And Megan, no one on your side of the argument seems willing to answer two simple questions. If every other country (don't split hairs, you know what I mean) can cover ALL of their citizens for LESS than the US does, with better outcomes, why can't we do that?
This is a favorite question of would-be reformers. There are two answers, one theoretical, and one empirical. We'll start with the theory, which won't be new to regular readers; I've gone over the that I think we aren't the same as Europe a bunch of times:
- More wage inequality means doctors need to make more
- The American political system is especially easy to lobby
- American public services culture is, in general, less effective than the Nordic countries, and no, this is not simply an artifact of Republicans criticizing government bureaucrats; the government bureaucrats do a great deal that is worthy of criticism
- Path dependence: it's a lot easier not to give people a new drug or treatment than to take one away.
- Intolerance of tradeoffs: we do not even do the very obvious things to control costs in the system, like rethinking extraordinary measures at the end of life. The harder tradeoffs are simply non-starters.
- American attitudes toward government: when told they can't have something they want, Americans do not say, oh, okay. They go on the news and call their congressman.
- Federalist and non-parliamentary democracy: in most other systems, the head of the government tells the government what to do. In our system, you need 220 congressmen and 50-60 senators. There's no way to implement the sort of technocratic change that reformers envision; the politicians will keep sticking their fingers in the pie.
- Conservatism: the American public is considerably to the right of any European electorate, and no, this isn't just an artifact of Republicans lying to them. They have different attitudes about how much they want the government to do, and how much they are willing to pay to do it. Many of the reforms that hold costs down in Europe are simply non-starters because they smack too much of socialism.
Anything you could do to a putative new system, you could do to Medicare. And the reason we haven't is not that we just thought of comparative effectiveness research, healthcare IT, or strong-arming provider payments last week. These ideas have all been kicking around for a long time, and in the case of the provider payments, have already been tried more than once. Providers learn to game the new payment rules, and if they don't, they get Congress to undo them.
But maybe the new system will be different. So let's look at the closest model we have for this system in the United States: the state of Massachusetts. Massachusetts has all the goodies in the Baucus bill: subsidies, guaranteed issue, community rating, an individual mandate, and employer penalties. Indeed, the Massachusetts program is probably to the left of where we're going to end up, on things like empowering the exchanges to negotiate with insurance companies and the size of the penalties for failing to procure insurance, two measures which are supposed to be critical for holding costs down.
Instead, costs have exploded. This excellent powerpoint from the State of Massachusetts has some compelling graphics.
Unfortunately, my PowerPoint-Fu being a little rusty, it's slightly hard to read, but if you click on it you'll get a full size pop-up. Here's what you'll see: between 1991 and 2004, Massachusetts had a rate of healthcare inflation that was just slightly above the US average, though the gap widened somewhat towards the end of that period. But from 2004 on, the rate of US healthcare inflation drops, while Massachusetts stays steady, until it is more than a full percentage point higher than the rate of US healthcare spending growth.
The cost of individual premiums also jumped sharply in 2007, as you can see, when insurance companies began to rate their experience under the new health care regime. And the Boston Globe says insurers are predicting another bumper year for premium increases, with an average expected increase of 10%. Meanwhile, the Commonwealth of Massachusetts is spending substantially more than it was expected to.
The Official Asymmetrical Information Fiance has a more complete guide to how the various combinations of mandates, guaranteed issue, community rating, and subsidy have performed at the state level. Answer: not well. Here's the nut graph on Massachusetts:
So I'll turn it around on reformers: why do you think that we can control costs, given that we couldn't at the state level? Massachusetts is a very liberal state, a very rich state, and it started out with a relatively low proportion of its citizenry uninsured. Proponents of reform often say it has to be done at a national level because states can't borrow money in downturns, but this doesn't explain why the spending side is headed through the roof. Why are you gazing past the cost control problems at home towards people who don't even speak the same language we do, much less share a political culture?
It's no good saying that well, we should try to be more like the Netherlands--you can't build a system on the assumption that you will, suddenly and for no apparent reason, be able to import someone else's political culture. Progressives are watching the whole health care legislative process with utter dismay as it produces a monster of a bill that not even its mother could love--and trying to love it anyway, on the grounds that it's a start. But this ridiculous hodgepodge, this hypertrophied Rube Goldberg apparatus, is not some startling aberration of the political process, induced by some Republican dark magic. This is the kind of thing the American political system produces. This is why all of our programs have a substantial element of the inexplicable and bizarre.
The cost of individual premiums also jumped sharply in 2007, as you can see, when insurance companies began to rate their experience under the new health care regime. And the Boston Globe says insurers are predicting another bumper year for premium increases, with an average expected increase of 10%. Meanwhile, the Commonwealth of Massachusetts is spending substantially more than it was expected to.The Official Asymmetrical Information Fiance has a more complete guide to how the various combinations of mandates, guaranteed issue, community rating, and subsidy have performed at the state level. Answer: not well. Here's the nut graph on Massachusetts:
And health-care costs have continued to grow rapidly. According to a Rand Corporation study this year, the growth now exceeds state GDP by 8%. The Boston Globe recently reported that state health-insurance commissioners are now worried that medical spending could push both employers and patients into bankruptcy, and may even threaten the system's continued existence.
So I'll turn it around on reformers: why do you think that we can control costs, given that we couldn't at the state level? Massachusetts is a very liberal state, a very rich state, and it started out with a relatively low proportion of its citizenry uninsured. Proponents of reform often say it has to be done at a national level because states can't borrow money in downturns, but this doesn't explain why the spending side is headed through the roof. Why are you gazing past the cost control problems at home towards people who don't even speak the same language we do, much less share a political culture?
It's no good saying that well, we should try to be more like the Netherlands--you can't build a system on the assumption that you will, suddenly and for no apparent reason, be able to import someone else's political culture. Progressives are watching the whole health care legislative process with utter dismay as it produces a monster of a bill that not even its mother could love--and trying to love it anyway, on the grounds that it's a start. But this ridiculous hodgepodge, this hypertrophied Rube Goldberg apparatus, is not some startling aberration of the political process, induced by some Republican dark magic. This is the kind of thing the American political system produces. This is why all of our programs have a substantial element of the inexplicable and bizarre.
Good post. And it isn't just Massachusetts. State level experiments attempting to provide universal -- or near universal -- care have failed in Tennessee, Maine and Oregon. Medicare is in a vast fiscal hole.
Every experience we have had with government-provided health care has ended with sub-par outcomes. Every experience we have had with state-run enterprises such as the USPS and Amtrak have been a mess. What reason is there to think a public option or more government intervention would produce a better outcome?
What's that Einstein said about the definition of insanity?
Awesome article, especially
"Progressives are watching the whole health care legislative process with utter dismay as it produces a monster of a bill that not even its mother could love--and trying to love it anyway, on the grounds that it's a start. "
I suspect there's a large degree of overconfidence at work. "It's a start" suggests that it will readily be amended and tweaked into what such progressives actually desire. Instead, I expect it will be more of a marginally controllable Frankenstein's monster with substantial resistance to "improvements".
Am I reading that wrong, or does the MA rate become lower than the U.S. rate from 2011 on?
Not only that, but why does it matter that "from 2004 on, the rate of US healthcare inflation drops, while Massachusetts stays steady" when the legislation didn't take effect until 2006? I realize it would be a pain to recalculate the change from 2006 on, but given the more favorable numbers post-2011 I'd say it weakens your argument.
Actually, should probably be from 2007 on.
I'm pulling it from work by the Commonwealth, which is defending its plan.
I'm from Mass and I'm responsible for 30+ employees - our health insurance went up 30% last year and possible double digits next year.
Single-payer advocates might argue that if you crack down too hard on Medicare reimbursements, physicians will leave the program; but if we had a Medicare-for-all time of plan, once it drove the private insurers out of business, it would be pretty much the only game in town. A handful of docs could still ditch it and run boutique practices for the wealthy, taking no insurance. But since there are only so many Americans rich enough to afford paying cash for health care, the rest of the docs would have to suck it up and take what Medicare-for-all paid. At that point, the government could put the real squeeze on.
