A belligerent commenter in a recent thread demanded to know why I thought a Massachussetts style reform would stifle innovation, huh? huh? Answer: it's the costs, stupid. The only way a Massachussets-style mandate can work (the basic idea is also popular in much of Europe) is to force the price low enough that middle-income families will be willing to pay it. Otherwise you either get non-compliance or repeal.
I know this is going to sound crazy controversial, but the reason that healthcare companies innovate is to make a profit. And those profits are the first thing that politicians target when they aim to keep costs down. Sadly, so far there's little recorded success with things like drug and medical equipment development outside of the private sector.
Dean Baker is proposing that the government should set up a parallel system, to prove how awesome it can be at drug development. Perhaps surprisingly, I agree--we should have empirical validation of the notion that the market is better at drug development. But the metric has to be the same as for private companies: an actual drug that people take. Drug development is not, as the activists screaming that the NIH "really" invents all the drugs, a simple matter of finding a target that might have some effect on a disease. Once you've found a target, you need a molecule that will hit it. And not just any molecule. It has to be small enough to dose orally, unless you're developing a short-term treatment for something really gnarly like cancer. It has to make it into the blood at detectable levels without gettng chewed up by the liver. Once in the blood, it has to do what you expect, which it often doesn't, and not do anything you don't expect, like kill the patients. It has to be cost-effective to manufacture, which means not only finding reasonably cheap ingredients and a short process, but also something that scales up to produce in industrial quantities--it's no good having a great molecule that can only be produced in .5 milligram lots by a team of devoted chemists. And oh, it has to improve the lives of enough people to make it worth all the research you've invested. Once you've nailed all that, and a few things I've forgotten, you have a drug. Until then, you have a maybe interesting chemical.
Unsurprisingly, I doubt that the government will turn out to be so good at this. The record of governments at inventing consumer goods is, she said with characteristic understatement, somewhat spotty.
« Tuesday recipeblogging | Main | Comment problems again » What's the matter with Massachussetts?19 Aug 2008 05:14 pm Comments (48)
The real dividing point in this debate is this: some feel that any inequality in healthcare is morally unacceptable. If person A, a CEO, can afford to spend $1,000,000 on the very best colon cancer drugs, then the plumber with the same disease should also be able to get them. Innovation-new and better products- is always available only to the wealthiest people initially. I would ask this question: what level of inequality is one willing to accept? 
There are times when the "competitive" forces of the markets discourage the best, most cost-effective medical care. For many years, my husband worked for an organization doing oncology research. One of his frequent complaints was that most insurance companies won't let patients participate in clinical trials, though the trials were for drugs already approved and provided crucial data on the best treatments. My father died of prostate cancer. When he was diagnosed, the treatment he was given was already five years out of date, but it was the treatment his physician was familiar with. There's also a tremendous inertia in the medical system. A good example is a company I know of that's developed a blood test to detect breast cancer. It's highly accurate. But the US medical establishment relies on unreliable mammograms. The blood test will tell you if you have breast cancer, but would require a mammogram to locate it. But the mammogram, as the first line of detection, is not always accurate, particularly in women with dense breast; but getting physicians to change detection methods may well take pressure from insurance (they have a vested interest, breast cancer is one of the major illnesses that trigger malpractice suits,) or government nudging. I would agree that private industry is better at innovating. But between old, large corporations wanting to protect research they've already invested in and the inertia in medical system, I think there's a large role for government to play in encouraging best practices.
JonF: You comment is exactly the reason why comment threads can be worthwhile. It's a cogent explanation for an opinion that I can't begin to wrap my head around. I would like to suggest that it's time to focus on consolidating our gains and ensuring that they are equitably distributed. Let me ask you this. If it's OK to deny everybody future advances in medicine (by shutting down the train of improvements) why is it wrong to deny just some those advancements (because they can't afford it)? Surely your proposal increases net human suffering. Not to mention that yesterday's cutting edge medicine becomes tomorrow's standard of care. Why does equity outweigh all other concerns? If there's something that large numbers of people really believe is vital and are willing to fund, then why not fund it through a targeted tax increase, sale of bonds of something like that, the way we fund (or uesd to fund) a war effort? What about things that are vital to (relatively_ small numbers of people? And given the pace and scope of breakthroughs in genomics, I think the advances of the last century are nothing compared to what's coming up. I think we're just about at the knee on the exponential growth curve. I really don't want to shut it down now. All that said I do think that advances in genetics are going to finally break the insurance model of health care funding. No insurer will write an affordable policy for a catastrophic illness that you're highly likely to suffer from. What I think we need to do is two-fold. One, break the expectation that someone else is responsible for paying your health care bills. Two, establish a basic standard of care (generic meds, non-cutting edge technology, etc.) accessible to anyone and paid for on a sliding scale. Sure, if you don't have the money you don't get the best/em> care, but you get reasonable care. Those who do have the money get the best care, and eventually that improvement in care trickles down.
