Over at First Things, Eric Chevlen, an oncologist, has a thoughtful piece on how we should think about rationing:
Limiting health care's availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual. Are the lives of the poor not of the same intrinsic value of those of the wealthy? To be fair, it is rare in the United States that poverty alone prevents the uninsured poor from receiving lifesaving intervention in a healthcare crisis. A poor man having a heart attack is not turned away from the emergency room, nor is the poor woman in labor sent away to have her baby at home. (I am not arguing that such enormities never occur, but the fact that such occurrences remain scandalous and newsworthy is a testament to their rarity.) Yet it is equally undeniable that the poor get a lesser share of the preventive care that can maintain health or of the quotidian care for the less dramatic challenges to their health.
There are two major alternatives to the allocating of health care on the basis of personal wealth. Both involve a large number of individuals agreeing (or having imposed on them) that the amount of health care they receive will not be in strict accord to how much they have paid for it. The cost will be distributed over the healthy as well as the sick, even though the benefit will inure only to those who are ill or who need health care to prevent illness. People accept the certainty of a bearable cost to avoid the risk of an unbearable one. But to the extent that these collective programs sever the connection between paying for health care and receiving it, they generate increased demand for health care. The individual feels that he has already paid for health care. When he is sick, or thinks that he is sick, he feels fully entitled to care with no consideration of cost. After all, he has already paid for it, hasn't he? Given the limited amount of health care that may be bought with the aggregate funds of the group, this untrammeled demand for it must always result in rationing. This is true whether the collective effort is a private insurance plan or a government program. Rationing is inevitable in all collective health care financing schemes.
Rationing must occur, but it need not be admitted. Denying the truth of rationing is more common in government-run health care schemes than private ones, because the government is reluctant to have the people know this ugly fact. Government-run programs, therefore, are more likely to disguise the rationing. This plausibly deniable form of limiting health care is called implicit healthcare rationing, and it assumes many forms. Rationing by termination occurs when patients are discharged from the hospital earlier than is medically optimal. Rationing by dilution occurs when second-best rather than first-best treatment is provided. Rationing by rejection or redirection involves healthcare providers turning away patients whose care will be inadequately reimbursed. This is commonly seen now in the Medicare and Medicaid programs, because those programs reimburse providers at a rate substantially lower than private insurance plans. Perhaps more common than those forms of rationing is rationing by delay, as exemplified by the outrageous amount of time patients in Canada must wait for hip replacement surgery or colonoscopy. The unifying theme in all these forms of implicit rationing is that, without admitting it, they force some patients to forego medical care that they want and are ostensibly entitled to receive.
Private insurance plans sometimes include an element of implicit rationing, but because they are, at heart, contractual agreements between the insurance company and the insured are more likely to ration health care explicitly. The many pages of the healthcare plan describe what is a covered service, which providers will be reimbursed for services, the duration of coverage, the dollar limit, and so on. The advantage of explicit over implicit rationing is obvious: It gives potential customers of the insurance plan information to use when deciding which insurance plan to buy, and gives them clear expectations of services to be delivered. Implicit rationing, by contrast, may have the sweetness of a promise, but is usually succeeded by the bitterness of a promise broken.
All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities. Thus we come to the terrible question we would so very much like to avoid: How shall we ration health care? How shall we explicitly ration it? So noxious a question is this, so offensive in its tacit assumptions and implications, that most politicians and wishful thinkers will deny that we need to address it at all. They will argue that the fundamental problem is one of distribution, not one of unmeetable demand. They will argue, with more enthusiasm than evidence, that an emphasis on preventive care would substantially reduce aggregate demand. Some will say we must reduce the role of government; others will argue that we should augment it. If only we will adopt their plan--they'll say--waste, fraud, and abuse will be abolished. There will be chicken--or at least chicken soup--in every pot, and a vaccine in every arm. People love honesty, but they hate the truth. To frankly acknowledge and address the ineluctable reality of healthcare rationing is not merely to touch the proverbial third rail of American politics; it is to lie across the tracks in front of the onrushing train.
Come, let us speak of unpleasant things. How is health care to be rationed? Who gets the short end of the stick?
... the insurance plan ... gives them clear expectations of services to be delivered.
That is a remarkably powerful pair of rose-colored glasses the good doctor is sporting.
"Limiting health care's availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual. Are the lives of the poor not of the same intrinsic value of those of the wealthy?"
Just so. In point of fact rationing anything based on wealth should offend our sense of the dignity of the individual. Merely because you are incapable or unwilling to produce enough value to exchange for the things you would like to consume is no reason -- in a society as rich as ours -- that you should have to forgo consuming them!
Why should the rich, smart & hard-working get to enjoy fine dining, exotic vacations and elegant tailored clothing while the poor, stupid & indigent must do without? Just because the rich are lucky enough to have inherited gumption and talent?
We will not have a just society until everyone has the very best of everything -- by which I of course mean that no one should have anything nice until everyone does. If that means that no one ever has anything nice ever again so be it. We shall be able to console ourselves that we are suffering for the greatest expansion of social justice the world has ever known.
On the specific topic of health, this line strikes viciously at my conscience: "nor is the poor woman in labor sent away to have her baby at home. (I am not arguing that such enormities never occur, but the fact that such occurrences remain scandalous and newsworthy is a testament to their rarity.)"
If even a single mother is turned away from a hospital we have utterly failed as a society. It is these kinds of stories, more than any other, that have convinced me of the dire need for an immediate adoption of a comprehensive, government-controlled health system in this country.
Once we have a proper, rational, compassionate health system like those enjoyed by Canada and the U.K. there will never again be a case of a pregnant woman w/o a bed to give birth in. It just will not be allowed by the compassionate experts brilliantly provisioning for our needs.
"We shall be able to console ourselves that we are suffering for the greatest expansion of social justice the world has ever known."
Mao managed to bring "social justice" to an awful lot of people in his lifetime. Of course now the Chinese are wrecking it with all that growth. They don't seem to appreciate the injustice they're spreading by allowing millions and millions to climb out of poverty.
It's too bad we can't order our society around the principle, "From each according to his ability, to each according to his needs." That would solve everything.
I must admit that I cannot tell whether you are being sarcastic, or you really are that big of an idiot.
You assume (wrongly) that "rich," "smart" and "hard-working" are all aligned. There are plenty of "rich" who are not "smart" (pick any number of "hard-working" athletes). Likewise, there are plenty of "rich" who are not "hard-working" (trust-fund kiddies come to mind). And there are plenty of "smart" who are not "rich" (thinking of scientists and others in academia).
I suppose it depends on your definition of "smart."
Likewise, there are plenty of "poor" people who are "hard-working" - who work much harder than the men in suits you probably idolize. They are not all stupid, either. Many have more common sense than some of the commenters on this blog.
The rich didn't all inherit talent (although I'll give you gumption, which isn't saying much. it takes gumption to rob a bank). Many inherited their family name and the wealth that came with it. Even the late Sen. Kennedy. At least he realized it was at least part blind fortune that he was born into wealth and status, unlike many of the nouveau riche we seem to be spawning these days.
Obviously it's a parody.
I don't think our system is perfectly just. I do think that attempts to make it more just via heavy progressive taxes and redistribution pretty consistently fail, morally. They are more likely to hurt those who have earned their bread than they manage to hurt bank robbers. And if money is fairly earned a person has as much right to give it to their kids as they do to buy a pool or a nice car.
I think you're right in many regards. I also note that politicians tend to unfairly demonize those who they want to steal from, Because it's okay to rob someone if they 'deserve' it.
"According to a study of Federal Reserve data conducted by NYU professor Edward Wolff, for the nation’s richest 1%, inherited wealth accounted for only 9% of their net worth in 2001, down from 23% in 1989. (The 2001 number was the latest available.)"
-WSJ
Coincidentally, the first site when googling inherited wealth.
Your ball.
This whole discussion is a train wreck. One one side, we have the old "if you're rich, you must have earned it; if you suffer, you must deserve it" holdover from Calvinism. On the flip side, resentment against those that may, indeed, simply be luckier, but a resentment that is blind and destructive in its own right, and misdirected. It isn't a problem that relatively few people enjoy luxury goods and lifestyles - that's why they're called luxuries. At one time, telephones and color televisions were luxuries. Resentment that someone, whether wealthy from hard work and talent or simply lucky, is enjoying a luxury that most can't, is a wasteful expenditure of emotional and intellectual energy.
But this discussion isn't about dinners at the French Laundry and trips to Bali. It is about a reasonable standard of medical care available to all members of a society that can, realistically, afford to provide a decent standard of medical care. Even if they are stupid and lazy.
That's right. Everyone who is rich is smart and hardworking. Everyone who is poor is stupid and lazy.
Although I do start to wonder, since I spy at least one idiot here who obviously has enough money (probably his parent's actually) not to worry about being in the wrong shoes. Could there be a rich lazy idiot? Noooo....not possible. And yet...
Lack of fine dining and elegantly tailored clothing won't result in your death, that's why.
Sorry, Buzz, meant that as a comment, not a reply to you. Must have hit the wrong button.
But an insurance plan does give a clear expectation of services to be delivered. Which is why people scream bloody murder about pre-existing condition exclusions, denial of payment for out of network treatment, etc. The people have an expectation of service that they feel they have paid for.
Yes. My experience in an individual plan has been there is a large gap between what you expect the insurance company to cover based on the contract and what they will actually pay when the bills show up. If you are not paying attention, they will hose you.
One of the many problems with the health care debate is the vast chasm between an academic discussion of the issues and a personal/practical discussion of the issues. Academically, insurance plans provide "clear expectations" because they are contracts, and the terms of the contract can in fact be located somewhere. But in a practical sense, insurance contracts are absurd. I am an attorney who generally reads everything I sign, but even I relied on the coverage summaries for my health insurance. Sadly, insurance summaries can be incredibly misleading, particularly (1) with regards to treatment insurance companies are most loathe to cover, such as therapy or maternity care, and (2) in individual plans.
However, Chevlen's comments on rationing generally are very instructive. The problems with private insurance contracts are myriad, but could be mitigated with either greater oversight or consumer protection laws that allow for broader definitions of fraudulent or misleading conduct in insurance contracts. Expanding government healthcare coverage would do nothing to change the fact that often people are not covered for the care they most urgently need, and as Chevlen points out, denial of care could become even more inexplicable under a government plan than it currently is under already inexplicable insurance contracts.
Sidetrack: I've noticed a similar problem with respect to advance directives (living wills). They contain much boilerplate about not wanting to live in a vegetative state, but are usually silent on the much, much more common scenario of severely declining health that remains far short of vegetative. Thus, they are of much less practical value than they could be if they reflected a clear, frank consideration of a person's wishes.
That was the single best discussion of the issue of health care rationing that I have seen anywhere.
"...Rationing must occur, but it need not be admitted. Denying the truth of rationing is more common in government-run health care schemes than private ones, because the government is reluctant to have the people know this ugly fact."
One of my naive, basic assumptions as a youngster, was that we actually voted for people who would be willing to talk truth, be frank and help us determine what we need, not just what we want. In the decades since getting the vote, my naivete has been sorely abused by the politicians who will turn themselves into knots so that they won't have to tell an ugly truth, but will smile and lie to us with the same alacrity as the taxman's hand invades our wallets.
The last thing we can do is leave the decisions for rationing up to any government run group. A gimlet-eyed accountant should, likewise, be prevented from setting policies or procedures that lead to a de facto rationing. My belief is that we need to energize people in the health care industry (dispensers and implementers, not insurers) to take the lead on what we have and what we can do. Surely there are enough people with a heart that is truly pure enough to work for the best in individuals and a society, and with an intellect to match.
Start there and then determine the pieces and the parts of what we've got, how much do we need and how to get the rest of the needs, or how to establish humane rules where rationing starts.