I should add: I always assumed this was the plan all along. How else do you "bend the cost curve" by giving more people health coverage? The only way that seems to work is to get the government share of health care spending to a critical mass where it can set prices.
The wording "rich enough to pay cash for health care" sounds really strange to me. I pay cash for health care (or, sometimes, use my credit card, but I'm sure that's part of what you mean by "cash") not only because I prefer it in general, but because I have no choice: I'm not rich enough to pay the price of medical insurance for a man my age with a preexisting health condition, nor anywhere near poor enough for Medi-Cal. I object to mandated insurance partly because every version of it I've seen would require me to spend way more for health insurance than I spend out of pocket—more than I can make room for in my budget.
Most Americans don't think of paying cash for medical care, not because they're too poor to afford it, but because their cultural expectations have been systematically warped by decades of a system that subsidizes employer-funded comprehensive health insurance at the expense of all other ways of paying for health care.
THIS.
You're assuming that doctors will stay in the business instead of pursuing more lucrative ways to make their living. You're assuming the same thing about drug companies. In reality, you'll get fewer docs practicing, fewer people entering the profession, and fewer drugs getting green-lighted for advanced trials. There's a technical term for what happens with these kinds of price controls.
It's called a shortage.
I haven't assumed that there wouldn't be any shortages under such a scenario, and neither have I advocated for one. It just seems like the Left's endgame to control costs (assuming they actually have one). Shortages may be a price they are willing to pay.
The problem, of course, is that it's really a price they are willing that everyone else pay.
Right. Which is why Obama's oft' repeated promise that we can keep our existing doctor/coverage is so disingenuous. So, too, is the claim that all the billions they plan in cutting out of the medicare budget will not reduce the standard of care. The proponents of a single payer plan know that their plan will only be successful in controlling costs if it reduces the standard of care by creating shortages and/or denying treatment (denying certain kinds of treatment and/or denying certain people care). They also know the public will reject their plan if they understood the plan would cause long lines at medical clinics, so they make promises they know cannot be kept.
Note: I understand proponents of a single payer system might just be wrong, in which case, they're not dishonest; they're idiots. I think they'd rather I thought they were "sharp" and "sophisticated" in crafting their message rather than be thought too stupid to flip hamburgers.
Sadly, the Left seems to think that it can deal with shortages through other interventions, such as free medical school tuition and larger NIH grants to research universities, along with a complex assortment of other mandates and subsidies.
"A handful of docs could still ditch it and run boutique practices for the wealthy, taking no insurance"
Initially, but I suspect this niche would grow rapidly as people got sick of dealing with the government program. The Feds would try to limit this sort of thing, but I think they'd get laughed out of court trying to stop a private market or otherwise trying to restrict access to medical care the patient was willing to pay for. Eventually we'd be back to something similar to what we have now. I do think the government could succeed in completely destroying drug and medical device innovation though.
there are already boutique practices for income levels that are more middle class (100/month for unlimited visits, as an example).
so it would not just be rich people who were able to access such practices and doctors.
Right, and that works for about a generation. That's about how long it'll take you to realize that my daughter, who currently wants to be a doctor but is only in 7th grade, will have decided to go into some other profession rather than spend 12 years in college only to slave on as a poor doctor taking whatever Medicare will pay. By that time, it'll be her kids who aren't considering careers in medicine. Of course the government will come up with some kind of incentive program to try to push new doctors into the pipeline, but the pipe will leak tremendously and their initiative will fail.
How do I know it will work this way? Because it's working this way now with math teachers. There are no longer enough (domestic) graduating math majors to staff all the math teaching positions, and approximately 50% of all high school math classes are being taught "out of subject" (i.e., by people without a major, minor, or certificate in math). Consequently the number of U.S. citizens who actually know enough math to pass it on diminishes each year.
And this is because of government-mandated math insurance?
Or maybe the math-heads all went into computer science...
There are other reasons that are more important. I do not have the reference handy but in Healthy Competition (yes, published by the Cato Institute), they point to data showing that the US has a better incident to morality rate than Europe for major degenerative diseases. Europe has a lower mortality rate because of ecological differences that lead to lower incidence rates. That shouldn't be too controversial given the higher rates of obesity (a reasonable proxy for metabolic syndrome) and eats a less healthy diet.
I have several times expressed a willingness to pay increased taxes for a bare-minimum NHS-style system, with a QUALY price perhaps 1/3 that of the current QUALY price in the U.K., as a safety net for the indigent. Such a system is extremely good at squeezing out the maximum lifespan from a minimum number of dollars. This would be coupled with an anything-goes, buy-as-much-as-you-can-afford system for people who would like, for example, coverage of the most recent, advanced, and expensive cancer and heart care treatments, even when they are old.
When I have proposed this to leftists, though, they have responded by placing great weight on the principle of equality-of-care-for-all. If you are going to place great weight on that principle, and you are not going to eliminate the essentially limitless coverage that the insured middle and upper classes currently enjoy, you are not going to reduce costs to European levels.
Huh. Are they willing to get the standard of care offered in Africa? Because we aren't going to be able to get a better standard there for a long time.
I refer to that as "Chicago-projects-style government health care." It should be adequate, but suck so much nobody would stay on it if they had a choice.
David, I've had similar problems proposing it to rightists. Mostly because I think they're being obdurate.
(Although I've also had leftists oppose it, too, because what they say they want is "everything." There's no compromise by either side on this issue, it sesms.)
One way in which y'all differ from those Dutch johnnies, and other Europersons, is that many more of you claim to be Christian. Yet when you face going to meet your maker in peace, and with dignity, you - metaphorically - start bawling and demand that zillions of someone else's dollars be spent to extend your lives by half a morning of unconsciousness. It's baffling.
Actually, the WSJ had an article years ago but a devout group of Christians -- Amish, in fact -- and how they managed to control health care costs. One way was to negotiate lower fees per procedure with the local hospitals, because the hospitals knew they wouldn't sue just because of a bad outcome: they accepted it as the Lord's will. The other way was to go to Mexico for all their non-acute care.
Good point, perfectly stated. Agreed: it's baffling. Perhaps there's some portion of the Bible with which I'm unfamiliar (doubtful) that implies that we should do everything possible to delay said meeting. Who knows - all mythologies are what adherents make of them.
I'm an atheist myself, but I'm pretty sure that the Bible doesn't exactly encourage suicide by failure to treat. Trying to live is hardly against the rules, even if death is less to be feared in their mythology than in mine.
Kid Mugsy asks an important question. I'm a Christian and I've often thought, "When it's my turn, I'll just get on with it." But of course it's not that simple these days.
Would my family consider it suicide if I started refusing treatment? Would they trot me into psychotherapy and make me discuss my purported deathwish until I relented? What does it mean to "fight to the death," "not go gentle into that good night." What is "giving up?" Is it cowardice?
And those are just some issues that come up when one tries to decide for oneself. If one of my family members were facing a mortal illness, I'd be devastated if they decided to refuse treatment. I'd do all I could to talk them out of it. So there you go.
Yes, if we could just get rid of those nasty beliefs that are contrary to the common good.
Derek
I'm not sure how expecting an insurance provider to live up to their agreement with you amounts to an unreasonable level of "bawling", metaphoric or otherwise.
"I want to be the one person who doesn't die with dignity"
-George Costanza
No one who has personally faced death could speak so callously, be he atheist, devout Buddhist, or run-of-the-mill Jew.
Callousness isn't fun, but it can be useful. What was TR's quote about the barbarian virtues and their importance?
Game, Set, and Match to MM; Very nice summary.
IMHO, the simplest Stopper is cost; Even if we were
not waiting to find out if the financial meltdown
is a V or a W, we could not afford the Plan.
Why discuss the matter further ?
Next question: Why are none of those who want this
expensive beast suggesting ways to generate enough
new wealth (value, not paper) to pay for it ?
why do you think that we can control costs
Eventually we will have to.
So why compound the problem before it must be addressed?
My answer: the time horizon of those in power is 2-4 years, and these choices won't have to be made for 7-10.