JonF, But how would you get people to take "No" for an answer? For example - we could say that all current medical treatments will be covered, but all new treatments will need to be paid with supplimental insurance or out of pocket. So, if you are diabetic, they will pay for your insulin and testing supplies. However, if they come out with a $60,000 lab grown pancreas, you're on your own. Costs will still rise - unless there is a global ban on medical reserach. And, I really don't see that as politically possible.
JonF, But how would you get people to take "No" for an answer? For example - we could say that all current medical treatments will be covered, but all new treatments will need to be paid with supplimental insurance or out of pocket. So, if you are diabetic, they will pay for your insulin and testing supplies. However, if they come out with a $60,000 lab grown pancreas, you're on your own. Costs will still rise - unless there is a global ban on medical reserach. And, I really don't see that as politically possible.
I really don't see [a global ban on medical research] as politically possible. Before even considering whether or not it's politically possible we should show that it's socially desirable. I don't believe that it is. There was far more equity in health care 100 years ago but, measured by outcome, even the poorest person now gets far better care than the richest person 100 years ago. Equity is simply not a good metric on which to base a health care policy. It plays a role, sure, but it shouldn't be the overriding concern.
Zic- Your anecdotes provide illustrations merely of this: that improvements in understanding, and in processes, do not always occur in an ideal fashion. There are delays, missteps, and sometimes even lazy, stupid, or selfish people doing things to impede progress. Why on earth, though, would you think that these are features only of a private, distributed system and not of a centralized one? You speak of government encouraging best practices. How will they know what best practices are? Yes, an outside, disinterested party is well-equipped, especially retrospectively, to point out what should, or should have happened, but is that what the government is likely to be, and in those circumstances? JonF's lamentable suggestion points out more clearly a central fallacy in redistributionist thinking - that of the static framework. Rather than looking at how both the poor and the rich have things better today than yesterday, and certainly have things even better tomorrow, one sees only today's inequality, and decides that this is so undesirable as to swamp other considerations. Which immediately generates the absurdity pointed out by SG. People, the 20th century was one big, sometimes very sad, often embarrassing exercise in displaying just how universally bad is the idea that equality can and must trump everything. We've pretty much come to accept that - due to our wealth created by, all together now, capitalism and technology - we can afford to support and want to support some measure of redistribution, whether a safety net or a minimum standard of living or what have you. But full-on 'make sure everyone has the same stuff' is exactly as bad an idea, and as unworkable a one, as it ever was. And was it ever. So stop it. Please. You can demonstrate how much you care, and how selfish and evil other people are, in many, many other ways.
JonF, But how would you get people to take "No" for an answer? For example - we could say that all current medical treatments will be covered, but all new treatments will need to be paid with supplimental insurance or out of pocket. So, if you are diabetic, they will pay for your insulin and testing supplies. However, if they come out with a $60,000 lab grown pancreas, you're on your own. Costs will still rise - unless there is a global ban on medical reserach. And, I really don't see that as politically possible.
There is another bug - I only hit "Post" once but it showed up three times.
There is no way to ensure equal health care for everyone. Start with the fact that there are huge variations in the quality of doctors, just like there are huge variations in the quality of professional baseball players. In a government run system, the best doctors will serve the politically connected. Is that morally superior to a system where the best doctors serve those who can pay the most? Public policy should be to ensure some minimal level of health care for everyone. After that, it should be at the individual's expense. Let's have the debate about what that minimum ought to be.
jmo, When I post a comment here, I get a page with the notation at the top that my comment was submitted. If I refresh this page, I have found that my comment gets reposted. This is a poor feature of this software, and I find I have to back out until I am on Megan's front page, then reenter the comments section.