While I agree that any sensible system must be put in the hands of those who are pure of heart and of extreme intelligence, I must break with you when you suggest that "The last thing we can do is leave the decisions for rationing up to any government run group."
As should be obvious to anyone, once you have identified those people who are purer of heart and smarter than anyone else, they should be given absolute authority to implement their beautiful world. Only a total absolute dictatorship in the hands of those few among us who are quite simply better people than everyone else will ever free the world from its fallen state and allow us to realize the progressive paradise on Earth that we would even now be enjoying except for the machinations of the venal and evil.
Surely you can see that only the government has enough power to allow these noble pure-hearted folk gifted with a stout intellect to fully realize the benefits they alone are capable of showering upon us benighted mortals?
They'll be too busy turning you into Soylent Green. Time to get ready for the 2nd American Revolution comrade.
Cute.
Oh no sir! Clearly you are mistaken. You falsely suggest that that an individual working for the public making decisions for the public is a fair arbiter. Are you not acquainted with the divine concept of the invisible hand? Everyone knows that free market decisions are the best at distributing scarce resources in any and every situation. Take a moment to consider roads. Now I know what you are thinking! "Why it's in the best interest of everyone that all people have the privilege of using them regardless of how much they pay for them!" Bah! Don't you see?! It's precisely because of that that we have to suffer with traffic. If only our government would let the wisdom of the free market allocate road use then we could clear up all this traffic nonsense because only those who pay the most into road upkeep would be using them.
Seems perfectly fair to me.
Perhaps I'm obtuse, but I'm not sure I see your argument for the market in roads. I think roads and road-use are both areas that would benefit immensely from more effective and powerful government involvement.
Clearly, the proper way to allocate road usage and prevent the creation of traffic is to search out the absolute best road-designers, traffic-modelers and other like experts and give them all of the information they need and let them figure out who needs to use the roads for what and when. There could be a panel of experts who analyze existing road-use patterns to determine which are effective and which are not. And, given the proper amount of power (which is to say: absolute power), they could quickly root out the poor uses and optimize the whole system.
Everyone's daily life would be immeasurably improved once they have a qualified expert taking account of their needs balanced with the needs of everyone else in planning their daily travels in effective and efficient ways. We could use the marvelous internet technology (created by the government!!) to distribute daily driving schedules to everyone each morning telling you exactly where and when you are allowed to drive that day.
That way there would be no traffic when everyone selfishly plans their commute for the same hour, or goes to the beach at the same time on the same day, or any of that. You would wake up to a rationally planned, clearly stated schedule that meets all of your reasonable automotive needs and roots out all of the waste and innefficiency inherent in leaving everyone with the 'freedom' to plan their own driving routes and trips ad hoc, willy-nilly all day and night.
Tell me, what sensible person could raise any objections to such a system? The only people opposed would be ideologues clinging to outmoded concepts of "personal freedom" and, of course, some evil lobby that somehow benefits from the traffic congestion needlessly generated by our current inefficient system. It would prob. be the Oil Lobby or some like group.
These are the kinds of straightforward, logical and reasonable solutions to life's everyday problems that can only be achieved with a powerful, progressive government. We would already have such a paradise except for the behind-the-scenes power struggles of the evil and deluded.
blighter,
I love your commentary. But, We could use the marvelous internet technology (created by the government!!) to distribute daily driving schedules to everyone each morning telling you exactly where and when you are allowed to drive that day..
I'm not sure that isn't one hell of an idea.
:-)
Also, I'm not suggesting "that an individual working for the public making decisions for the public is a fair arbiter." Not at all.
Rather, I'm making a point that I would think would be so patently obvious that it would go w/o saying except that I see people dispute it every day.
That point is simply this: humanity is not a great, undifferentiated beast such that everyone can be assumed to be equally selfish, equally stupid, equally wise, equally generous and the rest. No, some people are better than other people: more caring, more compassionate, smarter, more "fair minded" if you will, just in every way that matters for living in a just and peaceful world, better.
Progress relies on finding these people and giving them the power to improve our lives in the way that only they can. Those who argue for "freedom" say that "power corrupts" or that they "don't trust" someone to have that much power over their lives. But they only say these things because they assume that the person we give the power to will be some average, run-of-the-mill person instead of a progressive expert. Progressive experts are like gods among men. They know more, care more, feel more, have a deeper and truer sense of fairness, are better able to implement their plans, better able to see roadblocks that others can't even fathom than any other person.
When you put them in charge and give them absolute power, it's not like you're just appointing some mere mortal to run your life, someone who wouldn't do any better a job than you yourself would and would prob. do a worse job when he tries to run not just one life, but everyone's simultaneously. No, not at all.
Instead, you are trusting your life to someone who, yes, will be excercising absolute authority over every aspect of your existence, but in so doing he will be making your life incomparably better! That's why you must do it!
Your "invisible hand" and "market" seem to assume that the best way for everyone to realize their best life is for them to organize themselves, to make agreements and arrangements that seem to them the best and whatever overall system arises out of that will be the best.
But that is clearly madness. Why would you let everyone struggle on their own when you could just find the best and brightest, those who can see the whole problem at once and solve it just as easily, and let them determine all the arrangements so that everything is efficiently organized in everyone's best interests?
Now, I know what some say. These angelic specimens of humanity don't exist or if they did, we could never be sure of discovering them. How can we put so much power into the hands of people until we're sure of their abilities in this regard?
But that's the easiest part! Progressive experts are always just brimming with obvious good ideas that inspire in them a lust for power that would be a mark of evil in any lesser person. They will tell you they know better. They will engage in what might appear to be underhanded and devious machinations in order to gain the power needed to do good. They will quite literally stop at nothing to create the perfect world that they alone can see.
You're going to have gimlet eyed accountants choosing policies no matter what happens. You just get to choose whether these accountants are paid by the government, or by private insurance companies.
Unless you believe that straw can be spun into gold, you understand how patently obvious Obamacare's dependency on rationing is.
There isn't a healthcare system in the world, including Denmark with their EHR system already in place, that's significantly more *efficient* than the USA's - if they are more efficient at all. The Japanese, as in all things, are automated to a fare thee well.
This is not what keeps their per capita costs below ours. Their costs are lower because they provide fewer services. Period.
And where are the costs per capita highest? In 20 year old men and women? Obviously not.
If you are going to ration, with the aim of lowering costs, you are going to set your sights on one group first and foremost: the aged. The elderly. The folks 65 and older (or even 55 and older, if you want to be particularly cold about it).
If anyone is telling you otherwise, they're either a fool or a liar. Or both.
Well, except that in Canada certain exotic procedure - hip replacement, MRIs, certain cancer drugs, pre-natal imaging, and hospital beds not located in corridors - are brutally rationed for all age groups - killing the oldsters doesn't produce enough savings any more.
Do you have a link to that, Holdfast? Everyone I know (of a certain political bent) keeps harping on about the evils of a British or Canadian style health care system. Yet, whenever anyone actually goes to Canada or Britain, they're usually pretty impressed by both the quantity and quality of care delivered. Its pretty obvious that the two viewpoints are mutually incompatible, but the evidence points towards only one of them.
In my province the waiting list for hip or knee replacement is 2 years. In the neighboring province it is 5 months. The difference is due to abundant oil and gas revenues.
In the same neighboring province, a friend moved to the city for work. His wife got pregnant, and there was an 18 month wait for GP's.
A co worker of mine waited 6 months for an angiogram that resulted in a stent.
As we speak, in this province and the next, the government is cutting health budgets to attempt to keep the fiscal deficit under control.
Most provinces have either closed or seriously cut back any hospital services in small communities. In my area there isn't 24 hour complete emergency service.
I could go on and on.
If you have an emergency situation that requires immediate care, and you live in a major center, the care you receive parallels what you would get in a US center. If your situation can be put off, it will be. Hopefully you survive.
At one time the Canadian system was quite good. The doctors had say on what was done, the provincial health economists were not the drivers of the system. It changed in the early '90s when the Canadian governments were forced to live within tax receipts. The Laffer curve was inexorable, revenues decreased when tax rates were increased. The federal deficit was cut by cutting transfers to provinces for things like education, health and welfare. Provinces cut doctor's training and fees, operating rooms were empty and unused. The waiting lists we know and hate come from that time. The booming economic growth since that time has enabled some improvements in some areas, and essentially put off the necessary reforms that this recession will probably force.
What forced the governments to take the situation seriously was a Quebec supreme court decision that struck down the law in that province against private insurance on the basis that the provincial system deprived citizens of security of the person by denying timely care.
Most people are not ill over their lifetime. So most people would be happy with a system that doesn't work. The US is remarkable in that health is an issue for everyone, since everyone has to either sock money away or pay insurance premiums. A government run system would take that reality away, and put health care in the background. Something like VA care is currently.
Derek
Do you dispute these figures Rob?
"U.S. health insurance companies have the highest administrative costs in the world; they spend roughly 20 cents of every dollar for nonmedical costs, such as paperwork, reviewing claims and marketing. France's health insurance industry, in contrast, covers everybody and spends about 4 percent on administration. Canada's universal insurance system, run by government bureaucrats, spends 6 percent on administration. In Taiwan, a leaner version of the Canadian model has administrative costs of 1.5 percent; one year, this figure ballooned to 2 percent, and the opposition parties savaged the government for wasting money."
They're from this: http://www.washingtonpost.com/wp-dyn/content/article/2009/08/21/AR2009082101778_pf.html
I will.
You have cited to an editorial advocacy that cites to no primary source for a claim that may or may not be apples-to-apples. I'll wait for something better.
Meantime, what is about your post that responds to the points that (i) eliminating pricing incentives for individuals increases demand and (ii) cost control requires rationing?
How much does Medicare / Medicaid spend, and how much of its compliance costs does it push off on doctors? Also, if there is conscious choice not to incur the overhead that would result from aggressively pursuing fraud, how much does the resultant fraud cost? How about Masscare or Tencare? These would seem to be more relevant questions when discussing a US Government Option.
Sorry - my response was logged below, and not here. My bad.
I'm not sure at all that this is apples-to-apples. In most universal coverage systems the job of rationing care is forced on patients primary physicians or on other providers. In the fully private part of the US system, providers of care usually have every incentive to provide care and none at all to decline it, so insurers have to review claims. That's the vast majority of their oft-cited "administrative costs" even though its undertaken by medical staff.
So its not a fair comparison at all - the bulk of insurers "administrative costs" in the US private system are hidden amongst the "medical costs" when looking at universal coverage systems. I actually thinks its right for primary physicians to be responsible for rationing (in insurance industry jargon this is called capitation) but it makes it extremely hard to make comparisons.
Why is it the % of Healthcare dollars spent that matters?
If Medicare is rife with enough waste, abuse and cheating to, once eradicated, pay for insuring 40 million poeple, then Medicare is spending way too much healthcare dollars and inflating the denominator. As a result, the administrative cost looks tiny.
The better measure is administrative cost per user. Or just healthcare cost per user or per procedure.
Blighter said:
"If even a single mother is turned away from a hospital we have utterly failed as a society. It is these kinds of stories, more than any other, that have convinced me of the dire need for an immediate adoption of a comprehensive, government-controlled health system in this country."
A recent Drudge headline read:
"UK HEALTH SYSTEM: Babies born in hospital corridors: Bed shortage forces 4,000 mothers to give birth in lifts, offices and hospital toilets... *"
Clearly these are lies promulgated by the Evil Insurance Lobby.
Everyone knows that government planning never goes very far awry and when it goes even that little bit, it's a) ultimately for the best and b) the fault of shadowy conspiracies trying to undo the people's paradise.