I wonder to what extent this health care debate is hammering the dollar. Chinese leaders must be baffled watching us. First priority should be to get our fiscal and economic house in order. If we can't do that, we won't be able to afford our current entitlements before long.
I don't think our current political trajectory will continue like this, but if it did I could see Brazil having a higher sovereign credit rating than us in a decade.
"Progressives are watching the whole health care legislative process with utter dismay as it produces a monster of a bill that not even its mother could love--and trying to love it anyway, on the grounds that it's a start."
This is exactly the reality of the situation. Progressives are cheerleading this abomination because they view it as merely the next big thing in expanding government. Here's cheer captain Ezra Klein from today's Post: "The bill also, through the individual mandate, creates a national expectation and policy of near-universal health care, and just as Medicare hasn't been rolled back, I don't expect that will be rolled back. So there are two answers, I guess. One is that I think this bill is well worth doing even if it never expands. The second, though, is that it creates an underlying architecture for expansion."
That the legislation will almost certainly fail on its own merits doesn't seem to be a problem to Ezra. One wants to ask him, if Medicare--one of the prime sources of savings in order to pay for reform--hasn't been rolled back, then how will costs actually be contained?
In fact, he has a ready answer (already pointed out by Megan) to the whole cost argument: "The federal government, however, can deficit spend, so it doesn't have this problem. It also has a lot more regulatory power, and from a broader reform perspective (as opposed to paying for coverage perspective), can force a lot more changes to the overall system."
Translation--"Yeah, I know the CBO score is bullshit, that the bill will have cost overruns, and that we'll never make any serious effort to reform the health programs that are bankrupting the country, but so what--all that really matters is more government!"
If reformers want to use the issue of cost control as a reason for reform, fine, we can debate that. I hate it when they use the issue to advance their cause, then discard it when it no longer suits them.
This seems to be the political strategy à la mode of the Democrats — witness the current backpedaling on the "good war" in Afghanstan.
Doctors income accounts for 10% of less of health care cost.
If you cut all doctors income in half it would not even offset one year of health care price increases.
I am definitely going to need to see a source on that.
You could probably get a significant reduction by reducing the form of doctor compensation. When they are on a salary instead of on pay-for-procedure, they tend to work less, get paid less, and have better patient results.
More health care isn't better health care.
Easily located data indicates that physician income comprised 18.5% of national health care expenditures in 1990. It has been on a decline since 1960, so its current share is likely less.
Probably somewhere between 15-17%.
The current cost of health care coverage in Massachusetts is almost exactly where it was projected to be at this point before the program began. Mass health care costs have not exploded, they have risen as scheduled.
Interesting. Got a link?
"And Megan, no one on your side of the argument seems willing to answer two simple questions. If every other country (don't split hairs, you know what I mean) can cover ALL of their citizens for LESS than the US does, with better outcomes, why can't we do that?"
What no-one on his side of the argument seems willing to deal with is that the US government already spends as much as Canada and more than the UK see here.
So the US government has already proven that based on whatever inefficiencies it has, it can't provide for all of its citizens for the price that other countries do.
Gee! What a surprise the the US government spends more than the UK or Canada with their universal coverage.
In the US, government insurance covers 83 MILLION people (2007 figures). That's 2.5 times the entire population of Canada and 1.33 times the entire UK population.
http://www.census.gov/hhes/www/hlthins/hlthin07/hlth07asc.html
ed, can you not follow a link, or can you not read? The link clearly states that the US government spends a greater portion of US GDP on public funds for health care than the Canadian or UK government spend as a percentage of their GDP.
You didn't read the statistics properly. The US government already spends more PER CAPITA than Canada or the UK, but nevertheless only covers about 27% of the population
If you're reading it wrong, then so am I. Yes, the MA rate does become lower than the national average from 2011 on.
Of course, up to that point, the graph is completely accurate, but beyond that it's not to be trusted - in fact, it's probably wrong - because of the way the assumptions were tweaked ;-}
Well, up to that point (or rather, up to 2009) it's presumably accurate because it's based on actual historic data; post-2009 it's projections, which are uncertain at best.
Correction: First graph is (bizarrely) projected starting in 2005; i.e. the last five years of data are not included. Perhaps Megan should have made that more prominent.
Well, ScentOfViolets, how about trusting the two news stories from this year that Megan linked to, indicating that Massachusetts premiums and spending have risen far faster than what those projections made in 2007 predicted?
Except, of course, for the slight fact that she can't read her own graph(and that certain individuals can't either), and which shows the exact opposite of what she's saying it does. Kind of like the Elizabeth Warren study she didn't bother to read before writing multiple posts about how 'dishonest' it was.
No, you're the one who can't read a graph or understand statistics. It certainly doesn't "show the exact opposite." Massachusetts premiums rise considerably faster than the US in the initial period, and then very slightly slower in projections 6 or more years out. The difference between 5.7% and 7.4% is probably significant; the difference between 5.7% and 5.9% is probably not, and definitely isn't if the former isn't.
In any case, those are projections by the state of Massachusetts. You conveniently ignored her links to recent news stories showing that Massachusetts premiums are rising much faster than predicted even in 2007.
What John said; we're above the projections, not below them.
Just a couple more bullets come to mind:
1) The American population is very different from any individual
European country's.
2) European systems were set up several decades ago so that initial fixed costs have long been amortized.
3) European systems free-ride American medical developments and pay only marginal cost or variable cost while Americans have to bear the full cost.
I would definitely emphasize the point about federalism. I believe there are several states that have a coverage level well above the national mean. The real problems tend to be in the Southeast and Southcentral, where low income and weak Medicaid coverage combine to leave many more uninsured.
Megan's best article ever.
David Bernstein at the Volokh Conspiracy thinks Megan should be writing a New York Times column.
While I have read many comparisons to other health care systems (cost, outcome, longevity, etc) ...
However, I have yet to see a health care comparison based on legal liability.
I believe that I have read that we have the highest per-capita lawyer ratio in the world.
How does our tort law / defensive medicine approach compare to other countries?
Legal liability is a small part of the health care budget. It is like progressives pointing to administrative costs.
It may be a small part of the health care budget (which is really quite large!) but I am still curious how our legal system impacts our health care costs relative to other first world countries.
Defensive medicine seems to be a bigger part of cost than is legal liability (including med-mal insurance), except in certain specialties such as obstetrics. However, I haven't seen hard data on the extent of defensive medicine; it's all anecdotal. Though I haven't searched hard.
An interesting story (just anecdotal) about a former Edwards/Clinton/Obama speechwriter who moved from DC to Massachusetts and was shocked to find that all the reforms she'd been touting in her speeches, like community rating, mandatory issue, and a mandate, meant that her insurance costs were double in Massachusetts than in DC, and now she had trouble finding insurance.
Shocked! I tell you I'm shocked she's shocked! Of course this is when cognitive dissonance sets in.
Somehow I find myself thinking of Francisco d'Anconia's line in Atlas Shrugged: "Brother, you asked for it!" Or, in this case, Sister, I guess.
The uninsured speechwriter thinks the solution to Massachusetts' high premiums is a nationwide government-run single payer system.
Her cognitive dissonance is still functioning quite well.
(1) Can anyone recommend a source that doesn't use lots of academic jargon and complicated math, but that discusses and analyzes, with 110% intellectual honesty and integrity, whether universal health care systems and other countries really do or really do not produce better health care outcomes than the US (or produce mixed results)? Each side has their own set of facts that they throw out there to prove their point, and then a whole nother set of facts they throw out there to disprove the other side's point. It seems to me that an awful lot of people on both sides are cherry-picking and/or distorting data, and I simply don't have the intellectual capacity to keep all these facts, numbers, data, etc in my head to figure out who's right.
(2) To the extent other countries produce better health outcomes, how much of that is due to those countries living off of the medical and scientific innovations and developments that occur in the US because we have a more free market system (or, to the contrary, is the US not any more responsible for medical and scientific innovations and developments, once you take into account the relative size of our economy and GDP, than countries that have universal health care)?
Thank you in advance.
