Again, basic economics (hey, let's just call it common sense) -- which ideologues like Chet reflexively deny even exists -- dictates that supply will never be able to match demand if the free-market mechanism of price is interfered with. And, of course, that is one of socialism's axioms: the state knows what's best for you even if -- though you're an adult -- you don't realize that yourself.
So, in Canada, we're all treated equally -- equally badly.
While correctly pointing out the many shortcomings of Canada's socialized medical system, Holdfast says: "Canada does very well on things like routine Drs. visits ...".
Of course, even that is incorrect: millions of Canadians cannot even get a family doctor because there are not enough doctors available. Again, basic economics (hey, let's just call it common sense) -- which ideologues like Chet reflexively deny even exists -- dictates that supply will never be able to match demand if the free-market mechanism of price is interfered with. And, of course, that is one of socialism's axioms: the state knows what's best for you even if -- though you're an adult -- you don't realize that yourself.
So, in Canada, we're all treated equally -- equally badly.
Ms. McArdle:
I believe my second identical posting was caused by simply refreshing the comments page to see if anybody had responded.
ie Seems like a bug in the software because I definitely didn't post twice. I suspect this caused several of other previous multiple copies.
Re: So, in Canada, we're all treated equally -- equally badly.
If this is true why is there no great hue and cry in Canada to abandon the system? Sure, people carp about this or that problem with it-- nothing is ever perfect, there's something to complain about no matter what-- but when Canadians are asked if they want to convert to a US-style system, support for that is less than if you asked if they want to outlaw hockey. I don't think you can reconcile the popularity of single payor in Canada (despite gripes about this or that), with some grandiose claim that it's overall horrible.
Again, basic economics (hey, let's just call it common sense) -- which ideologues like Chet reflexively deny even exists -- dictates that supply will never be able to match demand if the free-market mechanism of price is interfered with.
It's really interesting how many Americans are experts on the Canadian health care system despite having never lived there, ever. If single-payer health care is so awful at providing enough medical care, one has to wonder why the only first-world nation suffering a major health care access crisis - as well as a substantial movement to adopt a completely new system - is the one without socialized medicine - us.
And, of course, that is one of socialism's axioms: the state knows what's best for you even if -- though you're an adult -- you don't realize that yourself.
I would expect a doctor to know what's better for me than I would, seeing as how my body didn't even come with an instruction manual. The free market simply can't efficient provide health care, because consumers can't possibly be in an informed position.
"If single-payer health care is so awful at providing enough medical care, one has to wonder why the only first-world nation suffering a major health care access crisis - as well as a substantial movement to adopt a completely new system - is the one without socialized medicine - us."
Chet, countries with single-payer have access problems as well. In a single payer system, the government might deny expensive treatment to everyone (or to the people who are not willing to wait in long lines). In a market based system, expensive treatment is denied based on ability to pay. The access problem is still present. It is just changed.
"The question was whether or not single-payer healthcare would result in an overconsumption of medical benefits, and there's absolutely no evidence that would be the case, since there's absolutely no incentive for people to get more healthcare than they need - because getting healthcare is such a generally unpleasant experience, traditionally, that only the mentally ill seek it out when they don't perceive a need for it."
Chet, you have the wrong picture in your head. Overuse is more than just more trips to the doctors office and hospital. It is also more diagnostic tests and more medication that would not necessarily be unpleasant.
Furthermore, it is pretty clear that the elderly and parents of children use doctors more when they are free. If parents weren't willing to put up with unpleasant situations, they wouldn't be parents. Similarly, the elderly have a lot of free time and a lot riding on maintaining their health (as older people are less resilient).
Single-payer systems have procedures in place to deal with the problem of overuse. One way is to make the health care experience so unpleasant that only people who really need medical aid bother to seek it. Another is to not offer (or not offer reimbursement) for certain treatments that are deemed medically unnecessary by the government.
Finally, there is evidence from the United States that overuse occurs due to single-payer systems. When Medicare was first introduced, it used a cost plus reimbursement system. Hospitals made more money if they provided more tests, treatments, and services to each patient. As a result, hospitals orderd more tests, procedures, and services, and Medicare costs ballooned. In the early 1980s, Medicare switched to a DRG system, which reimbursed hospitals based on diagnoses (rather than services provided). DRGs have helped slow the rate of growth in Medicare costs somewhat.
"question for privatized-healthcare's defenders is, why should we support the system that artificially holds consumption below that natural level?"
What is the "natural level" of health care consumption? Is that the level of health care consumption of hunter-gatherers? Couldn't one argue that any health care beyond hunter-gatherer health care is "artificial"?