If the kind-hearted, far-seeing folk running the fabulous NHS deemed that 4,000 women should give birth in hallways and bathrooms, you can be sure that those were abolutely top-notch hallways and bathrooms. Those women should be proud that they have been given the opportunity to serve their country by offering enormous savings to the overburdened saints running the healthcare system while at the same time enjoying hallway and bathroom environs that are the envy of the world.
Limiting health care's availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual.
Kinda scoots right by the obvious, don't he?
The problem is not the implementation of a rationing plan per se. Any scare resource has to be allocated in some fashion. The objection most people have to a government-imposed rationing scheme is the uncomfortable feeling that there will be more than a few people who get to jump the line.
I think the lives of the poor have less value then the rich. What do the poor offer anyways in terms of advancing civilization? Nothing. Turn them into Soylent Green already!
The salt article Megan linked to is an eye-opener as well.
Two paragraphs in particular reminded me so much of the Global Warming fight.
First there was this, laying out the fight:
Wow, these folk arrayed against the beneficial technocratic experts trying to save us from our self-indulgent over-use of salt b/c it "tastes good" sound impressive, don't they? Presidents of the American Heart Association, the American Society of Hypertension, and other international societies of hypertension. But we all know that behind impressive, public-minded sounding titles often lie the most vile of plutocrats, and sure enough:
The evil Salt Lobby has been working overtime behind the seens paying off doctors and scientists to make it seem like the science isn't settled! But there's a consensus and a dire need to save lives! The technocratic experts know it!
Isn't it odd how whenever a beneficial, compassionate, uber-smart, uber-compassionate group of experts tries to save us from ourselves there's always a shadowy group of bogeymen out there trying to stop their good work? How is it that there are so many evil powers in the world always interupting the good-hearted, noble work of those trying to drag us into the bright, beautiful, brave new world that only they have the wisdom to see?
A cynic might say that there are no especially noble groups, just different people pursuing what they think is best with the information they have access to, all of which is incomplete and none of which grants the authority to absolutely override everyone else. But I reject that false choice. No. There are good and great people among us who want nothing but to create a paradise for all. And there are evil people (Republicans, usually) who work tirelessy against them for no reason except that they enjoy suffering.
Can we ever shake off the shackles of our evil shadowy overlords and gallop towards that progressive paradise envisioned by our noble-hearted, technocratic betters? Say it with me: Yes we can!
I know the salt lobby is in the game for the money. The very worst I can suspect of them is that they're willing to kill me to keep profits up. But what do the anti-salt people get? Power, coupled with the conviction that they're wielding that power for the greater good. That gives me the willies.
Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.
-- C.S Lewis
Intriguing - I thought it was generally accepted that:
a) Only certain people genetically prone to low-renin hypertension benefit from reducing their salt intake
b) Even within that group, some people develop hypertension even though their salt intake is normal
c) Even within the group whose hypertension was accompanied by excessive salt intake, not all respond to lowering their intake.
ie. The whole thing about salt being a general hazard is basically nonsense. But then I grew up in the socialist hell-hole of the NHS where medical research doesn't immediately run into chronic trust issues.
Denying the truth of rationing is more common in government-run health care schemes than private ones, because the government is reluctant to have the people know this ugly fact. Government-run programs, therefore, are more likely to disguise the rationing. ...
Private insurance plans sometimes include an element of implicit rationing, but because they are, at heart, contractual agreements between the insurance company and the insured are more likely to ration health care explicitly. The many pages of the healthcare plan describe what is a covered service, which providers will be reimbursed for services, the duration of coverage, the dollar limit, and so on. The advantage of explicit over implicit rationing is obvious: It gives potential customers of the insurance plan information to use when deciding which insurance plan to buy, and gives them clear expectations of services to be delivered.
Sadly, all this is nonsense.
1) The author says that government health care programs don't want people to know what the limitations of their coverage are. But private insurance companies do? Of course not -- they have the same incentive. Have you ever heard an insurance company advertise the limits of its coverage?
2) In point of fact, there is an extraordinary amount of information available about what government health care plans cover. Here is a list of National Coverage Determinations (NCDs) for Medicare. These NCDs are public for lots of reasons, including the fact that they would be subject to FOIA. If there is a public document that provides equivalent information for a big HMO, I'd be interested to see it.
Occasionally, people complain to Congress about these determinations, and Congress pressures HHS to change its standards or simply overrules HHS by legislation. (State legislatures occasionally do something similar to private insurers from time to time by imposing mandatory coverage requirements.)
3) Do health insurance plan documents typically provide clear information about what the limits of coverage are? No, not really (and not because I think insurers are evil). Two reasons:
a) Insurance coverage determinations are frequently situation-specific, particularly under HMO plans. That's really the whole point of HMOs -- in theory, they hold costs down by making better decisions on the margins. This is why doctors spend lots of time on the phone with HMO reps trying to justify covering particular treatments. But you can't just look up the answer in the operative plan document; if you could, the phone calls would be unnecessary.
b) Frequently, coverage limitations in health insurance plans are stated in terms of dollar amounts. That is important information, to be sure, but not all that helpful if you don't know what the hospital is going to charge your insurer for various services you might need. ($5000 coverage limit on birth: Too high? Too low? Answer -- too low if you end up needing a C-section.)
NPR had a roundtable this morning on which was mentioned the fact that the Democrats were getting eaten up by the notion that they were going to limit Medicare and that they had, loudly and politically, opposed smaller cuts suggested by Bush several years ago. Will Wilkinson (sidebar here) has a recent post about 2 MIT economists writing a book about national savings praising Singapore's forced savings which is similar to Bush's defeated proposal which one of the economists as an adviser to presidential aspirant Kerry had urged him to demagogue against. It can be tough being the party of 'the working people' when you want to work new people. To paraphrase John Lennon, I think it would be 'good to see the plan' work in the way of reforming Medicare before we toss the whole health economy to the government. 'Implicit rationing' is the larger set of which restriction on innovation is an element that Megan has talked about before, and it is good to have a formal construct of it.
I do.
Here are some very different ones, from the New England Journal of Medicine:
http://content.nejm.org/cgi/content/short/349/8/768
And here's a fun one, also from the Washington Post.
http://voices.washingtonpost.com/ezra-klein/2009/07/administrative_costs_in_health.html
Here's my favorite, from the CBO. Note the first table...
http://www.cbo.gov/ftpdocs/87xx/doc8758/MainText.3.1.shtml
Do you like how, if you remove out of pocket payments from the equation, Medicare and Medicaid already account for FAR more than 50% of all health care spending? How can that be? How can our admin costs be so insanely high, when we're already "mostly socialized?"
Other than rationing, what magic are you claiming will happen when we absorb the remaining "troublemakers" with private insurance, and suddenly drive costs down.
I particularly like this last one, which shows that over 42% of ER visits are already billed to our "uber-efficient, centrally planned" healthcare system. That's right, Medicare and Medicaid. How can we tie that out with the CBO's claim that private insurance is barely covering 1/3 of the costs now?
Don't forget the UNINSURED, who - even though they have "no coverage" use Emergency Rooms more than anyone else. It appears as if they are being lined up and shot. Or maybe not. Perhaps, instead, they are actually being treated.
Thus *far less* than 50% of all ER visits are made by people with private insurance - and yet Admin Costs are through the roof. How can you reconcile that?
http://health.usnews.com/articles/health/healthday/2009/07/31/er-visits-mostly-by-medicare-medicaid-recipients.html
Medicare and Medicaid, per the CBO, already account for more than half of the insurance money being spent for health care. Private Insurance is barely 1/3. That is the back drop against which this "debate" should be made. Our government is already responsible for the lion's share of our "out of control" health costs.
So are you proposing that we give them more control? We've already hit an iceberg, and your recommendation is "full speed ahead?"
Sorry - this one was in response to Caliber, above.
Rob, I was responding to this statement from you:
"There isn't a healthcare system in the world, including Denmark with their EHR system already in place, that's significantly more *efficient* than the USA's - if they are more efficient at all."
I didn't say anything about Medicare/Medicaid/whatever being great, efficient, or anything else you talked about in your response. I was just trying to point out that other systems in the world ARE more efficient. Significantly is obviously an opinionated word; I'd say the difference in efficiency is significant, you can certainly feel free to disagree.
From the article in my original post:
"In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)"
Japan, I know. Still, pretty damn efficient.
I do appreciate the links, however. I read Ezra Klein quite often, but the other two were interested.
Before assuming Japanese superiority, you would first want to compare Japanese and American MRIs on a quality basis.
I would bet their radiologists get much less training than ours and earn much less (this is generally true of medical practictioners in Japan). I'm not sure I want my radiologist making the same as the guy asking me if I want fries with that.
A Pinto is cheaper than a Corvette, but for good reason.
I'm glad that you like Ezra Klein as an authority. Perhaps you like this column by him which shows that admin costs are rising even faster in private insurers than in Medicare or Medicaid
http://voices.washingtonpost.com/ezra-klein/2009/07/bill_kristol_says_thing_that_a.html
It is true that the growth rates of Medicare, Medicaid, and private insurance are well-documented. But the documentation shows the opposite of what Bill Kristol says it shows. The price of Medicare and Medicaid have gone up much more slowly than private insurance
Why would you want private insurers to have more control when they do even worse than Medicare/Medicare? I know, because "gumint is always worse" right?
You might be interested to know what kind of reform Mr. Klein favors. Well, he is a single payer man all the way-although he wouldn't mind a socialized medicine system, either. He has nothing but praise for the British NHS.
Heh, another gem from Klein.
The per-person Medicare cost has gone up less, the overall program costs have gone up much faster, and since we have to pay for the program that number is more relevant. Also, one of the reasons PHI costs go up is... government mandates. So Bill is entirely correct government is pushing up costs.
Then Klein says this:
Later in the interview, he says that the Army health-care system -- which is fully socialized -- is the best health-care system we've got, and the reason we can't give it to all Americans is that it's too expensive. Socialized medicine, in other words, works. The rest of us just don't deserve it.
Right, because "too expensive" = "don't deserve."
Megan, what do you think about rescission?
I did a site search, & nothing came up with your opinion on the practice, only that of commenters.
That 's because Megan and her libertarian commenters don't believe that private insurers do things like this. Megan has argued that private insurers rarely deny coverage, because they have every incentive to pay out claims. (I'm not kidding).
Megan and other commenters are mostly silent on private insurers' policy of denying coverage for pre-existing conditions. One commenter went so far as to deny the companies actually do this.
Here is a link that documents that they do:
http://www.healthreform.gov/reports/denied_coverage/index.html
This is a problem created by government. In a free market, people would buy individual policies with right of renewal and pre-existing protection. The government has created an exmployer-based system via tax incentives, and forces people to insure against mandated coverages whether they like it or not.
Of course insurance companies should discriminate against pre-existing conditions. This is like complaining your fire insurance was expensive or hard to get because your house was already on fire.
So if you're fine with discrimination against pre-existing conitions, precisely what problem did the government create? You seem to be saying that recision is a problem created by the government, but at the same time that its not actually a problem. In a purely private system, any insurer will price in any known risk, and if they discover they got it wrong they'll take any opportunity to avoid paying. They might offer you a fixed price for some fixed time period, but after that, they'll re-price your policy based on the known risks. To do otherwise would be analogous to an auto-insurance company promising never to check your driving record - its just about possible such a policy would be offered, but given the adverse selection problems it would have to assume all its customers were extremely high risk, so it would be unaffordable.
I think the employer-based system is crazy, but protection against pre-existing conditions is emphatically not one of the problems with it. To an insurer, employers form large, medically random groups with high non-risk-related barriers to entry. They can offer such groups policies that don't exclude pre-existing conditions and are still economically priced. Remove the pooling effect of employers, and there'd be no way for insurers to do this - they'd be forced to price in all know risks. This is in fact what happens with private medical insurance in countries that don't have the employer-based system.