Here's my go at intellectual honesty: we don't know. The problems are huge. To take just one: the US has better cancer survival rates than most. That's because we diagnose cancer earlier. But is that because treating cancer makes it better, or because a lot of those cancers were slow growing and would have killed people? Hard to say.
When you have imperfect information, you have to use your priors. But I agree, cherry picking is not the way to use them.
'...or because a lot of those cancers were slow growing and would have killed people?'
Would NOT have killed people I think?
Fuller explanation here: http://www.marginalrevolution.com/marginalrevolution/2008/12/progress-agains.html
Cute hypothetical, but it doesn't apply. Unlike 'economicitis,' cancers are often quite treatable and even the least treatable are now less intractable than they used to be and getting more so all the time. So the incurability assumption of this little exercise is DOA, not necessarily real-world patients.
The hardest evidence that cancer outcomes are better in the U.S. is that the absolute number of U.S. residents who die from all forms of cancer each year is now falling, year-on-year. This trend started a couple of years ago and is picking up steam. I am aware of no comparable trend elsewhere in the developed world. This effect is entirely a product of advancing innovations in both detection and treatment. Said innovations occur because the U.S. healthcare market allows innovating developers to both deliver their advances reasonably expeditiously and to make serious money from their efforts; not just a mingy percentage over marginal costs of production as is the case in socialized medicine countries. This is occurring despite the continuing growth of the U.S. population in absolute size as against the static or declining populations of, say, Europe and Japan. Obamacare would, of course, end such progress almost entirely.
Make no mistake, the so-called "health care reform" now on offer is not primarily about delivering more and better healthcare. It is about ideological leftists being in charge of everone's lives; that's their definition of utopia.
Define better health care outcomes?
Overall life expectancy from birth (given some form of identical set of definitions that we do not have)?
Survival rates of specific diseases or conditions (such as Megan's cancer comment)?
Is equality of care an issue? How about base level of care? Which really boils down to do you want to look at means, medians, modes, or some more complicated statistical measures.
Do you want to include quality of life issues in the outcomes? Waiting time for non-acute problems? Stress caused by lack of affordable health care or by having it tied to a job?
Does innovation matter? Its really hard to measure and its value depends on personal feelings about universal decent coverage versus limited great coverage but its certainly part of the overall health care outcomes over time.
Overall life expectancy from birth (given some form of identical set of definitions that we do not have)?
Yes, the devil is in the parentheses. The U.S. counts as a live birth any delivery showing a heartbeat as it comes out the chute. Most other nations record neo-natal death within some interval - often 24 hours - of delivery as a stillbirth. Given how much more the death of a newborn affects life expectancy statistics than does, say, the death of someone already well along in years, U.S. life expectancy stats are not usefully comparable to those of most other countries and there's no obvious and simple statistical normalization function that can be applied to make them so.
Similar, though lesser, effects are also attributable to the U.S. having a black population of roughly 1/8 the total that self-inflicts a lot of death in the 15 - 35 year age range due to gang violence, plus their appreciably lower overall life expectancy due to genetic susceptibility to diabetes and heart disease and their cultural predilection to diets that could barely be better designed to deliberately exacerbate both. U.S. life expectancy is bi-modal. If you're black, odds are you'll check out early of causes that are not much amenable to influence by changing the nature of the health care delivery system. If you're not black, you'll live as long or longer than a typical European.
Survival rates of specific diseases or conditions (such as Megan's cancer comment)?
Yes. As noted, the U.S. has better - in the case of many cancers much better - outcomes than alleged health care utopias like France or Scandahoovia. There are no statistical ambiguities to cloud matters here. Cancer is cancer and dead is dead.
Does innovation matter?
Hell yes, it matters! The improved cancer outcomes didn't just happen. They're the result of lot of hard work that, so far, can still be appropriately compensated financially in these United States.
Excuse me if I wander a bit from the topic to reach for a metaphor, but this whole debate reminds me of the lady who was sitting on a beach in Monte Carlo and an acquaintance came upon her whereupon she said, 'My dear, you're not having to work for a living are you! You look so pale.'
We've decided that the only moral way people have can health care is to have a health credit card essentially (if necessary paid at government expense). It would be so declasse' were they to have a VA patient ID card or a County Hospital card. Why to know of that would be like the lady above actually knowing somebody who worked for a living. A county hosptital for instance can have a budget, knows how many patients it has roughly, knows when it can buy an MRI machine, how many surgery residents etc. it will have, what it's pharmacy can have on the formulary. It can more reasonably control costs. And no you can't call your doctor and get a refill of Xanax on a weekend, but you know the price is right.
why do you think that we can control costs, given that we couldn't at the state level?
Because health care costs growing at a rate faster than the GDP isn't very sustainable. Arguably GM, Ford and Chrysler failed because of this. They're your canaries. Look for other large companies to fail, Boeing, Lockheed, Microsoft, IBM, or (continue) to move off-shore if cost control doesn't happen. Health care is a labor cost, even if it's private rather than a direct tax. Don't expect a signal to be ignored.
That's a non sequitur. Assuming that health care costs must be controlled does not presuppose a need for the government to control those costs.
Free market corrections on the large scale, especially on the scale of the US heath care bubble, tend to be brutal. It's often seen as a government function to anticipate and moderate huge corrections.
The health care market will correct in the long-term. Eventually the US will run out money to pay for it. The question is how bad does it hurt when that happens?
Yeah, rising health costs hit GM and the like fairly hard. No, they're not the only reason that they sank. GM went under because they spent too much money building mediocre cars, and that was the case because of an awful management culture, hideous union work rules, and massive legacy obligations that their competitors weren't saddled with. Healthcare was part of that, but it was maybe fifth on the list.
Ford didn't fail.
Ford didn't come close to failing.
Your point is invalid on this fact alone.
Do these people really not care how crazy partisan they look:
Uh-huh. Notice what it says at the bottom of the aforementioned graph: Source: Centers for Medicare & Medicaid Services (CMS), Office of the Actuary, National Health Statistics Group, 2007. But in any event, notice the hemorrhage-inducing cognitive dissonance: using the graph is okay as long it supports partisan talking points, but when it disagrees with them it must be wrong. I don't know how to explain this to someone like John, but once something as been introduced as evidence, you've got to accept it, even if later on it undercuts your case. You can't say, for example, that the CBO is the last word on scoring a proposal for one set of arguments, and then diss that scoring later on when it suits you. You can't, for example, say that Bush II was a conservative in 2002 when it suited you, then say in 2009 that he really wasn't all that much a conservative after he's crashed and burned ;-}
Massachusetts projected that it would save money on the mandate. But in actual history it didn't. Massachusetts projected that its costs would grow more slowly than the nation's. In actual history it didn't.
You now want us to trust the current Massachusetts projections.
Why? What part of scientific inquiry demands that?
"sonce something as been introduced as evidence, you've got to accept it, even if later on it undercuts your case"
First, this isn't true: we may come to realize that it was misleading evidence. But in suitably nuanced your idea is sound.
Second, the graph has a lot of information on it. Some if it is facts about health care costs in Mass. Those were the evidence for Megan's claim. There is also other information on the graph though - numbers that are projections. Those are not what Megan was using as evidence, and it is dubious to take them as evidence, since they are mere projections.
What gets me is that the same people pushing for Obamacare, to cut costs, are the same people who regularly judge our morality and compassion based on how much we spend on things like govt healthcare programs. If you're going to say you want it to cut overall spending, don't you need a prior history of wanting spending cuts to give yourselves some credibility?
The fact that the long-term trend is unsustainable is not evidence that the government will be able to solve the problem. Government interventino into health care a la the current health care "reform" bills may delay the correction. Yes, an unsustainable trend will not continue forever. But actions we take now may encourage a quicker and less painful correction or a delayed and more painful correction.
So let me rephrase Megan's question: why do you think that the government run system being proposed will help control costs, given that state run systems generally made the problem worse?
I don't, for a start, it isn't anywhere near sustainable. US pols are too afraid of cost containment and/or fee hikes.