"If single-payer health care is so awful at providing enough medical care, one has to wonder why the only first-world nation suffering a major health care access crisis - as well as a substantial movement to adopt a completely new system - is the one without socialized medicine - us."
Chet, countries with single-payer have access problems as well. In a single payer system, the government might deny expensive treatment to everyone (or to the people who are not willing to wait in long lines). In a market based system, expensive treatment is denied based on ability to pay. The access problem is still present. It is just changed.
"The question was whether or not single-payer healthcare would result in an overconsumption of medical benefits, and there's absolutely no evidence that would be the case, since there's absolutely no incentive for people to get more healthcare than they need - because getting healthcare is such a generally unpleasant experience, traditionally, that only the mentally ill seek it out when they don't perceive a need for it."
Chet, you have the wrong picture in your head. Overuse is more than just more trips to the doctors office and hospital. It is also more diagnostic tests and more medication that would not necessarily be unpleasant.
Furthermore, it is pretty clear that the elderly and parents of children use doctors more when they are free. If parents weren't willing to put up with unpleasant situations, they wouldn't be parents. Similarly, the elderly have a lot of free time and a lot riding on maintaining their health (as older people are less resilient).
Single-payer systems have procedures in place to deal with the problem of overuse. One way is to make the health care experience so unpleasant that only people who really need medical aid bother to seek it. Another is to not offer (or not offer reimbursement) for certain treatments that are deemed medically unnecessary by the government.
Finally, there is evidence from the United States that overuse occurs due to single-payer systems. When Medicare was first introduced, it used a cost plus reimbursement system. Hospitals made more money if they provided more tests, treatments, and services to each patient. As a result, hospitals orderd more tests, procedures, and services, and Medicare costs ballooned. In the early 1980s, Medicare switched to a DRG system, which reimbursed hospitals based on diagnoses (rather than services provided). DRGs have helped slow the rate of growth in Medicare costs somewhat.
"question for privatized-healthcare's defenders is, why should we support the system that artificially holds consumption below that natural level?"
What is the "natural level" of health care consumption? Is that the level of health care consumption of hunter-gatherers? Couldn't one argue that any health care beyond hunter-gatherer health care is "artificial"?
Chet, countries with single-payer have access problems as well. In a single payer system, the government might deny expensive treatment to everyone (or to the people who are not willing to wait in long lines). In a market based system, expensive treatment is denied based on ability to pay. The access problem is still present. It is just changed.
It's reduced, if the claims of "increased load on health care" are to be believed.
I mean you people are trying to have it both ways. First I'm to believe that single-payer health care results in an increased load due to expanded access, then I'm to believe that single payer doesn't increase access at all, it just re-arranges the chairs.
So which is it?
Overuse is more than just more trips to the doctors office and hospital. It is also more diagnostic tests and more medication that would not necessarily be unpleasant.
More tests because doctors decided they were needed. More medication because it was determined to be medically necessary.
You haven't explained how that's "overuse", or anything besides the level of health care use rising to its natural level from a period of artificial restriction.
Furthermore, it is pretty clear that the elderly and parents of children use doctors more when they are free.
Not coincidentally, those are the exact same people - the elderly and children - who require more medical attention. I'm not seeing the problem. Why is it a problem when the elderly and children seek and receive care for their medical issues?
Because you might have to wait an extra hour to get a splinter pulled? If you think it's in society's interest to restrict care to the elderly and children in order to privilege able-bodied, affluent adults, you're more than just insane, you're fundamentally amoral.
What is the "natural level" of health care consumption?
The level where people who have genuine medical problems receive attention for those problems. You're advocating another system, where we artificially underload the system by completely denying care wholesale to the poor.
Where's society's interest, there?
The other part of the argument that doesn't make any sense - under the current, for-profit system, doctors have every incentive to artificially inflate the number of people coming in for treatment (hence the popularity of useless procedures like full-body scans, chelation therapy, acupuncture, etc) because either the person pays out of pocket or their insurance does.
Under a socialized system, with doctors making a flat salary instead of running their own business, there's no incentive for such medical waste. Health care use would certainly expand (increasing to its natural level) but that might very well be offset, to some degree, by an end to the practice of doctors recommending useless procedures simply for profit.
Unless, you're about to tell me that medicine is the one business in America that doesn't ever try to expand its market?
Chet, my short response is the following:
1) You have many factual errors in your posts that indicates that you have not studied this issue sufficiently. For example, most industrialized countries such as most European countries, Canada, Japan, and Australia do not have salaried doctors. Instead, doctors are reimbursed for services by the government. (The UK is the only exception of which I am familiar.)