So if you're fine with discrimination against pre-existing conitions
It's not "discrimination" it's basic economics. If you were an insurer, would you sell fire insurance to someone whose house was on fire? That isn't insurance, it's charity.
This wouldn't matter if everyone had their own guaranteed-renewal policies, but government created a system in which people generally don't buy their own insurance but instead are provided it by an employer. If you had a choice, would you ever buy a policy under which you would not be covered? Of course not.
So instead of markets, we get mandates and court fights.
Not true. Megan had a post not too long ago discussing how the inherent difficulty in writing comprehensive contracts for medical insurance made healthcare insurers naturally more prone to doing such things than other forms of insurers. Everyone knows what a house on fire looks like and what the insurer's responsibility is in that case, but medical insurance is far more technology-based, and as such is much harder to come up with a real agreement for that will stand up in the future.
You can "ration" food by not letting poor people have as much, or we can all stand in bread lines. Etc.
Yes, U.S. healthcare is less efficient, in the same way U.S. food consumption is less efficient than in North Korea, where people get just enough to avoid starvation (in some cases, less).
By this measure, though, the poorest countries in Africa probably have the most "efficient" healthcare, because the first ten dollars of healthcare go much further than dollars 3,490 to 3,500.
MRIs are a good example. Do you do an MRI in a situation where there's a 10% chance it will find something, or only 20% or greater? The second is generally going to be more cost-efficient, because MRIs are expensive, but overall outcomes will be slightly worse.
Dave, (hey, I'm a Dave too!) here is a quote I already posted:
""In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)""
Here is a quote I haven't already posted:
"The world champion at controlling medical costs is Japan, even though its aging population is a profligate consumer of medical care. On average, the Japanese go to the doctor 15 times a year, three times the U.S. rate. They have twice as many MRI scans and X-rays. Quality is high; life expectancy and recovery rates for major diseases are better than in the United States. And yet Japan spends about $3,400 per person annually on health care; the United States spends more than $7,000."
And of course, in America it's pretty rare for people to actually starve what with food stamps and all. I'm not really sure what point you're trying to make, but by analogizing health care to providing food you seem to be saying we should make sure everyone gets enough health care through government intervention.
I'll report my response:
Before assuming Japanese superiority, you would first want to compare Japanese and American MRIs on a quality basis.
I would bet their radiologists get much less training than ours and earn much less (this is generally true of medical practictioners in Japan). I'm not sure I want my radiologist making the same as the guy asking me if I want fries with that.
A Pinto is cheaper than a Corvette, but for good reason.
----
As for food rationing, the point is we can either have lots of inefficient food (or health care) or very efficient but very little food (or health care). So far 100% of people die in both cases anyway; the benefits are all marginal and become ever more marginal the more you spend.
Regarding radiologists, I think that's probably right, but one thing you definitely do have to consider in the US system is that most US medical professionals are massively over-trained for the bulk of their jobs. Its structural - the insurance-based nature of the system means there's no incentive for providers to keep their costs down, and regulation and liability considerations give them every incentive to employ fully-qualified doctors where nurses and technicians would do just as well.
but one thing you definitely do have to consider in the US system is that most US medical professionals are massively over-trained for the bulk of their jobs.
I'll grant you the AMA has very cartel-like behavior and should be reformed. So why aren't any "reformers" talking about doing this?
Its structural - the insurance-based nature of the system means there's no incentive for providers to keep their costs down
Again, I'll grant you the lack of competition for individual policies is bad and should be reformed. So why aren't any reformers recommending we do away with the perverse employer tax incentive that has largely destroyed the individual market?
I suspect that breaking the AMA's cartel doesn't even pass the sniff-test for political feasibility, sadly. Doctors have near universal public respect and tons of cash. Politicians need cash and have negligible levels of public respect. Its not just not a fair fight, its not even interesting. Even in the UK, probably the developed country where the state wields most influence over health care, the government tip-toes around the doctors - they could (and have threatened to) destroy the NHS in a matter of months if they withdrew their cooperation. So they get paid off.
The biggest problem with restoring the individual market by removing the incentives for employers to provide coverage is the massive problem of pre-existing condition coverage. As I said above, no sane private insurer would fail to price-in pre-existing conditions, but that would exclude millions of sick, middle-class people from being able to pay for their care. Whatever you think about the ethical consequences, its clearly not politically feasible. There may be some cunning free-market solution to this but it eludes me. The individual mandate, compulsory issue, and banning pre-existing condition discrimination, whilst I don't much like them, do provide a clear route to getting rid of the tax break - its just hard to do the latter without doing the former first. From your perspective the cure is probably worse than the disease, but that's the politics of it, as far as I can see.
In a free market, people would buy individual policies with right of renewal and pre-existing protection.
From whom? Seriously, name me the U.S. insurance company that offers this at any price. Oh, I get it, they will after the libertarian millennium arrives. Pie in the sky, that's all you feed us.
Before assuming Japanese superiority, you would first want to compare Japanese and American MRIs on a quality basis.
Why? This reminds me of car nuts who insist that a Ferrari California is incomparably superior to my Mazda Miata, which, obviously, it is not: I can only look at a California, whereas I can drive my Miata.
Is a gold-plated MRI a valuable good in itself? Or is it merely one of hundreds of technical tools to achieve the real goal of longer life and greater health for patients? By the second criterion - the one that makes sense - Japan's health care, as a whole, is clearly and undeniably superior to America's, and to add insult to injury, the American system costs us twice what the Japanese system does (16% of GDP compared with 8%).
Seriously, name me the U.S. insurance company that offers this at any price.
Several do. It's been around for decades.
http://tankinlian.blogspot.com/2007/07/guaranteed-renewable-health-insurance.html
Why wouldn't they? It's just another option. Every contract has an acceptable price point. You act like insurers just hate people or something.
They have twice as many MRI scans and X-rays. Quality is high; life expectancy and recovery rates for major diseases are better than in the United States.
Uh oh, here comes life expectancy again.
LE correlates very badly with medical quality for the obvious reason that other factors correlate as strong or stronger. Japanese diet and lifestyle probably has more to do with their LE.
LE is also not calculated the same in different countries because infant mortality is calculated differently.
I'm skeptical they have similar cancer recovery rates, as it's been known for a long time European rates trail ours badly.
Any figures to cite? Those I've seen have America doing well for some cancers (we're really good with breast cancer) and doing equal or inferior with others. Mostly it is a wash for a great deal more money.
Of course, I shouldn't have to point out Japan isn't in Europe as well.
Of course, but I would be surprised if Japan was doing all that much better than Europe, given their similar situations.
Here's some overall numbers.
http://www.seattlepi.com/national/141141_medi25.html
I haven't seen comparisons to Japan.
I would like to see some more methodology studies on Japanese numbers. Japan's numbers are screwy in a lot of areas for reasons having to do with their honor/shame culture.
Megan, you’re right. The whole notion of “rationing” should be confronted head-on. And the article you cite does a good job of clarifying that the healthcare system in place today is indeed ‘rationed’ healthcare. So, obviously, it would be wrong to make the statement that healthcare reform would move us toward “rationed” healthcare – because we’re already there:
- About 15% of Americans don’t have any health insurance at all
- Many Americans are enrolled in HMOs and do not get to use their preferred doctor
- Insurance companies and HMOs currently place limits on treatments they will cover, limit coverage to a specific dollar figure, eliminate coverage for those who submit reimbursement claims, refuse coverage for those with preexisting conditions, etc.
Also, if you really do want to confront the notion of "rationing" seriously, it would seem to me to be helpful to clarify (as many times as needed) that the healthcare reform proposals out there do not feature a government-run healthcare system that would replace what we currently have now. Rather, they involve introducing a government-run insurance plan that would compete with private insurers as a way to (via the addition of another option) provide insurance for more Americans and help drive down healthcare costs. This is an important distinction that everyone should understand if in fact we really do want to confront the issue of “rationing” honestly because so many people automatically link “rationing” to “government-run healthcare” – but that’s not really what we’re talking about here.
In any event, it is appropriate to confront the issue of whether or not adding an additional government-run insurance plan to compete with private insurers will result in “more” healthcare rationing. For me at least, one thing that gets sticky in this discussion is that many people can’t seem to separate true “rationing” (limiting care) from “reducing waste.” Rather, they automatically assume that if something is reduced or eliminated, then care has been ‘rationed.’ I disagree.
Take for example the prescription drug Ambien CR. Ambien CR is no more effective than Ambien (duh, it’s the same drug) it just dissolves a different way. And Ambien is now available in generic form (Zolpidem Titrate). Some insurance companies won’t cover the cost of Ambien CR (and to me, rightly so, because it offers no benefit over lower cost alternatives) but some still will. The cost of Ambien CR is about $5-$6 per pill. The cost of Zolpidem Titrate (generic Ambien) is about 60 cents per pill (or as low as 25 cents per pill at Costco). So why should Ambien CR be covered by an insurance company?
Yes, in a sense, saying you can’t get exactly what you want is “rationing” – but why should an insurance company (whether it’s private or a government-run program) pay for something that offers no real benefit versus lower cost alternatives. Last year, Ambien CR sales were $285 million dollars. I have no idea how much of this was covered by insurance companies. (All of it? Half of it?) But I’m guessing there’s a good chunk of “savings” to be found there.
I also have a question for you. Where does this notion of “inherently scarce goods” come from in the first place? What exactly does that refer to?
It seems to me that companies that produce replacement hips would be happy to make a few more if demand rose. And if I’m not mistaken, there would be some new money coming into the healthcare system (something like $1 trillion over 10 years) to afford hiring additional doctors to perform more operations. Again, we’re not talking about moving to a government-run health program that replaces what we currently have; we’re talking about introducing another insurance plan option – so wouldn’t the laws of supply and demand work the same way they do today?
If we lived in a country with not enough cars for everyone we wouldn’t go around screaming about “rationing” -- and one party wouldn’t start broadcasting that the other party wants to take cars away from seniors. We’d figure out a way to build or import more cars. Wouldn’t we?
Everyone keeps talking as if there is some “rule” that whatever happens with healthcare reform, the infrastructure must stay the same. But if in a given city there is increased demand for an additional MRI machine, wouldn’t that (duh) get purchased?
Take for example the prescription drug Ambien CR. Ambien CR is no more effective than Ambien (duh, it’s the same drug) it just dissolves a different way. And Ambien is now available in generic form (Zolpidem Titrate*). Some insurance companies won’t cover the cost of Ambien CR (and to me, rightly so, because it offers no benefit over lower cost alternatives) but some still will.
I think this is illustrative of the divide between those who see pharma adding value as opposed to not. The "CR" in Ambien CR stands for "controlled release"; to refer to it as "dissolving in a different way" glosses over a lot of pharmaceutical formulation innovation.
Controlled release is a bit of an art form; it requires formulating the drug with various excipients and engineering the pill so that it delivers the drug slowly over time. (I don't know the specific structure of the Ambien pill, but it's not just a mushed together bit of powder.) Whether or not the slower release adds value depends on the nexus between the person's individual physiology and the unique characteristics of the drug? What do high blood levels of Ambien do to patients in one shot do to patients versus lower values over time? I dunno, but seeing all the folks who sleep-drive on Ambien tend to indicate to me that there may indeed by added value.
Whether or not this is indeed added value is up to the bean counters; but to pretend like there's zero added value is disingenuous.*
* It's "zolpidem tArtrate", not "titrate."
**Yes, yes, pharma uses CR formulations to extend patent life; if indeed the CR formulation adds no value, people won't buy it.
Lack of productivity increase may be the primary reason why health care rationing is now on the agenda.
"Limiting health care's availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual.": the problem with this statement goes much deeper than it may seem.