Doing nothing is a choice too. It just leads to a California-like budgetary implosion (and a lot of jobs in China and India).
Actually, that's not the way the procedure works. For decades, conservatives have said that 'Americans have the best health care in the world.' So it's entirely reasonable to ask them why by certain markers this does not appear to be the case. Going in the other direction just gives you a type of 'God of the Gaps' argument that is so beloved of Creationists: Yes, they will say, given form A and form B, you did find transitional form C between them. But you need to show the existence of transitional forms D and E between the forms A and C, and the forms C and B. Once those are found, they will say, ah, but you haven't shown the existence of forms F, G, H, and I, so you haven't proven anything.
And so, for example, I've had conversations with people who were convinced that all Europeans were happily chomping away on their muesli breakfasts, tramping for miles over the countryside and abstemiously avoiding alcohol save for a celebratory glass of wine amongst friends and family. When I pointed out that there were several countries where the citizens weren't particularly active, and where they smoked in far greater numbers than Americans, and drank much more heavily per capita, and they still have better health outcomes, these people then retreat into something along the lines of 'Well, what about obesity? Have you looked into that? You haven't? Well, until you do, you haven't proven anything.' And someone here - I think he's still around but posting under a different moniker - smugly proclaimed that until I analyzed everything, soil, climate, population genetics long-term effects of trace supplements, etc., I couldn't say that other countries had a better system of health care . . . and that since this was impossible to do, I couldn't 'prove' my case, and that I was a wussy liberal no takebacks so there.
Well, yeah. That's why science is set up the way it is. That's why the burden of proof are on people like this Mixner guy, not on me.
considering that it's not conservatives who are allowed to set the terms of what constitutes 'good healthcare outcomes', i would suggest the entire comparison operates in total bad faith from liberals. they insist on comparing small, homogeneous populations with shared cultures, who eat diets vastly different than the melange of american cultures, with the messy diverseness of america. and then any statistic in which america does better than those countries is handwaved because all the hospitals are not equally crappy (the WHO study functions this way, as but one example).
the american population is stuffed full of unhealthy grains (yes, virginia, whole wheat is not that great for you, and neither is corn) and driven away from the saturated fats that keep diabetes type 2 away, and also keep weights relatively low.
where non-americans in other countries are eating more processed grain-filled and soy-filled crap, they are getting to resemble the very unhealthy americans.
just to get pap smears done in america was a battle that took about a generation. the pap smear-- a cheap preventive technique.
the dirty little secret is that going to the doctor isn't why some populations live longer than others-- it is diet and activity type, plus genetics. in japan the okinawans eating lots of fat boost their numbers, even though that population is not visiting the doctor 15 times a year as is the typical japanese average.
the french get in a lot of saturated fat, and so they do pretty well despite all the bread they eat. same for the italians and their olive oil.
diet is so key and the american nutrition norms have been broken, telling people to abandon saturated fats in favor of processed grains and soy and 'lo-fat', and now they are all hungry and obese, and need government-funded healthcare from the same government that gave them the horrible food advice in the first place.
and we're exporting that sickening diet to other nations-- see for example, the UK.
america could see its healthcare costs plummet if meat were back in its correct place as part of a healthy diet, along with fresh vegetables, if people could load up on saturated fats (which result in lower food consumption due to a high level of satiety), if people knew that fat and cholesterol can be healthy. type 2 diabetes would reverse with just diet, saving a fortune. many obese and overweight people would gain healthy muscle mass and drop some of the fat (all of it in some cases). that would make joint issues less of a growing problem, and thus also save money.
but none of these dietary changes mean going to the doctor extra, or popping a bunch of pills, so there's no incentive to get people back on a pre-1950s diet with the bonus of antibiotics for infections.
I wish more doctors would figure this out.
Three years ago, I was pushing 275 pounds. My body was revolting against my mind and my actions and I could feel it, but I didn't understand it. It was if I were out of balance or off-kilter.
I tried low-fat diets, and low-carb diets, exercising like crazy, and SlimFast and all that crap, but to no avail. Then I met a guy at the gym who turned me on to a diet based on one designed for diabetics, but also used by bodybuilders to get rid of fat.
Suddenly, my whole life changed.
In May of 2007, I weighed 260 pounds and was about 33% body fat (the missing fifteen was all I accomplished in the year leading up to that month). My cholesterol was through the roof, my blood pressure was extremetly high, and I was in constant pain and emotional distress.
In May of 2008 I weighed 165 pounds and was 5% body fat. My cholesterol was normal as was my blood pressure.
The difference was all diet. I began to eat six meals a day that consisted of protein and saturated fat and all of my carbohydrate intake became fresh green veggies and low-glycemic stuff. Further, I discovered what you eat *together* makes a difference as well. Proteins shouldn't be consumed with high-glycemic carbs and what-not. Also, I only eat real butter, real sugar, honey...etc I don't do margarine or high fructose corn syrup.
My total caloric intake is now around 3000 calories per day with most of that coming from protein and saturated fat.
I spend one hour every day in the gym lifting weights and I do twenty-five minutes of cardio at a reasonable pace.
Today, I'm forty-two and a very healthy 180 pounds with a 32 inch waist and about thirteen percent body fat. I'm very active and my health hasn't been this good since I was eighteen.
I still follow the diet, but I'm not as strict because I don't need to be. I still work out every day, and I play baseball and basketball, I do triathlons, I ride bicycles and skateboard with my son...
Most people have no idea how much fun it is to feel this way and be able to be this active. They just complain about how bad they feel and continue to stuff themselves with corn, and wheat, and high fructose corn syrup and the like.
Funny thing is that my GP still refuses to believe that I achieved this through the sort of diet I'm describing.
Her loss :)
Sigh. What I said - you introduced this as evidence; don't whine when someone else uses the same source that it's 'not reputable'. Or are you officially withdrawing this graph as any sort of evidence that supports your position? Btw, did you ever admit you were wrong about that Warren report and make a public apology?
What I said - you introduced this as evidence; don't whine when someone else uses the same source that it's 'not reputable'.
For clarity's sake, do you 'oficially' take the position that 1) actual historical facts and 2) projections of future events are equally reliable (or must be deemed so by anyone who relies on historical facts) if presented on the same sheet of paper?
MM wrote about Medicare/Medicaid: It negotiates huge cost discounts with providers.
Not quite. They may negotiate with big hospital chains, but they do not negotiate with physicians at all. They simply set the rates at whatever Congress tells them to. At least they never negotiate with my wife, who is an actively practicing M.D. In contrast, there was some negotiation with Aetan, Prudential, BC/BS on the rates in the contracts they offered for being a "participating physician".
You're right; bad usage. They *secure* huge discounts from providers without negotiation.
Right. Even though I specifically addressed this, you just have to get something in that suggests that somehow, I'm wrong about a very elementary point.
NO. Either withdraw this as evidence and find something else that says the same thing, or accept it for what it is - some numbers put out by some organization which you deem to be credible. I'm guessing that what happened here is that once again Megan didn't bother to actually look the whole thing over before posting; she saw part of one thing that she thought supported her position, and didn't bother to check beyond that before running with it.
"NO. Either withdraw this as evidence and find something else that says the same thing, or accept it for what it is - some numbers put out by some organization which you deem to be credible. "
You're being crazy. Historical facts are evidence. Projections, even in the same report, aren't the same as historical facts. They just aren't. Pretending that they are, isn't serious.
No.
That's all a silly response like this deserves, but on the outside chance that you really don't know this, I'll elaborate. When, however, the figures are done by the same organization for the same report, and graphed on same time series, then, yes, unsurprisingly, I do take them to be of comparable reliability (all other things being equal.)
Thanks, that's all I wanted to know.
All other things being equal? Like things that have actually happened and things that may or may not happen in the future? I still think you're trying to say that the projections are of equal reliability as data drawn from what has happened. Whether the source is HHS or MA, I just don't think that's true.
So the answer you're looking for is "yes", then?
Uh-huh. Well considering that I am not a liberal, but rather a pretty straight-arrow hard-headed pragmatic sort, I'm saying the same thing: If American health care is 'the best in the world', how come other countries have populations who enjoy greater life expectancies?