Jon F., I suggest you run for office on the platform of telling people (and their families), who are dying and/or suffering from diseases for which there is little in the way of effective treatments, that from here on out consolidation and equitable distribution are the primary concerns. Let us know how that goes. Proposing major health care delivery reform, with the goal of cutting spending, is pointless until one is willing to look someone, and their loved ones, in the eye, and say "Sorry, pal, but it's time for you to take a dirtnap. Happy travels!" Also, how long will it take until someone in this thread proposes that the model of capital management which produced the F-22, the V-22, and Nimitz-class carriers is a good one for developing goods which will be personally used by tens of millions of consumers? This subject is almost entirely immune to rational examination.
Keeping aggregate health care costs down under our current system will have little effect on "innovation." The problem with our health care system is millions of ways that money gets spent on administrative tricks designed to keep people off of the insurance rolls and useless treatments that have nothing to do with improving people's health. Just look at per person spending on health care administrative costs in in the US versus countries like France, the UK, hell, any country with a halfway decent health care system. Now, I am someone who happens to think that the patent system matters for spurring innovation. But I don't see European pharmaceutical companies throwing up their hands and saying "Hey, we have government sponsored health care. I guess it's time to close up our R&D shop." No, our current system is designed to generate drugs that keep people taking consistent doses over the long term--cholesterol drugs are typical of this phenomenon.
Eriver -- The concept of "Best Management Practices" has long been used by a number of industries. Many are defined in the rule making that stems from law; environmental best management practices are a great example. And there are already groups like the American Medical Association that can, and to some extant, do set standards. But such standards are themselves an investment -- particularly in the practice of medicine -- because of the steep learning curve that doctors constantly need to maintain to keep updated. There's a tremendous drive for corporations to protect investments in treatments/testing/equipment that have gained acceptance but are outdated. And there's the inertia of providers that have invested in equipment and training that is outdated by innovation. I'm not convinced that market forces are the best place to put our trust in deploying innovative health care in the face of these obstacles; particularly if you consider where those forces have brought us to today. But I live in Maine, where folks regularly drive to Canada to buy their prescription drugs because they're cheaper. Same drugs, same manufacturers, different price.
SG: *I think we're just about at the knee on the exponential growth curve. * Exponential growth curves are self similar. They don't have a knee. Sorry, I'm a former mathematician, couldn't let that one slide.
Zic- "I'm not convinced that market forces are the best place to put our trust in deploying innovative health care in the face of these obstacles; particularly if you consider where those forces have brought us to today." Jeez, Zic, there's very little innovation in health care that doesn't come from the US. And again, the whole inertia/protected investments thing - sure, yeah, that sucks. Why would you expect the government to do better? Don't get me started on BMP. It's not like all the consultants are taking early retirement because there's nothing left to do. My wife's at a steel mill right now.
Ninja Zombie, You're are, of course, correct. But on a macro scale it does look like there's one. Who was it who said "man's greatest failing is the inability to comprehend exponential growth"?
Eriver, Zic's quote was about "deploying" innovations, not "developing" innovations. They're not the same thing. I get the impression that he was talking about a government mandated standard of care that didn't allow you to (unknowingly) be getting treatment that was years out of date simply because your physician couldn't be bothered to stay on top of the most recent advances. I don't know how I feel about this, but it's not inherently ridiculous.
Megan- Two quick thoughts: (1) I suspect that you vastly overrate the importance and value of technological innovation in improving the health status of the population as a whole. I think there's some fairly compelling evidence that many innovations (diagnostic scans, back surgery, heart stents, prostate screening, and many many pharmaceuticals) are vastly overused, and may, in the aggregate, do more harm than good. Brownlee's Overtreated is a very good overview on this. (2) For the sake of argument, let's assume you're right and that improvements in the quality of healthcare are largely dependent on market driven technological innovations. Then consider these facts: for some time now, every other country in the industrialized world has (a) regulated healthcare far more significantly than the U.S., (b) as a result spent significantly less per capita on healthcare than the U.S. and (c) seen health outcomes that are comparable or slightly superior to the U.S. From these basic facts, it follows that, if technological innovation really is so crucial, then the rest of the industrialized world has been freeloading in a major way on the innovation that the United States funds. To put it another way, the reason they can afford to spend so much less on healthcare than we do, is because we are paying much of the cost of developing new treatment for them. If this is the case, this seems like a major, major drawback to the status quo, and one I'd be curious how you'd address.
gaucho, apparently, you do not believe that European pharmaceutical companies are aware that they can sell their newly developed drugs in the United States' market, and thus earn profit margins not reduced by price controls. I saw an interview with a Norvatis exec a few weeks ago in which he openly stated that it was the U.S. market where the lion's share of his company's profits were derived from. GW, the freeloader problem is indeed real, and a damned hard problem to solve, without risking depriving oneself of future innovation, in an effort to stop the freeloaders.