One hundred years ago, proposals to socialize food production (for example) or transportation were debated and even implemented in many countries.
Why are we debating 'socializing health care' in some form this time around, and not food anymore? Because over the years, producing food has become so efficient, thanks to productivity gains, that it is a minimal part of most peoples' or nation's budgets, and therefore almost a non-issue.
Not so with health care. I am not seeing more patients per hour than 10 years ago, let alone compared to a physician 50 years ago.
Patients per hour may not be the optimal way to measure health care productivity - what is? - but it forms an important part of reimbursement reasoning, and therefore of cost. I have some data to support this argument, but have not found an economist group to co-author with.
If we had had similar productivity gains in health care as in most other sectors of the economy, there would now be less need of rationing.
The major problem with 'socializing health-care' that I see is that any remaining incentive for increased productivity may be removed - and therefore the productivity increases we have seen in farming, manufacturing, transportation, etc, materialize much later than otherwise, or never.
N.B. I put 'socializing health care' in quotes, because I realize for example that the Medicare portion of expenditures is already 'socialized'. Please dispute my productivity argument, not the way I wrote it.
I also realize that Ms McArdle's concern is with pharma innovation - but pharma is only 10-20% of health care expenditures, and (productivity) innovation of health care delivery would have a much broader impact.
Some ardent libertarian might make the argument that the very reason we have seen productivity stagnate to such an extent in the medical sector is the already heavy involvement by the government that you noted.
They might make the comparison to your food example by observing that productivity was not just showered down upon all the nations of the Earth, rather those that went the furthest in implementing fair, socialized food systems saw the least productivity growth to the point that eventually their fair systems were overthrown in favor of evil, unfair, market systems that could provide copious amounts of cheap food and many other benefits besides.
That obsessed libertarian would probably finish his point by asking whether we might not see a similar process repeat itself in the healthcare sector were we to actually reform the system more towards an actual market instead of the employer-tied, government crippled behometh we have today.
Not me, you understand, I'm in favor of government take over of just about everything, because I know things always work better with a knowledgeable expert in charge. And when they don't, it's because of the underhanded work of evil men.
But I've hung arond this blog long enough to know the predictable libertarian arguments against the beauty of socialized medicine/food/clothing/housing/etc. so I figured I'd save them the bother of making it.
(See all you selfish libertarians? That's what giving progressives do! We give of ourselves for others! Why must you fight us on that?)
YeeHaw!! Look at Me. I'm a stupid di#k who is so sick of my own retarded Sophmore young-republican position that I pose as someone else and argue theirs, so that all the unwashed masses can be enlightened by how stupid it is.
Blighter,
LMAO!
Over the course of human history we've developed a very successful system for rationing scarce resources. It's called "prices".
The fundamental flaw in all our reasoning over health care is the assumption that people who can't pay for health care are yet entitled to it. Imagine for a moment a world where you paid for health care the way you pay for your groceries, or housing, or auto maintenance. A world of varying price and quality, of easily available information to arm yourself with as a consumer, and of ample supply. Now contrast that vision with your observations of goods provided by the state. Doesn't that make you want to give the market a try?
We have given the markets a try. We got no health insurance for children, seniors and the poor, so we got Medicare and Medicaid. We now have 46 million uninsured, rescission, and no insurance if you have a pre-existing condition (like pregnancy). I mean, haven't you been paying attention?
You should really pay attention to the argument.
Noah is claiming we have a good rationing system. You are claiming "Omfg no, your rationing system doesn't give everyone everything they want!" So what?
It doesn't give 46 million people anything. Wouldn't you call that market failure? Oh wait a second, there's no such thing as market failure. Awrighty then.
Stonetools,
The market also doesn't provide me, and most people who want one, with a Ferrari in place of of my Toyota. By your definition, that is also a market failure.
That may or may not be a market failure. To show that it is, you will need to a) learn what a market failure is (hint: it isn't just a situation you dislike) and b) show that the current situation is one. You haven't even attempted to do this.
Incidentally, there are not 46 million uninsured. 14 million of them are eligible for medicaid and are de facto insured (the moment they need medical attention, they can sign up for medicaid). Of the actual 32 million uninsured, 27 million make over $50k/year and simply choose not to buy insurance. It is unknown how many of the remaining 5 million are illegal immigrants.
http://www.washingtontimes.com/news/2009/jun/25/who-are-the-uninsured/
We do in fact have mechanisms, right here in the USA, to ensure that people have access to food and housing even if there income isn't sufficient for it, not because they're "entitled" to it, but because the sight of people dying of starvation in the streets is not normally thought to be a sign of a pleasant, civilised, well-run society, and most of us would like to think we live in such a thing. We don't have such a system for auto maintenance, because cars aren't (contrary to what some people believe) absolutely essential to the maintenace of human life, and thus their absence rarely results in widespread death. Quite the reverse, really.
Of course we also have such mechanisms for health care - actually we have at least three just at the federal level - because health care, like food and housing, an unlike auto maintenance, is essential to human life. Its more controversial because health care is more expensive that food, its more controversial just "how much" healthcare is essential, and health care needs, unlike housing needs, are somewhat negatively correlated with the ability to pay.
So, umm, with respect to the real world, as opposed to the libertarina utopia where the poor are allowed to starve under bridges, what was your point?
Left out of all the rationing discussion is how the system would react to a shortage situation. In a market-driven economy, expanding capacity is always an option. In a cost-managed economy, expanding rules for rationing is more likely.
Which is probably how we got to our "expensive" system.
But which would you prefer?
Yes, this aspect is always mislaid in these debates.
Come, let us speak of unpleasant things.
How is health care to be rationed?
Who gets the short end of the stick?
Appropriate 2nd question: Implies
groping around in the dark, and
picking up a tool by the wrong end. :)
Instead of assuming that the State must decide,
start by letting the individual patient choose
their ranking on the waiting list at their hospital,
a list which includes patient age and prognosis.
If that is not enough, have a get-acquainted party
for the remainder.
That Inuit Grandma does not get thrown off the ice;
She walks out into the snow on her own.
I have a feeling that a lot of the opposition to health care is precisely fuelled by the belief among seniors that if coverage is extended, tens of millions of "those [people" will come into the system and they will have to wait longer for procedures.
One guy put it like this :
" I want there to be a safety net, but it shouldn't catch too many people".
Kevin Drum is pretty blunt on this:
The problem, of course, is that the U.S. rations by denying healthcare to poor people, and the Krauthammers of the world don't really care much about that. What's more, for all that we like to think of ourselves as nice people, most middle class Americans don't care much about it either.
http://www.motherjones.com/kevin-drum
Ezra Klein finishes off the canard that we don't ration
Twenty-seven percent of Canadians wait more than four months for treatment, versus only four percent of Americans. Twenty-four percent of Americans can't afford medical care at all, versus only 6 percent of Canadians. And the American numbers are understated because if you can't afford your first appointment, you never learn you couldn't afford the medicine or test that the doctor would have prescribed.
We ration
http://voices.washingtonpost.com/ezra-klein/2009/08/we_ration_we_ration_we_ration.html
Here is a picture of what our rationing looks like:
http://www.nytimes.com/2009/08/13/health/13clinic.html
INGLEWOOD, Calif. — They came for new teeth mostly, but also for blood pressure checks, mammograms, immunizations and acupuncture for pain. Neighboring South Los Angeles is a place where health care is scarce, and so when it was offered nearby, word got around.
For the second day in a row, thousands of people lined up on Wednesday — starting after midnight and snaking into the early hours — for free dental, medical and vision services, courtesy of a nonprofit group that more typically provides mobile health care for the rural poor.
Seems they're all so bloody stupid that they never heard of that secret - Medicaid, which also provides dental coverage.
Of course, many might just happen to be illegals, and we all know that US citizens should pick up all costs of everything for them. By the way, since illegals, and the liberals who support them, get to pick which laws they can ignore, what laws am I allowed to ignore?
I think they're expecting you to ignore the 2nd amendment.
I guess maybe you should read the article, where you would have found out this:
The bleachers of patients also reflected the state’s high unemployment, recent reduction in its Medicaid services for the poor and high deductibles and co-payments that have come to define many employer-sponsored insurance programs.
Many of those here said they lacked insurance, but many others said they had coverage but not enough to meet all their needs — or that they could afford
In other ways, cutbacks in Medicaid and the failures of private health insurance is causing this shortfall in care.
I'll just skip over your assumption that everyone in the LA area is an illegal immigrant and note that all the reform bills specifically exclude aid to illegal immigrants.
I don't know about you, but it seems your mother was allowed to ignore the one about not copulating with pigs.
Just by the by, I note that your excerpt from the linked article is fully 1/4 of the entire column (971 words out of 3760). I'm pretty sure that goes beyond fair use.
But honestly, that has to be the best content I've ever seen here. Let's not discourage Megan from doing anything that improves her work, including just not doing it and replacing it with other people's work.
"Seems they're all so bloody stupid that they never heard of that secret - Medicaid, which also provides dental coverage."
And some of us are so stupid we don't know that Medicaid covers dental expenses in less than half our states. California isn't one of them.
That's not true. In California Medicaid covers dental.
Yes, let government get out out of health care, because as we know, government is evil incarnate. So start by disbanding the NHI, because we don't need basic funding of medical research. Since smallpox was eradicated purely through government action, we obviously need to bring it back and polio too. (Lets hope blighter gets the first infection of both).No need for immunization campaigns if there is a swine flu outbreak: the free market will take care of that!
We need to close down all the military and VA hospitals, because we don't owe those soldiers and veterans anything.Indeed, since the military is all about central planning and government, lets disband the armed forces. And oh yeah, there has been no innovation of any kind in the military ion the past 200 years because as blighter has argued, innovation in government institutions is just flat out impossible.(What are you going to believe- blighter's arguments or your own lying eyes?)
No innovation came out of a government laboratory, the United States did not reach the moon as a result of a government program, and the computer, the atomic bomb,the communication satellite, and the Internet was developed purely through private research.
Blighter cites agriculture. Of course government has never paid a penny in subsidy to any farmer.Government never granted land to any farmer in the nineteenth century and there has been no government funding of research into better crops, fertilizer, or pesticides . There was never such a thing as the Rural Electrifician Programme and government never built a single dam, canal, railway or road anywhere that helped farmers irrigate their crops or bring their produce to market. There is no US Department of Agriculture, no Farm Credit Administration, and no system of land grant colleges set up to help farmers. (Thanks for giving us the true libertarian history of agriculture in the USA, blighter).
Yes, blighter, let the free market work. Instead of a national army, mercenaries. Instead of the police, vigilantes. Instead of fire departments-well, fires don't happen all that often anyway. Let freedom reign!
Medicaid in California USED to cover dental expenses, but (to my best knowledge) California eliminated dental coverage for adults a few months ago because of the budget crunch. If you have an abscess or a similar dental crisis, you can get teeth pulled in an emergency room without paying for it. That's the only dental care most emergency rooms provide. They'll present you with a bill on the way out, of course, but you don't have to pay it if you don't mind losing your credit.
From what I've been able to discover, less than half our states now offer Medicaid dental coverage to adults. I don't know how dental coverage is treated in the health insurance bills now making their way through Congress, and I don't know what states plan to do on dental coverage when the economy recovers.
Okay, I just looked it up. Coverage is required for kids under federal law, but they essentially did away with coverage for adults on July 1st. I know someone who had all her fillings replaced in June at taxpayer expense. Good timing for her.
It's rather disappointing to see Ms McArdle fall into the "trap" of re-defining rationing. When opponents to health care rationing use the word they use it in the traditional sense: of government restriction of the ability to purchase despite the ability to pay, not this newfound (and disingenuous) sense of "the distribution of scarce goods is affected by the regulations defining the market hence all law is rationing" that the Left conjured up to hoodwink us.