I don't see how that's anything other than a completely fair question. And one that conservatives have been ducking for a long, long time.
Conservatives and others have been pointing out to you that we do not know the reason.
Considering that there are a large number of variables that go into life expectancy (health care being only one of them), there is no reason to expect that the country with the best health care will also have the best life expectancy.
Can you come up with any evidence that health care variations (between first world countries, or regions within a fixed first world country) have any statistically significant effect on life expectancy? If not, then I see no reason why you would expect health care and life expectancy to be related at all.
in my orca-sized comment up above, i mention diet as the primary factor in life expectancy, and antibiotics access as a useful adjunct.
if someone wanted to account for dietary distinctions across populations, you would get a very different set of life expectancies, because american diet is sufficiently poor in nutrients that it kneecaps much of the benefit in extending life fancy technology can grant.
you would also have a decent guess as to what effect, if any, extra doctor visits had on said life expectancy.
women get less care in, say, sweden, but their babies are healthier. this is because invasive intervention is not always the medically soundest thing to do. so our insane c-section rates are 'expensive' and 'produce low outcomes', but sweden is 'spending less' and 'getting better outcomes' by 'not doing as much healthcare for pregnant women'.
and that is just one example of how socialised healthcare is not magicking up longer-lived women with cheaper healthcare. they just get less healthcare, and this is actually the healthier call.
Racial homogeneity is a major factor in maternity outcomes in all of the Western European countries. Many of the common pregnancy complications such as preeclampsia, gestational diabetes, and prematurity appear to correlate with race itself, not just with socioeconomic status.
Per WHO, though, the US perinatal mortality report of 7/1000 actually puts us on par or slightly ahead of such countries as Denmark (8/1000), France (7/1000), the Netherlands (8/1000), Austria (7/1000) and the UK (8/1000). Ours is a bit worse than Finland, Canada, and Germany (all 6/1000), and Sweden at 5/1000 has one of the lower rates in Western Europe, but the disparity is not as dramatic as you might think. Highly-medicalized Italy, whose CS rates are as high or even higher than the US, also has a low perinatal mortality of 5/1000, which suggests that it's not just as simple as blaming the interventions.
(Perinatal mortality is the correct statistic to use when we're talking about maternity care, since it measures later-term stillbirths and infant deaths up to 30 days of age. Infant mortality includes all deaths up to one year of age, the majority of which are caused by accidents, non-birth-related illnesses, and SIDS. It's useful in other health care contexts, but it tells us little about the quality of prenatal care and delivery.)
@ Emma B.
do these other countries you've listed measure perinatal mortality the same way? you are speaking of a distinction beyond gram-weight or 24 hour-lifespan.
that said, i have certainly been the first to note that homogeneity is pretty relevant.
if vitamin d deficiency is a root cause, it makes the US statistics look very very different, once accounted for.
which is an interesting side project-- how would more doctor visits solve that problem? making vitamin d pills is extremely cheap, but the medistablishment keeps saying vitamin d is bad even as they keep upping the recommended amounts.
Yes, this data is all from the WHO Perinatal Mortality Report, using a common definition. Perinatal + neonatal mortality is useful because the definition is strict: fetal or intrapartum deaths after 22 weeks gestation as well as live births who die in the first 28 days. Even if a country didn't count very small or very preterm infants as live births, they would still show up in the stillbirth component.
Section 4.4 of the linked report has a good discussion on underreporting and data accuracy, but the short version is that it's as close to an apples-to-apples comparison as we're going to get.
And since a goodly number of people have missed this the second or even third time around, it looks to me as if the source for this graph was Centers for Medicare & Medicaid Services (CMS), Office of the Actuary, National Health Statistics Group. That is, contrary to John Thacker and others, that graph does not appear to be 'projections by the state of Massachusetts'. That's not the main point of course, though he seemed to think it counted for something.
SOV, I begin to think you are being deliberately obtuse. The source for the graph is the State of Massachusetts, as helpfully linked by Megan immediately before said graph. Text on the graph suggests the source of the data that it reflects is the CMS. There is no clear statement of whether all the data, or simply the historical data, is from the CMS.
Beginning to be obtuse? His entire method is deliberate obtuseness. Either that, or his is a complete moron.
THe source for the actuals is CMS; the source for projections is their data.
The U.S. has the best health care in the world.
Here's a nice little mantra:
U.S. does 2x as many transplants http://en.wikipedia.org/wiki/Organ_transplant#Demographics
U.S. has best cancer survival rates http://www.seattlepi.com/national/141141_medi25.html
Death panels in Britain are putting people to death who could have recovered http://www.telegraph.co.uk/comment/letters/6133157/Dying-patients.html
U.S. has more MRIS "it was found that Canada had 4.6 MRI scanners per million population while the U.S. had 19.5 per million" http://en.wikipedia.org/wiki/Comparison_of_Canadian_and_American_health_care_systems
U.S. has about twice as many MRIs as OECD average http://www.oregoncatalyst.com/index.php/archives/2594-Chart-2-US-has-better-access-to-health-tech-than-world.html
U.S. gets new drugs 1 year sooner "On average, the FDA approval came 1 year ahead of clearance by the European Medicines Agency (EMEA)." http://www.nature.com/nrd/journal/v6/n4/full/nrd2293.html
"Prostate cancer mortality is 604 percent higher in the United Kingdom and 457 percent higher in Norway. http://www.hoover.org/publications/digest/49525427.html "Prostate cancer mortality is 604 percent higher in the United Kingdom and 457 percent higher in Norway."
"The top five U.S. hospitals conduct more clinical trials than all the hospitals in any other developed country" http://www.hoover.org/publications/digest/49525427.html
U.S. performs more operations than any country in the world. http://www.usatoday.com/money/industries/health/2009-09-22-health-countries_N.htm?csp=34
Lower U.S. life expectancy is not a result of health care http://repository.upenn.edu/cgi/viewcontent.cgi?article=1012&context=psc_working_papers
Okay see, as a Canadian-American, this comment to me is why American health care is kind of crazy.
#1: Why is the perception that you *need* to have the best in the world? Just think on that seriously. Maybe some tiny little European country is going to have the best. Maybe top-20 care is what a huge diverse nation should aim for.
#2 Counting the number of MRIs and even surgeries does not necessarily tell you a lot about health outcomes. You don't measure the success of a company based on how many consultants it hired. ("We spend the most money on testing our product! Too bad it doesn't sell...")
I will admit that MRI is a limited resource in Canada even to the point that it can be annoying. My husband tore his ACL and had to wait two months to get a MRI to confirm the tear. However, when I was showing signs of what might've been a stroke, I had one that day. Only the second was going to impact on life expectancy. In terms of quality of life, having to wait two months for a knee is annoying, for sure. But from injury to the end of physio was about 7 months total - what we consider reasonable, up here. And if his knee had stopped hurting? He wouldn't have had it.
#3 Here is a comment that will really drive people mad but I feel the comments about getting drugs "first" and the clinical trials are based on an assumption that a fast pace of development always leads to positive outcomes. I think American medicine is skewed to "magic bullet" thinking that new drugs result inevitably in good results.
Maybe the idea that good medicine is equivalent to the speed in delivery between research and patient is something that could be examined. Leading diseases leading to reduced quality of life or death still include diabetes, heart attack, and stroke - diseases where you can throw a lot of drugs and treatments at them, but the best thing is not to develop them in the first place, and a certain percentage of people can actually do that via lifestyle.
I'm not blaming patients but I'm saying that it's entirely possible that something cheap or free and low-tech could turn health outcomes around way better and faster than the latest lipitor. Maybe, for example, if people don't have to work two jobs to maintain health insurance they have more time to exercise and eat properly.
I don't think a study's been done but I think it is interesting that what Americans seem very obsessed with preserving in their healthcare system - the best, fastest treatments for even the most uncommon conditions - sometimes seems a bit like window dressing. Of course I don't want my family member with a rare blood disorder to die and I want all that research NOW TODAY. But I don't measure the success of the system solely on that one rare disease.