Here's a link to a story on the Massachusetts health plan: Unless somebody refutes this, I conclude a) over 400,000 more Massachusetts residents have gained medical insurance due to the plan, b) emergency room use in Massachusetts is down, c) Massachusetts doctors are not fleeing the state in horror, d) Mass General is still a great hospital, e) they're still doing medical research at Harvard, and f) insurance companies in Massachusetts are still making money. In short, Megan's post, like all of her comments on medical insurance, are alarmist and ill-informed.
Stan, is there some reason to believe that delivering health care in Massachusetts is nontrvial to medical research at Harvard, compared to the total market for health care delivery? Is there some reason to think that medical research at Harvard is indicative of what is happening with regard to total private capital devoted to medical innovation, or are you one of those people who believe that private capital is trivial to bringing valuable medical innovations to market? It would be nice if you thought a little bit before adopting a ridiculously sarcastic tone.
SG- Yes, zic's emphasis was on deployment, and my second (quick) comment specifically addressed development. My bad. Nevertheless it is not clear that government will be any better able to identify best practices that a distributed market model. There is always a lot of waste, inefficiency, and just plain bad decisions in an unfettered market, and it's not all creative destruction. Yet it creates more than enough wealth to make up for all that. The illusion that we can superimpose deployment of goods onto an existing market-like engine of creativity was the subject of most of my first post. It would be superior if tomorrow and twenty years from was bound to look exactly like today. But it is not so. And that's why decoupling development and deployment even for the sake of an argument is more than a little shaky. Insurance companies perform some of the functions of health boards in countries with nationalized health care, and they are routinely vilified for them (as are the borards in Britain, France, etc.) Determining which procedures, tests, are valuable, helpful, cost-effective, etc., and making sure everyone gets them - is it really difficult to see how this would, and already does, stifle progress? Instead of lots of experiments, we have one best guess. Again, great if tomorrow will look just like today. Or if you want it to.
"""" The only way a Massachussets-style mandate can work (the basic idea is also popular in much of Europe) is to force the price low enough that middle-income families will be willing to pay it. Otherwise you either get non-compliance or repeal."""" This is not true. There is a simple way: hide the costs. Tell people that they're not paying, that their employer is. Take it out of their paycheck before they get the money. It normally works.
I get the impression that he was talking about a government mandated standard of care that didn't allow you to (unknowingly) be getting treatment that was years out of date simply because your physician couldn't be bothered to stay on top of the most recent advances. Instead, you can get a treatment that's years out of date because the government office in charge of the standard of care either doesn't bother to stay on top of advances or is excessively cautions and beset by inertia. The FDA is the target of much criticism for delaying lifesaving drugs. I don't know how much of that is really justified, but adding a second institution to the government which also ponders safety and efficacy is not obviously going to produce good results. And that's aside from the constitutional implications of moving regulations on the practice of medicine to the feds.
Time heals all wounds. The great thing about our health care system is drug patents and their limited time periods. The government granted monopoly for 20 (or however long it is now) years draws massive private investment in new drugs. But the fact that they are time limited allows Wal-Mart to sell $4 generics. It's win-win for most of us.
In discussing a national standard of care, you'd have to have some data on what the impact of out-of-date treatments are. I don't have that data (or even a gut feel on what it might be), so I'm not personally arguing for or against it. I can certainly imagine implementations where the cure was worse than the disease. But I can imagine implementations where it's not. Suppose that, instead of approving new treatments, they were limited to pruning out protocols that were determined to be ineffective (or simply less effective) than newer treatments. They oversaw the exit instead of the entrance. Or, they didn't have any enforcement mechanism per se, but if your doctor was following a course of action not on the recommended list, it required a more informed consent. It would encourage doctors to stay up-to-date (lazy doctors would want to avoid the extra paperwork) without unduly hindering dedicated doctors from pushing forward with new protocols. Or, instead of defining any particular course of treatment, they established an infrastructure where anonymized patient data was (required to be?) entered such that researchers could perform ad hoc "clinical" trials with back tested data. They create a nationalized health data exchange infrastructure to facilitate developing an improved national standard of care. Like I said, I'm not necessarily advocating any of this, but it's not inherently crazy. The devil's in the details.