When WWII ended, did people speak of rationing ending or rationing merely changing?
As the linked article details at some length, health insurance companies do precisely the same things governments do when they determine who gets care paid for and who doesn't. Why should we use different words to refer to the same behaviour, except to confuse the issue?
No-one here is arguing that ordinary regulation or the price mechanism is an example of rationing - the linked article dismisses that in the third paragraph, and in a rare burst of intellectual honest that apparently escaped you, Megan didn't reintroduce that particular red herring.
Look smarty-pants. Rationing is done by governments. Period. It's a socialist ploy to keep the rich from enjoying the fruits of their intelligence and labor, so that looters can get their "fair" share.
Look it up in the dictionary.
Private companies by definition cannot ration anything. The particular practice you are speaking of, not covering procedures that are deemed not medically necessary or the result of a preexisting condition --like most cancers (genetics, anyone?) -- is a contractual business relationship that produces wealth for individuals. And last I checked, society is still made up of individuals. So that is the good of society. This is what makes health care possible in the first place.
Websters-
Rationing: The act of limiting or proscribing access to certain goods in order to preserve said good for the purpose of transferring them to looters instead of smart, hardworking, producers. Rationing can only be done by governments. Period.
Giggle. Nice. Very nice.
My insurer can only determine within the bounds of contract (here's why I'm wishing this wasn't tied so much to employment...) what the policy will/will not cover. It can't forbid me from purchase. It cannot ration.
The British NHS used to offer universal, cheap or free, dental coverage of a rather basic standard. Under the present government, this has dwindled away so that people find it increasingly difficult to find an NHS dentist - and all without any official announcement of a change of policy.
Copy any system you like, America, EXCEPT the NHS.
Hmm. Have you lived under both systems Kid? I have, and the NHS has definite benefits. It doesn't win hands-down, but it does win in some areas.
This is an easy one: Doctors.
Gah. Health care is not a fixed resource. The more we pay for, the more we can get. Scarcity only occurs if the prices are capped or citizens are prohibited from using their own money on it. This limits the ability to divert more resources into, and receive more of, the health care service.
If you want to subsidize it, fine. There are even some low "out of pocket" cost subsidies like capping torts that most people would be tolerable to. If we want to subsidize chronic illnesses, fine. But don't pretend that we can get more of what we want just by artificially limiting it.
That's right. Money can be directly converted into healthcare, since there is no mechanism that limits the number of doctors. The only thing that limits healthcare is anything that limits the total money supply, which should be the gold standard in the ideal case. If you abolish private insurance companies, and the estimated 420 billion dollars that they create in salaries, dividends, profits, and "other," you will have 420 billion less to spend on creating more doctors, CtScan machines, virility pills, and virility pill commericials. Google "velocity of money multiplier," "CTScans," and "viagra."
Rationing in medicine is called triage, in any emergency, when there are more victims than a facility can handle the victims are triaged. minor problems wait, severe problems are taken care of immediately, People who are too injured for successful treatment are made comfortable and the already dead are sent to the morgue. It is a very efficient system. that distributes care to those who need it and can bnefit form it first. Not neccesarily the guy with the most money.
IMHO those so greedy, shallow and hateful that they blame everyone but themselves for the emergency should be actively added to the fourth category just to protect society from them.
You fools. Don't you realize that America is already a Socialist hell-hole? Now you want to take away my last vestige of freedom... PRIVATE HEALTH INSURANCE??! We already have death-books that tell us when we have to die, jackbooted government thugs that march us off to prison if we drink and drive WITHOUT hurting anyone, government administrators that tell us where we can and cannot construct our cell towers, our roads, our hunting shacks! What guns we can buy-- what bombs we can set off-- what age girl we can sleep with -- what borders we can and cannot cross -- what our children are allowed to believe!
THERE IS NO FREEDOM!! I will die to protect my right to PRIVATE HEALTH INSURANCE that can refuse me whatever treatments I see fit to be refused from by of at, small print or large. This is my right, and it's your right too and there will be no other "choices" I will allow, when the "choice" we are being offered is the "choice" for a NON PRIVATE ACTOR to compete against these plans that we currently choose freely, and later will only choose at the point of a barrel of a gun. That is the "choice" of deathpanels and beaurauocrats and Frenchies and LOOTERS!!!. THIS WILL NOT STAND!!
Let me tell you a little story. I was in France. Don't ask. My friend's child got sick while I was there, which was disgusting and probably the result of the fact that France is a poor socialist hell-hole even though they pretend to be so fancy and rich. Anyway. The guy calls the doctor and the doctor COMES TO HIS HOUSE AND EXAMINES THE BOY! He just had a little fever!! This is what socialized medicine means. Doctors being awakened in the middle of the night and marched to your house at the point of a gun (socialism remember) because your precious little child has sniffles and is barfing!!
WAKE UP!!! GLEN BECK PLEASE WAKE AMERICA UP!! I'm SCARED for my country!! It's dying. Our health care is easily the best in the world!! Why would we trade it for doctors at the points of gun barrels in the middle of the night?
Wow. I admit I got a little wound up there. I'm sorry, I struggle with my temper sometimes. Don't we all?Let me try to be a little more reasoned.
If you have a desirable good, like say healthcare, and you give it away for free, the market dictates that everyone will come and get it. I'm not saying people get sick just for the fun of consuming resources, but really, what free good does not get over-consumed. They bring free bread to your table, are you really going to order a full meal? There is a lemon in your water and free sugar on the table, are you really going to order lemonade? Who does that?
Tell me what sane person is going to lay off free services, whatever they are? Let's see, I can sit home with a fat unattractive belly, or get it stapled and lippoed for free. What am I going to do? Hmmm. Just guess. Then the government runs out of their "free money" they printed illegally and has to tell me "no no, none for you, that isn't "medically necessary." Two weeks later, I'm dead from a heart attack.
This is socialist medicine people. Get used to it. Free tummy tucks for the "socially useful" (eg. looters like Taggart) and hot death for the rest of us poor schlubs that are too dumb to see how wonderful socialist utopias run by Acorn death panels can be.
bupalos, don't be ridiculous. Except for the indigent, none of the plans going through Congress call for free medical care. They subsidize insurance, that's all. There will still be copays for medical care and prescription drugs. And what in God's name are you talking about with your death panel mishegoss?
Perhaps the death panels are a bit overblown, but you have to admit that there is a seed of truth in them. If you are giving out free health-care, you will eventually somehow have to "cull the herd." It's economics 101. Google "public goods" and "externalities" and then filter the search by "KONDRATIEFF WAVE." It will blow your liberal mind.
Well, I am between jobs right now, so the glorious private health insurance system's death panels has shut me out. I say bring on our Acorn overlords. Heil Obama!
No, I don't have to admit there's a seed of truth in what you say. The health care won't be free, and even if it were a democratic government would never "cull the herd". If I felt our government would ever consider something like this, I'd be out of here in no time. The health reform measures under consideration closely resemble the plans used in Switzerland and the Netherlands, neither of which have anything like the death panels Governor Palin is bloviating about.
Although I support the House version of health insurance reform, I realize it has serious deficiencies, the main one being the lack of adequate financing. If I were in the business of advising opponents of the Obama administration how to proceed, I'd reserve the death panel arguments for audiences dumb enough to believe them. Most of the people posting here are intelligent, and would appreciate rational arguments rather than cockamamie talking points.
Most of the liberal commenters posting here are intelligent, and would appreciate rational arguments rather than cockamamie talking points.
Fixed. Quite a few of the right wing posters have swallowed the Palin Kool Aid.
I have perused the many arguments for and against rationing and can't help but to respond to both sides of the argument as the great Socrates would: Is it true? Can you ABSOLUTELY know that?
I think, therefore I am. After that, we can't ABSOLUTELY know much of anything.
Those who are supporting the health care system and have the potential of continuing to do so will receive preference. Those who have ceased supporting the health care system and have no potential of doing so in the future will be issued pain pills and warehoused (cheaply), or offered the "little black pill".
"Those of us who are about to die salute you." You may survive this time, but your time will come too. Enjoy.
The more we pay for, the more we can get. Scarcity only occurs if the prices are capped or citizens are prohibited from using their own money on it. This limits the ability to divert more resources into, and receive more of, the health care service.
Quite so. The thing is, I don't know of any system, anywhere, that prohibits citizens from spending their own money on procedures not covered by national plans. Supplemental insurance schemes are widespread in Europe. I've lived in South Korea and Japan; both have fairly high-quality national health care systems, and in both you can easily purchase supplemental insurance to provide additional coverage if you want it.
Like most libertarians, I prefer market-based solutions when it comes to social problems. But the idea that the government providing some kind of health scheme will ipso facto lead to restrictions on citizens' right to purchase health care on a market basis is a canard.
A rational libertarian speaks.
So Japan- a country that we bombed halfway back to the Stone Age in 1945- has a high quality national insurance system.
So South Kore- a colony up to 1945 and a Third World country up to about 30 years ago- has a high quality national health care system.
And we still don't. Awrighty then.
Oh, you like the Korean system, do you? In Korea everyone has clinic-type care through the government - I think they take about $15 out of your paycheck. It's great for getting antibiotics and such. But if you need, say, an appendectomy, you're on private insurance. Some relatives of mine were basically bankrupted about six months ago when the father needed emergency surgery.
Actually, there's been quite a bit of controversy about that recently in the UK, because the NHS denies you all care if you pay privately for a rejected or not-yet-approved drug.
So Japan- a country that we bombed halfway back to the Stone Age in 1945- has a high quality national insurance system.
So South Korea- a colony up to 1945 and a Third World country up to about 30 years ago- has a high quality national health care system.
Note - I said "fairly" high quality. I haven't had any issues in either of these countries, and the statistics say their quality of care is high, but I am young and fairly healthy, so I might not be the best person to ask.
For what it's worth, most Japanese and Koreans with whom I've discussed health care are happy with the quality of what they and their relatives (most of my friends are also young) receive, though not necessarily with the cost, particularly for younger people who don't get back in services nearly what they put in in fees.
I'm not sure their systems are models that we ought to follow, but I can attest that the idea that the U.S. is the only country in which it's possible to get the best possible medical care is patently false, as is the claim that a national health care system necessarily leads to the death of private insurance - I currently have a private plan, because for someone of my age and health profile, it's a better deal, and the Japanese government doesn't have an issue with this.
Actually, there's been quite a bit of controversy about that recently in the UK, because the NHS denies you all care if you pay privately for a rejected or not-yet-approved drug.
That may be so, but A.)there's no reason for us to copy the NHS as opposed to other systems - in fact, most people (including me) think copying the NHS would be foolish as it's one of the less functional national systems, and B.)even if we did use the NHS as a model, there's no reason we'd have to copy all aspects of it, and in fact I think the public hew and cry against it would prevent things like this.
Certainly if nationalized care led to a restriction of consumer choice in the health care market I'd be against it - I wouldn't touch single payer with a 10 foot pole. But a well-designed public program that conserved consumer choice, I wouldn't be opposed to.
Emma - That's actually not quite right. You can go outside the NHS for treatment a much as you can pay for and take whatever drugs you want (providing they're legal and prescribed for you by a doctor, obviously) and pay their full cost. This doesn't affect your entitlement of get treated under the NHS. What you can't do is go to your NHS doctor and get a prescription for MyracleWonderDrug and then pay privately to get it filled, or undergo treatment in an NHS hospital and pay to take a non-approved drug at the same time.
The restriction isn't there to prevent private care - Its there to prevent doctors from mixing up their private and NHS practices the way dentists do (to the extent any still take NHS patients at all).