2) Single payer, socialized, and other health care systems have rules and regulations in place to prevent overuse. For example, a doctor might need to go to a review board before an expensive procedure is approved. Furthermore, many of these systems tend to be slow about rolling out cutting edge medical technology.
3) I support expanding access to health care services to the poor even if it means more government involvement. However, if we are going to get there efficiently, we need to get our facts straight. Advocates of expanded health care access tend to be their own worst enemies because the overstate the benefits and understate the costs. As a result, opponents can use advocates own arguments against them.
Chet, my short response is the following:
1) You have many factual errors in your posts that indicates that you have not studied this issue sufficiently. For example, most industrialized countries such as most European countries, Canada, Japan, and Australia do not have salaried doctors. Instead, doctors are reimbursed for services by the government. (The UK is the only exception of which I am familiar.)
2) Single payer, socialized, and other health care systems have rules and regulations in place to prevent overuse. For example, a doctor might need to go to a review board before an expensive procedure is approved. Furthermore, many of these systems tend to be slow about rolling out cutting edge medical technology.
3) I support expanding access to health care services to the poor even if it means more government involvement. However, if we are going to get there efficiently, we need to get our facts straight. Advocates of expanded health care access tend to be their own worst enemies because the overstate the benefits and understate the costs. As a result, opponents can use advocates own arguments against them.
*I mean you people are trying to have it both ways. First I'm to believe that single-payer health care results in an increased load due to expanded access, then I'm to believe that single payer doesn't increase access at all, it just re-arranges the chairs.*
Chet: you are confusing the supply side and the demand side.
Demand side:
Making a good free to the consumer increases demand for it. The relevant figure here is a 30% increase, according to the RAND study (which you have completely ignored).
Supply side:
Replacing bureaucrats at private insurers with bureaucrats in Washington does not increase the supply of health care. The same number of medical procedures, exams, etc will be performed. So all this new set of bureaucrats can do is move existing health care from some people to others.
The government has effective and non-effective programs. I'd have to disagree that leaving government services to private enterprises will make for better government. The reality is, most of government is outsourced to the private sector - $800 billion worth a year to be exact. Many of today's problems are still caused by the private sector, so it's not all government's fault.
For a nicely balanced site of the pros and cons of government, you should really visit http://ohmygov.com/. It's new, but it's funny and informative.
The UK is the only exception of which I am familiar.
So it does happen. Where's the inaccuracy you referred to? My only point in even bringing it up is that there's a whole suite of features we can build a social medicine system out of - salaried doctors, NHS pharmacies, etc - that address all the objects of cost overruns in the system. Someone was concerned about people getting cheaper medicines at a doctor's office than at the pharmacy, thus wasting the doctor's valuable time. Well, we can make medicines as cheap at the pharm as they are at the doctor's office - problem solved. Whether or not they do that in Japan, as opposed to the UK, is simply irrelevant. We can pick the best features of the best systems. We don't have to simply copy the UK, or Canada, or Japan.
Single payer, socialized, and other health care systems have rules and regulations in place to prevent overuse.
So what are we so worried about?
Making a good free to the consumer increases demand for it.
Again, this is ludicrous. The demand for health care isn't going to increase - the access to health care will increase to match a demand that is already there and not being met. But people don't want to go to the doctor when they don't have to, because that's an unpleasant experience.
Load on the health care system will increase to its natural level. That's obvious. The idea that demand is going to increase is ridiculous. Nobody's going to say "huh, think I'll go waste time at the doctor's office today. It's free, after all."
Replacing bureaucrats at private insurers with bureaucrats in Washington does not increase the supply of health care.
There's no reason to expect that it takes nearly the same number of bureaucrats to administer a single-payer system as it takes to administer our system. Indeed the substantial reduction in administration costs is one of the reasons for doing it.
The same number of medical procedures, exams, etc will be performed.
I would expect even more would be performed, as load on the health care system rose to its natural level. But we're hardly at a point where we've achieved full, efficient use of our healthcare system now. Many doctors struggle to keep their private practices afloat. Time and resources are wasted sending patients from out-of-network hospitals to in-network clinics many miles away.
Access to health care increasing, means that in dollar terms demand for health care is increasing (unless all those people with new access don't use it)
Also demand will increase at the margin among people who already have access.
People do indeed make decisions about whether to seek treatment or what treatment to get partially because of economic costs.
The even applies to people who are insured and consider copays and deductables.
It also does apply to "wasting time at the doctor's office"
There is no reason to expect substantial reductions in non useful administration cost.