GW, There are a few problems with your discussion. 1) The value of an innovation and the overuse of an innovation should be treated as different issues in my mind. Curtailing innovation because an innovation can be overused seems like throwing the baby out with the with the bath water. For example, I have seen studies that argue that angioplasty might be overused. However, those same studies indicate that the benefits to angioplasty in general are large. (In economics terms, this is the difference between marginal and total benefit.) 2) Refusing to pay for innovation because some people will free-ride on your expediture does not strike me as particularly rational.
GW, There are a few problems with your discussion. 1) The value of an innovation and the overuse of an innovation should be treated as different issues in my mind. Curtailing innovation because an innovation can be overused seems like throwing the baby out with the with the bath water. For example, I have seen studies that argue that angioplasty might be overused. However, those same studies indicate that the benefits to angioplasty in general are large. (In economics terms, this is the difference between marginal and total benefit.) 2) Refusing to pay for innovation because some people will free-ride on your expediture does not strike me as particularly rational.
Megan, The argument about drug discovery holds little water. New drugs that have proved use have a protected period and are sold at high cost. "Me too" drugs, the most common new drug made (statins as an example) do as well, but that doesn't mean we should use the more expensive I would favor eliminating subsidies and having a Medicare plan available for everyone. After one person in your family is denied service or made to call 100 times to get reimbursed for something, I guarantee you will switch. Thanks, Josh
Stan, Massachusetts is already facing unanticipated cost overruns in it's new healthcare program, and has yet to institute any cost controls. Indeed, the state is asking the federal government to pick up half the cost, something that is not only not a guarantee, but is just a means of diverting the costs out of Massachusetts. A mandate/subsidized insurance program will face a cost containment problem with healthcare costs increasing at excess rates of inflation. How this certain problem is addressed is the point of McArdle's blog entry. As healthcare costs continue to escalate, the state of Massachusetts will have to limit its subsidies in some manner.
If it's OK to deny everybody future advances in medicine (by shutting down the train of improvements) why is it wrong to deny just some those advancements (because they can't afford it)? "If it's ok to deny people futuristic robot butlers, why is it wrong to make people slaves now?" "If it's ok to deny everybody magic pizzas that don't exist, why is it wrong for some people to starve to death?" I wonder if you can even conceive how stupid a question you've asked.
Chet, What is difficult to conceive is why you think your analogies make any sense?
Stan, as Yancey says, the Massachussetts program is costing more than expected, and heavily reliant on a federal subsidy that expires this year. As the costs mount, the state is going to either have to spend a hell of a lot more money on it, or institute cost controls. Your point about Harvard is just silly. Medical innovation invented in Massachusetts doesn't stay there; if it did, there wouldn't be very much of it.
I used a sarcastic tone in my earlier post because I don't understand Megan's argument. The premise of her original post is that the cost of the Massachusetts program if implemented nationally would preclude innovation in medical science. Huh? We don't have a law saying the US can spend only x dollars on all health related issues, so if we spend y dollars on health care only x - y is available for medical and pharmaceutical research. If spending more on providing health care causes less to be spent on research, why doesn't spending y dollars on highways or missile defense or the Iraq War have the same effect? Opportunity cost isn't specific to spending on health insurance. There's a second aspect of her argument that I'd like to think isn't really there. This is the notion that it's necessary for low income people to go around with rotting teeth and substandard medical care so that the rest of us can enjoy the fruits of medical innovation. This sounds like John C. Calhoun's argument in favor of slavery. I don't want to think Megan feels this way because she seems like a decent person, so I hope I'm only imagining this.
Chet, there's no reason to be rude simply because you're unwilling or incapable of following the discussion. When you find yourself confused, you should either politely ask questions or simply keep quiet. You'll save yourself embarrassment.