Not entirely true. Canada actually has a fair number of bans on private insurance - it varies by province, and the Quebec ban got struck down a few years ago(see Chaoulli v Quebec), but there are still more limits than you would expect.
Megan:
Right. We never had to talk about the "R" word until doing so might benefit the holders of existing, inherited or entrenched privilege.
Then all of a sudden we "have" to tell the "truth" and "confront" it because we really don't want white middle-class-and-above Americans to have to confront the actual rationing that has characterized our system for decades.
Bupalos:
Look smarty-pants. Rationing is done by governments. Period. It's a socialist ploy to keep the rich from enjoying the fruits of their intelligence and labor, so that looters can get their "fair" share.
Look it up in the dictionary.
Well I actually looked up "rationing" on Wikipedia and found the following:
Rationing is the controlled distribution of resources and scarce goods or services. Rationing controls the size of the ration, one's allotted portion of the resources being distributed on a particular day or at a particular time.
in economics, it is often common to use the word "rationing" to refer to one of the roles that prices play in markets, while rationing (as the word is usually used) is called "non-price rationing". Using prices to ration means that those with the most money (or other assets) and who want a product the most are first to receive it. Such rationing happens daily in a market economy. Non-price rationing follows other principles of distribution.
http://en.wikipedia.org/wiki/Rationing
Let me break it down. Those who claim that "rationing can only be done by government" are wrong-dead wrong. They are so completely and totally wrong that it took 5 seconds of searching on the Internet to vaporize their claimed "definition".
The lie that "Rationing only applies to government action" can take its place in right wing hackery beside " Stephen Hawking would be dead if he grew up in the UK and was treated by the NHS."
OK, I think that I have refuted enough right wing buffoonery for one day. I'll rest from my labors till tomorrow.
Did you read that wikipedia entry? All the examples are government initiated.
The system we have now doesn't ration care any more than the grocery store rations Pop Tarts. See if you can't try to win an argument without trying to change what the words mean.
Please read in the article where they say that they are going to focus on government-initiated rationing. The point is that economists use the word to also apply to price -initiated allocation of resources.
According to economists, the grocery store can be said to ration pop tarts. Re read this:
Using prices to ration means that those with the most money (or other assets) and who want a product the most are first to receive it. Such rationing happens daily in a market economy
You can't get around that. There is no "argument". It's game over.
CRIKEY!!
I cannot believe we are four weeks into this discussion and I have to spell this out. RATIONING: The real losers from the current politics, the losers if we stick with the current, generally unregulated, health insurance process we have are the 48-58 year-olds. This is the voter-rich (I almost wrote fat) part of the demographic curve. What are the Republicans thinking?! And we are not "losers and shirkers."
The Republicans have made the old folks very scared. I know, our 75-year-old parents, one pair in PA and the other in FL are now terrified and one just had a hip-replacement to avoid the coming 4-year queue. We keep trying to reassure them that they will be fine, but after Wall Street failed them so spectacularly last year, they aren't taking any chances.
We have had employer-provided health care continually since we graduated in 1980. We have a college graduate who now has to be insured under COBRA! If we lose our jobs, as is more and more likely, we could fall into the "unemployed and paying-thru-the-nose" category. All so Megan can have her BOTOX treatments and her groovy designer glasses on a "health care spending account." Some people are tax-preferred, and some people pay real after-tax dollars.
I want Washington to fix this. I am shocked that the Democrats think we don't get it. I am shocked the Republicans think we don't get it! I had a Republican fund-raiser call me from Wisconsin last night. I asked him what I am supposed to do if I lose my job. He told me to go "down to the county." I suggested that might be a government program. I also told him that I would donate to the Republicans when they start to negotiate in good faith. He told me my comments were "the most respectful he had heard all day." And, "You have given me some things to think about."
Our elites are failing us. Where are these town-hall folks in Iowa? Tell Grassley to quit hurting our country. Tell him that Rahm has screwed up so badly that we will never trust the Democrats to govern again. So you all win, or lose. So stop with the political games. Go fix the health care system!
Current American health insurance is "generally unregulated"? Who knew?
Since he asked, we should do this. Ration by giving incentives to citizens who consume as little as possible as cheaply as possible, but try damned hard to allow every citizen to afford what they need.
Steve, you are right. If we went to a completely private, paid for, free market system, the problem would actually be under-consumption of medical care, from a public health perspective. Or, in other words, if we allowed people to buy their own vaccines at the marginal cost of the vaccine, there would be a socially dangerous level of immunization. We would have to force people to come for their shots.
If we did this we would find that we have too many trained knee surgeons, there would be far fewer ACL replacements. If every state could double its annual production of doctors (at present, CA, for instance, graduates only 1000 doctors a year for a population of 38 mm so our doctors come from China) there would be drop-in clinics and doctor adverts would support the local newspaper. Free market competition anywhere it could be introduced would really drive down prices. The Pharmas would hate it and so would the AMA.
But, Megan would lose her tax-privileged status. Despite her free-market principles, she really likes having a special deal from the government, she just doesn't want to tell you that that is what she's protecting. She doesn't want to give up her subsidized care. And it is intellectually dishonest. Easier to panic the old folks with talk of rationing.
Most of the current health care debate seems to miss the point by focusing merely on the demand side of the equation. Whether we pay for health care by higher premiums or higher taxes, whether we allocate care based on price or a government formula, isn’t it all just six of one thing, versue a half-dozen of the other? Rather than fighting over how to divide up the pie, shouldn’t we just figure out how to make the pie bigger?
Any new health care policy should be measured against the yardstick of whether it encourages additional supply of health care goods and services. Certainly as baby-boomers age, and medical technology advances, we’re going to see a tremendous wave of demand for additional health care. We need to encourage additional supply to meet that demand, expand access, and hold down prices.
The question is – does the proposed health plan encourage anything of the sort? Will reduced payments to providers encourage increased supply of providers? No. Will additional regulations encourage more supply? Probably not. Rather than cutting payments to providers, will anything being discussed reducing cost that the providers themselves bear? Even the emphasis on federal government emphasis on electronic recordkeeping seems to be more a case of the government inserting its control over the health care system rather than a genuine effort to cut costs.
On the other hand, mandates to carry health insurance, mandates as to what that insurance must cover, subsidies to purchase it, perhaps a public option, and not allowing insurance companies to charge higher prices for those who are likely to consume more health care services. This will certainly stimulate additional demand, over and above what is already coming down the pike with an aging population. How will the supply-demand imbalance get resolved?
I enclose a link to an interesting article regarding the financial challenges the the UK NHS will be facing.
http://news.bbc.co.uk/2/hi/health/8091427.stm
BTW, I think maybe the people who will be most upset when the plan passes are the under-30 crowd, many on say $30-40k/yr income but no insurance. They probably will be annoyed to be paying 25% of their after tax income on expensive health insurance that they feel they don’t need. And supposedly it’s forcibly signing up all these young health people that’s going to magically keep insurance premiums down for the rest of us. Many of the currently uninsured are in for a rude shock!
Well, the reform plans don't really deal with supply side much ( but neither does the current system or the Republican plan). The reason is that its hard to do. You can change the occupational licensing laws to allow more medical care to be delivered by nurse practicioners and physician's assistants (over the objections of AMA and the Republicans) and offer scholarships and awards to change the mix of doctors and medical providers to be more oriented to geriatrics care, but there is no silver bullet. It will require government intervention, though. There is no magic "free market" solution.
You should understand that just because the NHS is experiencing budgetary problems due to rising health care does not mean NHS=fail. It just means that the NHS has the same problem every other health care system in the world has-out of control health care costs. (BTW, it's interesting that right wingers ALWAYS talk about the NHS, but never refer to the more successful national health care systems in Sweden, France, Switzerland, etc.?)
Of course under-30s don't feel they need health insurance. If we are young, we generally just don't feel we need ANY insurance.They generally don't feel they need car insurance, either, but that doesn't stop us from mandating car insurance for all.
Where are you getting this 25% from? The reform plan limits out of pocket insurance costs and while the number is not yet set in stone, I believe that 10% of income is about where it's at. So no way will a person with 40K a year in income be paying that much out of pocket.
And that seems rather realistic too. I work for a large corporation with a large and varied risk pool-- and an excellent Fortune 500 benefits plan. Counting my employer's share of the premium as income (which is appropiate) my total insurance costs are about 9% of my total income.
The excellent piece by Dr. Chevlen echoes what Dr. Richard Fogoros has been writing at The Covert Rationing Blog http://covertrationingblog.com/
He has also written a book and I recommend it to the readers of this blog.
There is big disconnect between much of this discussion and the real world of controlling the utilization of medical care, which is done all the time. Health insurers routinely, where allowed by state law, deny mental health visits over a certain number. There is no medically defensible rationale for their behavior.
In the workers compensation system, insurers routinely deny treatment that is not recommended by "best practice" guidelines, which are drafted using the same methodology proposed in Congress: by sifting through the findings and credibility of medical research. These denials are medically defensible if they attempt to control excess or wrong treatment. Say, 100 physical therapy visits. There are controversies, such as over some pain mitigation treatments.
The idea is a win-win: control for questionable medicine, and improve the effectiveness of treatment while reducing costs.
Come, let us speak of unpleasant things. How is health care to be rationed? Who gets the short end of the stick? Not smug Dr. Chevlen, that's for sure.
His article seems to be an attempt to resolve a social problem by philosophy, which is actually pretty common when it comes to large-scale sociology. That's because there aren't too many opportunities to do actual experiments in large-scale sociology, but here's one:
Take two groups of mostly-literate, industrialized nations. In one group establish a variety of nationally-run universal health care systems; subject the other group to health care controlled exclusively by the desire of millionaires for profit.
Simmer for fifty years. Now compare outcomes. Which group has worse results in obvious actuarial measures such as life expectancy and infant mortality? Which group experiences a far greater degree of customer dissatisfaction? And which group squanders three to six percent more of their GDP, just heaps up trillions of dollars of its wealth in a pile and sets it afire, to achieve these miserable, inferior results?
Your experiment has been rejected by the journal of sociology due to the utterly shitty experiment design. In particular, we found the following failures in the experiment:
1.) Your sample size is too small (one of your groups has only a single nation in it).
2.) No attempt has been made to control for confounding factors which affect health far more than medicine (lifestyle, demographics).
We recommend resubmitting to a journal of political advocacy.
"Which group has worse results in obvious actuarial measures such as life expectancy and infant mortality?" Well in the US we measure all births with any sign of life as live births while in various European countries it only counts as a live birth if it meets certain weight and/or length requirements such as over 1 pound or 12 inches in length. That skews the rate quite a bit.
A question for you. Which group has better 5 year cancer survival rates? Its 66.3% for men in the US vs 47.3% for men in Europe. 62.9% for women in the US vs 55.8% in Europe. (link)
Which group has created most of the drugs that have led to increased life expectancy and survivability including that of those people who live in the other group?
Until we have the savy to keep the earth healthy we will not be able to be healthy either. The mantra "don't crap where you eat" when followed will save a continent of money which will then be available for us.
Reagan was shot by a certified lunatic, as was Garfield. Kennedy and McKinley were shot by left wing loners. I give you John Wilkes Booth as right wing in his own social context, but that was a while back, and I think we can forgive the Democrats by now.
Megan, did you really write that?
Does David Bradley know you're so flip about assassinations?
How you can you look at yourself in the mirror? I'm not joking.
What exactly is so offensive about that?
"Limiting health care's availability by the criterion of personal wealth rightly offends our sense of the dignity of the individual."
Rightly?
Assuming the existence of differentials in wealth, there is one way of avoiding such differential availability: a legal hard limit on the amount of health care you're allowed to have regardless of your ability to pay.