Welcome to America. We like to get our stuff and we like it now. Did I say "like"? I meant "demand."
Politicians are too cowardly to stand up and tell Americans we can't have it like that forever without bankrupting ourselves. So we probably will bankrupt ourselves. (I'm not necessarily blaming the politicians -- they are reacting rationally given what voters do. It would take a politician of extreme courage to change this course.)
"Federalist and non-parliamentary democracy: in most other systems, the head of the government tells the government what to do. In our system, you need 220 congressmen and 50-60 senators. There's no way to implement the sort of technocratic change that reformers envision; the politicians will keep sticking their fingers in the pie."
As the old saying goes, a camel is a horse designed by committee.
Does the first graph show anything at all? At the bottom, it says "2005-2017 data are projected."
Scent of Violets: things in the future have to be projections unless they have a time machine. Projections aren't as accurate as historical facts.
Sigh. Look at the bottom of the graph. Do you see what it says:
Gee. 2005 on is 'projected', but that's perfectly okay:
Do you have anything you want to say to me? Something, like, 'sorry, guess I was wrong'? Or are you going to grope around for another reason why you and Megan and company are still 'really' right?
Funny thing that, but for some of us, being consistent is important. If you want to argue about costs rising faster than the national average, and you've got sources you can point to, fine. But don't use a source, and then declare it off limits when it goes against you.
Oh, why don't you go "sigh" yourself. You wrote a preposterous response to Rob Lyman's question and I was responding to that. Go back and read what you wrote at 6:13 pm. You're flailing around like one of those wacky clown head sprinklers.
Um, nobody's declaring any sources off-limits, unless it's you, SOV. They're pointing out the unreliability of some evidence from some sources, and saying why it's unreliable. Is the difference unclear to you?
I think Megan should have either highlighted the 2005 cut-off, or found a better source of data. Though the latter may be impractical if, as it appears, this is still the data Massachusetts is publicly relying on. In any event, none of the people you're attacking have shown any inconsistency.
Why does intellectual dishonesty come so naturally to Megan? Let's look at the graphs in detail. Forget the projections -- just look at the actual hard data.
Keep in mind that the Massachusetts health care reform passed in 2006.
From 1991-2000, the Massachusetts growth rate exceeded the national average. But that includes three years when the MA growth rate was essentially flat (1997-1999). Was health care spending in the US flat during those years as well, or was this just a temporary blip? Why are we dividing things into pre-2000 and post-2000? The graph does appear to have an inflection point at 2000, but maybe that is more apparent than real.
Starting in 2000, the MA health care growth rate climbed to 7.4%. It has remained at that level for the entire decade. The passage of a health care reform in 2006 did not affect that. In other words, MA's health care reform DID NOT cause MA's health care costs to increase. Repeat: DID NOT. So why lie about it?
Starting in 2005, US health care costs began to grow more slowly. But what is special about the year 2005? Did anything noteworthy happen that year that would cause the US health care growth rate to suddenly decline? Not that I know of. Medicare Part D took effect in 2006. What seems more likely is that 2004 was a blip year -- a year of particularly high health care expenses, for whatever reason. So when you divide the decade into 2000-04 and then 05-09, it makes it seem as if the first period had substantially higher growth than the second. In reality, probably the growth during that period was pretty constant, and pretty constantly lower than in MA.
Even if the decline in the national growth rate in fact decreased in 2005, do we know why? Was it broad-based? Were there some regions that had higher growth rates and others where health care cost increases fell dramatically? Was MA's growth rate particularly high, or one of a number of states who continued to see high cost increases? You can't draw any conclusions based on this single piece of evidence about national growth rates.
In other words, this chart provides NO USEFUL EVIDENCE at all that the MA program is increasing costs. None whatsoever. So again, why lie about it and claim that it does?
The data in the first graph is "projected", not actual, starting in 2005. So what it tells us is what Massachusetts expected to happen after it implemented Mass-Care.
Incidentally, casually slurring people as liars does not bolster your credibility.
What evidence do you have that superior life expectancy in these countries is 'diet and superior nutrients' and not better health care?
one can ask you where the evidence is that health care (and i'd need a definition of what 'health care' constitutes) is even tied to life expectancy.
the lowest life expectancies are in countries plagued with problems that have naught to do with 'health care'.
TallDave put up some interesting links. Give them a look.
the thing is, we don't have evidence that 'health care' or 'a certain type of health care system' or 'health insurance' is what increases life expectancy. we just have a lot of attempts to link life expectancy with healthcare use or access. it is demonstrable that pregnant women in sweden are consuming less healthcare. fewer c-sections, epidurals, etc. that's a behavior thing, not a 'health care' thing. so in that example i gave, despite having abstract access to more 'health care', the women consume less and get a better result (healthier births).
Like I was getting at above, though, the correlation between less-interventive and healthier births is a very tenuous one.
The Netherlands is the prime example of this. They're well-known for having a significant number of midwife home births -- 30% is the oft-quoted number, although I've read an abstract suggesting it's closer to 10% in many areas. The in-hospital births are often midwife-attended, CS and epidural rates are low... and their perinatal mortality is somewhat worse than ours.
Italy's CS rates approach 85% in some private clinics, and the national rate is on par with ours. I'm not familiar with epidural rates or midwifery presence, but I doubt they're much better than us, with that kind of a CS rate. Yet their perinatal mortality is noticeably lower than ours. If it's all about the interventions, why?
I am fully willing to concede that less intervention may produce less expensive births, because even uncomplicated epidurals and CS aren't cheap. However, that's a far cry from saying that they produce universally healthier births. AFAIK, and it's a topic I've paid a little bit of attention to over the last couple years, Sweden is actually one of the few countries whose perinatal mortality rates actually do support the intervention/health hypothesis. It's a complex problem, and Lamaze/Bradley childbirth is not necessarily the solution.
Speaking of intellectual dishonesty:
"Every experience we have had with government-provided health care has ended with sub-par outcomes. Every experience we have had with state-run enterprises such as the USPS and Amtrak have been a mess."
1. Apparently the writer has never heard of the VA system. Or Medicare for that matter, which has not produced subpar outcomes over the life of the program. In fact, Medicare has had a dramatically positive effect on the health care provided to seniors compared to the care provided before Medicare was passed.
2. Has the USPS been a mess? Really? Yes, I know it loses money. On the other hand, it's not run for profit. It's run to provide a needed social service. If it were run for profit, it might not have daily mail deliveries to rural routes (which I am sure are massive cost drains), or daily mail pickups from every location. Or it might charge more. There is no evidence that any private company can do US mail more cheaply. Yes, I understand no private company has been given the opportunity. But 41 cents for a letter is really cheap. What is the lowest rate FedEx charges? Like $7 for ground? Do we really think FedEx would be profitable if it was charging 41 cents?
But if you think that it's a gigantic mess to provide good mail service to all people in this country, well more power to you I guess.
3. But you didn't claim that USPS was a disaster. You claimed that EVERY experience with state-run entities has been a disaster. Thus, I would like you describe how the following institutions are nothing more than a big mess:
*US Armed Forces
*National Institute of Health
*Center for Disease Control
*Public Universities, including such top-notch schools as UC-Berkeley, UCLA, University of Michigan, University of Virginia, University of North Carolina and so on.
* The US Department of Justice
* The Food and Drug Administration
* Federal judiciary
Just to name a few. I await your response.
They ain't got no response as usual. Its the same numb-skull libertarian talking point that is repeated over and over , although any moron can see it's nonsense-well any non-libertarian anyway.
Whoa there, hoss. UVA is a state school, but it is not a state run school.
And while the Armed Forces health care has gotten a lot better over the decades, it's still not as good (access times, outcomes) as what I get privately.
Maybe you shold read yesterday's WSJ, which has a column in it outlining the various state experiments and their results (hint: they're all costing way more than anticipated and therefore busting budgets or getting scaled back) before you start ranting this way.
If the reform being discussed in Congress were about making more government health care like VHA, it would make my heart feel super-happy.
But we're not getting that. If we're getting what we deserve, we must have done some horrible horrible things.