The premise of her original post is that the cost of the Massachusetts program if implemented nationally would preclude innovation in medical science. No, it was that innovation (in the private sector) occurs because of the profit motive, and a MA style system, if it is to reduce costs, will have to reduce profits. Doing so will make innovation less/unprofitable, and so we will get less or none.
if technological innovation really is so crucial, then the rest of the industrialized world has been freeloading in a major way on the innovation that the United States funds. To put it another way, the reason they can afford to spend so much less on healthcare than we do, is because we are paying much of the cost of developing new treatment for them. If this is the case, this seems like a major, major drawback to the status quo, and one I'd be curious how you'd address. You have nicely summarized the overall situation G-Dub. The fact that profits may be made on medical innovations in America has made America the source of much of the world's medical innovation. I would also like to note that Will Allen has correctly identified the reason why there is still any significant medical R&D conducted outside the U.S. - to wit, that non-U.S. medical innovations can be sold here at American prices, garnering American profit margins and benefiting from American intellectual property protections. Is medical innovation worth the high cost burden to Americans? I vote yes. Current high expenditures on medical research are investments in a much better future - one of disease- and degeneration-free lives of indefinite length. American life expecancy has advanced by roughly four months per year over the past decade or so and the rate of this advance has also picked up steam. In the last three decades, death rates from many diseases that are primarily those of old age, such as heart disease and cancer have fallen. In the last three years, even the absolute numbers of deaths from cancer have fallen in the U.S., though the total population here continues to increase. It is true that Europeans and other citizens of advanced industrial nations that run strongly nationalized/price-controlled health care systems benefit comparably while paying much less of the R&D burden, but I say, so what? If I get to live significantly longer, and enjoy a better quality of life while doing so, then dragging along some parasitic Canadians/Europeans for the same ride doesn't strike me as too high a price to pay. There is excellent reason to believe that the current trend of accelerating life expectancy improvement will continue. Human biochemistry is complex, but not infinitely so. It has a finite number of failure modes. Modern health care research depends increasingly on computational models, gene sequencing, cell sorting and other information technologies the capabilities and costs of which are governed by Moore's Law. Thus, the basis of the tools needed to improve human medical well-being are getting at least three orders of magnitude more powerful for a given cost each decade, while the complexity of the problem being addressed - how to produce good human health of arbitarily long duration - is essentially static. At some point, then - probably within the next three or four decades, - human medical well-being will join Trigonometry as a closed field in which there are no unsolved propositions. Thus, the current high expenditures for medical research, and the application of the innovations that flow out of it by the health care system, will self-limit as they reach a point of effective completion. When we can all live indefinite healthy lifespans, I'll be happy to let Zic have his desired stasis. By that time, of course, no one will have to mandate such a thing. Looked at from the standpoint of long-term demographics, it seems inevitable that the relative magnitude of the current free-rider problem is only going to decrease in the interim. European populations are already more elderly than America's and most are reproducing at barely half to two-thirds of the replacement rate. Thus, until the time when all humans can enjoy perfect health idefinitely at trivial expense, we can afford to drag the free-riders along as there will be fewer and fewer of them over the next generation of two anyway. In another hundred years, we'll all - Americans and Euro-weenies alike - laugh about this and wonder what all the fuss was about.
Rob, I don't understand your comment. Medical innovation doesn't come from insurance companies. It comes from health care providers, i. e. doctors, pharmaceutical companies, and manufacturers of medical instruments. The system used in Massachusetts is concerned with the financing of medical care. That's all it does. It's already reducing costs because emergency rooms in Massachusetts aren't being used as much for routine medical care, and because, despite what many people in this forum seem to think, there are benefits to early detection of medical problems. I don't see how this inhibits medical and pharmaceutical research. Sorry for being obtuse.
Dick, You paint such a lovely picture I'm reluctant to disagree, but I vote for unforseen complications making things complicated. As for the Massachusetts Mandate, I live in Mass, and I use independent insurance, and so far, it has been lovely (My costs went down by 1/2). The problem is that the state can't really afford to pay for it, so we will either need to have higher premiums, lower benefits or much higher taes starting in a year or two. I hope that someone will manage to get the whole system to work, as it's the best chance we have to sustain both private innnovation and something approaching universal access. At the moment, I just don't see that happenning.
The system used in Massachusetts is concerned with the financing of medical care. That's all it does. As long as it does not attempt to squeeze providers' profit margins, then no problem. I am not sanguine that they will avoid squeezing providers' margins, and our gracious hostess is up front about assuming that they will.
Now that I can finally reply, I will state that I threw my comment (#1) out there as a deliberate provication. And I can't say as I'm happy with what I got back. Apparently the attitude that flourished under the Divine Right of Kings and aristocratic privelege is alive and well and in America.