Because there is no way that any system, public or private, can give everyone the amount of health care a Bill Gates could buy. He could easily afford to put a full-time pediatrician on his household staff to care for his kids, after all, and there's no arrangement as a society we could make to give that to everyone; we don't have enough pediatricians.
So, the implicit claim here is that it is necessary, in order to preserve the dignity of the individual, to threaten a man with prison should he choose to use his wealth to provide health care for his children that exceeds the level society as a whole can provide for everyone.
If that's what is meant by "dignity of the individual", I want no part of it.
Re: So, the implicit claim here is that it is necessary, in order to preserve the dignity of the individual, to threaten a man with prison should he choose to use his wealth to provide health care for his children that exceeds the level society as a whole can provide for everyone.
Right now we threaten people with prison if they refuse to pay their due share of the taxes required to fund education for all children. We don't however threaten anyone with prison if they chose other options for their own children's education, provided only that they do make some such provision. I don't see why healthcare can't work the same way: provide full standard coverage for everyone, but if people want to go beyond that and make some private provision instead, then by all means allow it. Your dichotomy is a false one, as shown by the fact that a middle policy exists and works quite well in education.
"Middle policy"? Our current education system still limits the availability of education by the criterion of personal wealth; if you don't have enough money, you have to go with public schools, while those who are wealthier have access to better schools.
Sure, health care can work the same way, but then we still have a situation where availability of health care is limited by the criterion of personal wealth, which "rightly offends our sense of the dignity of the individual." No matter how good your care is, if Bill Gates can get more or better because he's richer, then your options have been limited by the criterion of your wealth.
I offer no false dichotomy between a system that helps no one and a system that prohibited all private purchase of care. I simply point out that any system short of the no-private-purchase-allowed model still has cases where some people have more available health care. By the standard proffered in the first quoted sentence, any "middle policy" is still an offense to the dignity of the individual.
I simply point out that any system short of the no-private-purchase-allowed model still has cases where some people have more available health care.
Even that sort of system doesn't eliminate disparities - Europeans (not to mention Americans) often fly to Thailand, India, or other places where high quality medical care is available in order to have procedures not covered in their own countries performed cheaply.
There's no way to eliminate disparities in health care quality - Bill Gates is always going to be able to afford things the average American can't. But pursuing that argument is the sort of semantic hair-splitting that shouldn't be allowed to sidetrack the debate. What's important is making sure that people don't die of preventable causes because they're uninsured, or spread infectious diseases because they can't afford preventative measures or treatment.
I prefer to make our approach to this problem as market-based as possible, and I don't want socialized medicine or anything like it. But to me, the Republicans have no credibility on this issue, because they refuse to acknowledge that our health care system even has problems, when anyone who's put any effort at all into studying the problem realizes that is not the case. Reforms are necessary - opinions differ on what kind, of course - but anybody who claims that the status quo is fine doesn't deserve to be taken seriously.
Do you have any evidence this occurs under our current system?
As far as I'm aware, the best evidence we have (the RAND experiment) suggests that giving people insurance does not improve their health. That is to say, the situation you are describing does not occur to any statistically significant degree.
It is difficult to take libertarians who argue for the efficiency of private health care at their word. Even if they believed private care was less efficient, they would still demand it on the basis of its superior moral footing, in their view.
Those who argue for government-subsidized or government-run care aren't saddled with that problem. They make no claims as to the moral superiority of government-run programs.
To be sure, there are "anti-capitalists" who make resentment of wealth a rhetorical staple, but these are fringe characters outside of the liberal mainstream. And only a few of these folks are willing to say the government's better to do something that's more beneficially provided by the private sector.
Honesty, indeed. Libertarians have a lot of 'splainin' to do, if they want to be honest, and it's not about private efficiency, but about the morality of letting poor children die when they can't afford a doctor.
Why don't those poor children go out on the free market and buy private health insurance? After all, TallDave and others tell me that markets NEVER fail
Those who argue for government-subsidized or government-run care aren't saddled with that problem. They make no claims as to the moral superiority of government-run programs.
Rafael, have you ever read a Paul Krugman column?
it's not about private efficiency, but about the morality of letting poor children die when they can't afford a doctor.
I thought that was what SCHIP was for?
Interesting. So anti-capitalists who make resentment of wealth a rhetorical staple are fringe characters outside the liberal manistream? Hmm, that inplies that Obama, Pelosi, and Reid are outside the liberal mainstream. Who knew?
Krugman never argues that the nature of government participation in healthcare provision makes it morally superior, regardless of performance. Rather, he argues that the performance is superior, and that superiority in providing care to all as needed makes it more moral than the private model.
Every libertarian should recognize and be prepared to deal with that distinction.
As for SCHIP, indeed it is a model program and one that many have called to expand. Though it is anathema to libertarians, who love to say they value personal freedom, but seem so unprepared to deal with situations were it comes at the expense of compassion and other communitarian values.
Ever heard of "tough love"? It's not compassionate to make independent people into wards of the state and utterly dependent on the whims of politicians and state financing.
The libertarians I know strongly believe in a social safety net, but also believe that what has been created is far more than a social safety net.
Back in another life, one of my unmarried workers, who had health insurance through her state job, got pregnant. During her pregnancy, she got upset that her state health insurance required her to go to a hospital 3 miles away instead of the hospital which was only half a mile away. So she quit her job to receive welfare and Medicaid, which sent her to the hospital only half a mile away. Three months after giving birth, she got another state job.
I think that's an example of providing too much of a social safety net.
If a libertarian "strongly believes" in a social safety net, there would be little or nothing philosophical to separate them from a liberal.
Yes, individuals abuse government programs, just like they abuse private ones. Suppose ``your'' unmarried worker had instead quit because Kaiser Permanente required her to got to a hospital three miles away. You'd probably praise that as free market competition in action!
Your "wards of the state" formulation doesn't wash when it comes to health care. The nature of medicine is such that all non-medical professionals have no choice but to become "wards" of the medical establishment when faced with serious illness. It just isn't realistic to "shop" for an orthopedic surgeon to mend your son's broken arm after a harvesting accident. Nor is it feasible to simply go without regular pap smears or chest x-rays because you feel the quality of care is too low or too expensive or too inconvenient.
With health care, there is already an element of coercion built in to the equation. In virtually all significant cases, you have very little choice but to follow the doctor's instructions.
Classical liberal, perhaps, but certainly not the current socialist crop.
There's an old adage: give a man a fish and you feed him for a day; teach him how to fish and you feed him for life.
The current leftists believe in giving fish to people, with little or no incentive for the people to learn how to fish. Small-L libertarians believe in proper incentives. We're really not heartless as the leftists decry; we believe strongly in feeding people. We just recognize that it's far far better for people to fish for themselves and not be given fish. Unless, of course, they are physically or mentally unable to.
Now, what the hell does your response have to do with the clear cut dilemma set out by RK? That's problem with libertarians.-they spit out these declarations of abstract principles-"Government is the problem" and " Free markets never fail" when faced with real world situations.
If you seriously want a safety net, then the reform bills have that:
* universal coverage , like what's been achieved in virtually every industrialized country and even countries like Singapore
* reform of Medicare to eliminate waste, fraud and abuse
*setting up of national exchanges to foster competition
* the prohibition of unfair industry practices, like denial for pre-existing conditions
* individual and employer mandates requiring all people to be in the risk pool
* subsidies for the poor and working class to buy insurance
* a government insurance plan to offer insurance to those who can't afford private insurance plans and to prevent price gouging
That's the basic reform agenda , as set out in these bills. Its hard to understand why it seems so horrible for libertarians . Note that countries like Australia, Japan , Spain, and Taiwan have not turned into socialist hell holes because they all now have universal health insurance. They still fish in all those countries :-).
This article is nuts to assume that government insurance is more likely to implicitly ration than private insurance. Contractual obligation means nothing since most people don't have the resources to sue for breach of contract. Moreover, if anything, Private Insurance is less honest. While government will tell you that you have to wait N weeks before you get treatment, private insurance uses rescission. (ie Selling you insurance until you get sick, then revoking your coverage when you require expensive treatments.)
While the author uses a subjective estimate of their impression of media coverage, we can use a little conditional probability to get an estimate of the exact rate. It turns out that for people who need serious treatment in the private insurance market, the rate of rescission is as high as 50%!
http://tauntermedia.com/2009/07/28/unconscionable-math/
Note also that the other techniques mentioned are used in the private market. Perhaps the author isn't aware of the hmo; an organization structured to provide implicit rationing.
On a separate note from the author's poor reasoning. I think we can characterize how we'd like to the healthcare market using a little simple algebra.
The current system can be described by this equation:
y = (c-s)*x
X is the quantity of care. C is the unsubsidized cost per unit, S is the employer subsidy, and Y is the total cost.
The slope of this line(c-s) is the marginal cost. The marginal cost is decreased by the subsidy, thus people tend to over-consume.
IMO the ideal to aim for is:
y = c*x + b
b would be a baseline level of care provided by the government. Thus no one has to go bankrupt because they can't get treatment and everyone can get preventative treatment that improves overall public health and lowers everyone's costs.
The employer subsidy is removed, so that the cost per unit is higher. With a higher marginal cost, people will be less likely to overspend out of income, although the option would still be available, and they wouldn't not face risk when changing jobs.
Obama's plan is probably more like:
y = (c-s)*x + b
It keeps the employer subsidy, but provides the baseline level of care. So it formally gets us halfway, but by allowing people to transition on the exchange out of employer provided systems, or by allowing employers to pay for coverage without providing it*, we decrease reliance of the system on the subsidy. With luck, this would decrease political support for the employer subsidy which we could then remove to reach the ideal.
Reasonable discussions of healthcare should really be in these terms; comparing along the various dimensions of reform that have actually been proposed. This irrational fear of government administration is plain stupid. The government is just another large bureaucratic actor, efficiency-wise it is comparable to a multi-national corporation, with slightly larger economies of scale, and If the popularity of Medicare and the VA are any indication, it is an actor that happens to be quite adept at providing healthcare.
*by accepting the fine for not providing coverage under the employer mandate
I don't have a problem with rationing per se because everything in life is rationed in one way or another.
The thing I have a concern about is how rationing will be applied, and by whom. It's not so much granny vs baby, but other determinations which concern me.
__ Will the disease lobby of choice be allocated more health care dollars (as was/is done internationally with HIV/AIDS vs. malaria, the later which disables/kills far more people but gets less dollars to combat)?
__ Will the ethinic lobby of choice get more health care dollars allocated? Ditto the sexual orientation lobby du jour ... etc.
__ Will the uppity-ups get moved to the front of the line, have their own separate health care system, doctors, hospitals, etc. (as happened in the USSR)?
__ Will the drug makers influence which diseases get allocated the most dollars in order to sell more of a specific drug?
We don't have a good track record on these issues under the system we have now. Just imagine when an even greater number of petty beaurocrats get their mitts on this kind of power.
But then, most of my concerns about health insurance reform proposals are of the 'out of the frying pan, into the fire' category.
Rex: The give fish/teach fishing simile doesn't hold in health care, unless you expect to teach orthopedic surgery, childbirth, anasthesia, radiology and oncology to the guy or gal who pumps gas into your car, builds your house, does your taxes or glues together your running shoes.
Applying market behavior models to health care ignores the conflict of interest that emerges when doctors are compelled to treat patients as profit centers.
Why isn't this too obvious to mention?
People have to eat to live. Do grocers have a conflict of interest in selling food on a profit basis?
People need shelter. Do house builders have a conflict of interest in selling homes on a for profit basis?
Doctors, nurses, other health care workers work for a salary. This is 'profit'. Should they work for free? Are they preying on the ill to make a profit?
Everyone who draws a salary is making a 'profit' off off their labor.
I think what we are talking about here is whether or not a certain level of profit is acceptable or not ... and the problem comes into play in who decides that.