*First off, I would have no problem running on a platform of denying things that don't even exist to people (What? You mean I can't have a Jetson's aircar?)* Good idea, lets just shift it backwards in time a little bit. How about we deny people health care invented in the past 30 years? This would certainly make medicine cheaper. No more of those expensive MRI's, CT's are 80x80 pixels (the size of icons on your desktop), and the only drugs available are no longer patented (hence cheap). For some reason, I think most people would not like this. *That's a lot easier to sell* You've come up with a nice way to hide the costs, as with the broken window fallacy. You could probably fool a lot of people this way, apparently including yourself.
I ask a question with my first comment, Jon- what level of inequality will you accept? From your second comment, I take it that you will accept no inequality in the case of healthcare. Is that the case?
What you said doesn't even make sense... "I would have no problem running on a platform of denying things that don't even exist to people" That's all well and good... until some of these things become available - how do you think people will react when you refuse to pay for them? How are you going to convince people not to be upset about not having access to new technology?
How do people manage to convince themselves that their envy is a virtue, and elevate that belief to the point where they find the non-envious morally deficient? JonF, I hope you have good health insurance. You're going to hurt your shoulder patting yourself on the back.
JonF, it is hard to take you seriously when you refuse to argue in good faith. Divine right of kings, permanent underclass, losers who don't deserve healthcare, nobody is arguing in favor of those things. Indeed, they have argued quite the opposite, that market economics will in the long run provide better health care for everyone, including the poor you insist you care so much about. Those other things are all just a bunch of crap that you made up because you are unwilling to have an honest discussion on the subject of how healthcare incentives affect innovations. Since our host's policies prohibit personal insults, I'll keep to myself my opinions of people who engage in such dishonest debate. You can probably guess anyhow. You profess to be skeptical that there are any lifesaving inventions to be had through medical research, but it is hard to understand how such a position could arise except by willful ignorance. The last few decades have seen enormous strides in medical technology that have saved countless lives. Moreover, those treatments, initially available only to the very rich, have gradually become standard for all patients. In other words, the system has in the past worked just as the market advocates claim it does. You claim that in the future it will be different, but you offer no argument as to why; indeed, you speak as if you think no such argument is necessary. I guess it's easier to head off arguments about costs vs. benefits when you arbitrarily assign the costs of your position to be zero. It is true that there are some people who are ill-served by our system, but then that is true of any system. Why is it that you judge market outcomes by their failures, ignoring the successes, while you judge socialized outcomes by their successes, ignoring the failures? Moreover, I happen to think that failures in our healthcare system are more a result of poverty generally than of anything specific to the way we provide healthcare. Perhaps we would be better served by getting government out of healthcare and concentrating instead on the root causes of poverty. But the false dichotomy you have created does not even admit such a position. Either you are in favor of dismantling the market for healthcare, or you are one of those "divine right of kings" jerks. This is an intellectually dishonest position, to say the least. Despite everything I've said above, I'd be willing to support subsidizing healthcare for the poor. I think that a health reimbursement account of the sort you are starting to see in some private insurance plans would cause the least harm to the overall market for healthcare while providing a good level of benefits for the poor. However, such a system would still admit inequality. Trying to insist otherwise will only make everyone worse off, cost countless lives, and doom innumerable others to poor quality of life. And, to borrow your turn of phrase, hell will freeze over before I sign on for that. Given your professed moral rectitude, I'm surprised to find you in favor of it.
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Megan,
Any healthcare reform worth doing (including a McCain style overhaul) will, one way or another, be aimed at stiffling healthcare inflation: AKA, bringing down costs. I think we just have to accept that fact. We can't spend an infinite amount of money of healthcare. Something has to choke off the ever-increasing flow.
I think the real querstion is, why do we need a lot of innovation in healthcare these days? In the past century or so we've worked wonders beyond what our ancestors could have believed. While there are a few things we'd all put on a wish list (treatments for Alzheimers, for the remaining cancers, for MS, etc.) I would like to suggest that it's time to focus on consolidating our gains and ensuring that they are equitably distributed. If there's something that large numbers of people really believe is vital and are willing to fund, then why not fund it through a targeted tax increase, sale of bonds of something like that, the way we fund (or uesd to fund) a war effort?
Posted by JonF | August 19, 2008 6:04 PM