I suspect that this isn't so much intellectual dishonesty as it is laziness combined with mule-headed resistance to any sort of admission of a mistake. Probably what happened was that she saw something that on a first-pass casual inspection looked as if it supported her, but rather than methodically research what was actually being shown, she just slapped it up there without further review.
Later, after it's pointed out that what's being shown does not in fact support what she's saying, she can't back down . . . probably our fault for trying to chivvy her into an admission of error rather than doing the gentlemanly thing of finding sources for her that could be substituted in for the poor backup.
Maybe. On the other hand, her claims about that chart don't pass the smell test. Megan has proven over and over again that she's no economist. But anyone with a passing familiarity with charts and graphs -- which she should have, given her MBA and consulting work -- should immediately see red flags when trying to draw the conclusions she draws.
Somebody here has been pointing out that all the data after 2004 is a projection. That's a detail that could be the result of an innocent mistake. Indeed, I didn't notice that on my first glance at the chart.
Trying to say that MA health care costs grew faster after 2005, however, is nonsense even if that data was factual, and she should know that. Or consider her use of a SINGLE DATA POINT about health insurance premiums to draw conclusions about the effects of heath reform. Yes, insurance premia did appear to go up a lot in 2007 (if that is an actual number); but they went up more in 2004 and just as much in 2000.
Using a single data point to project a trend is dishonest almost by definition, unless it is a damn strong data point and there are few confounding factors.
Well, my realization of the miniscule chance of meaningful health-care reform in the USA was when I saw the reaction of Americans to HMOs. As far as I could see, outside of a few egregious cases, the HMOs were doing *exactly* what they were supposed to be doing, substantially reducing health-care costs by restricting coverage and rationing care.
The Americans were up in arms!
Meanwhile, across the border, Canadian health-care operates like one giant HMO, and Canadians are for the most part, okay with both the fairly similar outcomes to American health-care and about 1/2 the cost.
I suspect Megan is right, it's not the American health-care system that needs reform, it's the Americans.
[Before I get lynched, it's a *joke*, honest!]
Dear me. Did Megan and her merry libertarians confuse themselves with maths and graphs again? What a surprise. I mean, that's never happened, right?
I'm now quite certain that her figures are far superior to the CBO's... OK, that's to ridiculous for me to type. Irony has its limits. I have to say, it takes some chutzpah to argue that one half of a graph is accurate,when it agrees with your argument and the other half inaccurate when it disproves your argument. But hey, that's just how libertarians roll.
They like the facts, till it disproves their theories, then its facts out the window.
"I have to say, it takes some chutzpah to argue that one half of a graph is accurate,when it agrees with your argument and the other half inaccurate when it disproves your argument. But hey, that's just how libertarians roll."
Let's talk about intellectual dishonesty. Here is a hypothetical case: half the graph represents empirical data, the other half represent projections made or endorsed by someone with a vested interest. I take the data as evidence but not the projections. This doesn't take any chutzpah at all. It just takes a little bit of common sense.
Now, it may be that this is not the circumstance we are faced with. (Since the "data" for the 4 years before the graph was published is also "projected".) But SOV has been content to argue against this strategy in the abstract, as, evidently, are you. And that means that either you're not sensitive to an obviously important distinction that is starting you in the face, or you're intellectually dishonest.
So if you lived in Europe, you might be a centrist because the government works okay, but in America, you're a libertarian because our government sucks?
I think you may underestimate the degree to which the lousiness of American government is, in fact, an artifact of post-Goldwater conservatism. It wasn't until that movement took power in the Reagan administration that you started to see civil servants appointed who opposed the basic missions of the government departments they headed, as a backhanded attempt to undermine and eventually shrink government. Though that doesn't explain why the legislation is so bad.
Anyway, I'm glad to see you agree that European government is, on average, better than American government. Would you say that gradually implementing reforms that make America work more like Europe might ultimately bring us to a point where we could attempt limited versions of their excellent social welfare policies?
In effect, Megan and all libertarians pretty much argue that Americans are just too stupid to get universal health care right. They don't quite put it that way directly, but in effect that's their argument.
Gosh, I guess if libertarians thought people were as smart as YOU clearly are, they would instead argue that Americans live under a system that is by design inefficient in some ways, as a check upon the politically powerful, with side-effects that include making it more difficult to implement some kinds of arguably-positive change.
Oh, wait, that's what Megan DID argue. Well, damn, you sure saw through her! Fancy high-falutin' language meant to mask her disdain for stupid 'mericans. Good thing she couldn't fool you.
Heh. Let me put it another way.
Americans would never put up with universal health care.
They would demand that their congressman fix the problems inherent in universal health care.
It would end up costing 2-3X what any other country spends.
Case in point. We had an election in our province earlier this year. The ruling party did the usual stuff, downplaying the plummeting revenues, etc. Shortly after the election, they cut budgets to healthcare. 20% less MRI's in one area, closed operating rooms, etc. They just announced a dramatic increase in fees for extended care. None of this was in the election campaign, and with the parliamentary system, screaming at your representative is a waste of time. They are whipped. No horsetrading health care spending in his area for his vote.
As Megan said, Medicare has been out of control in spending for a while, and there have been numerous efforts to keep a lid on things. They haven't done it. They won't do it.
Derek
As Megan said, Medicare has been out of control in spending for a while, and there have been numerous efforts to keep a lid on things. They haven't done it. They won't do it.
That's some crystal ball you have there. You DO realise that the health care bills all include proposals to reform Medicare and institute cost controls, right?
I also note that Canadians (and you say that you are Canadian for the most part seem quite happy with their universal single payer health care system and have zero interest in moving toward our perfect free market system? Why is that , you think?
It's in the proposal, yes. Will it actually happen? Doubtful.
About half of Canadians think that single-payer is a bad system and want to allow private payment for healthcare. Nobody likes the US system, because the US system is awful(it's just marginally less awful than most of the proposed "fixes" to it). But that doesn't mean it's all happiness and light up here, either.
Stonetools, we've had proposals to introduce Medicare cost controls for 30 years. You seem to think that this is the first time it has occurred to anyone to introduce a bill cutting provider payments or setting up a commission to decide which treatments are reimbursable at what rates.
Alsadius's claim notwithstanding, Canadian health-care is probably the government's single most popular program.
HOWEVER, that doesn't mean that it will work for the United States, and not because "Americans are just too stupid to get universal health care right".
As a whole, Americans value a lot of things very differently from Canadians. Look at the reaction to HMOs. Canadian health-care is essentially 1 big (okay, 13 big) monopoly HMOs.
If Americans were up in arms about HMOs performing rationing and triage (and I find even those Americans who would like to see single-payer seem to hate HMOs), then they pretty much hates the only thing that really makes single-payer work!
So, I think the Megan is partially right. At least at the current moment, I don't think America is temperamentally ready for a health-care system that won't cost 3 arms and 4 legs.
I do think it grows closer to it as time goes on, but it's still a ways off.
On the other hand, there are a bunch of sensible reforms that can take place without going nearly that far, and it appears public support for that it pretty low as well. I guess Americans really are different.
Tom, I'd agree that it's popular in theory. "The government should ensure that no person is denied medically necessary care for reasons of inability to pay" routinely polls over 90% here. The practical system gets a lot of flack, and like I said, moving from single-payer to two-tier routinely polls in the neighbourhood of 50% support, depending how you ask.
Evidence?!?!?! I would think that's part of the definition, living as I do in an advanced country.
You betcha. Places like Canada, Sweden, Germany . . . Oops! Please. I've asked you a straight question, and you're ducking it. You said, and I quote:
What evidence do you have for this theory? I don't see that you've presented anything. It seems that - as usual - it's an ad hoc sort of explanation for the 'fact' that despite having the 'best health care in the world', Americans don't live as long as people in other countries.
I would think that's part of the definition, living as I do in an advanced country.
But evidently without benefit of an advanced education.
Life expectancy at birth is strongly influenced by infant and child mortality- the fact that many other countries do not count live births the same way we do skews life expectancy. In fact two of the countries you mentioned count any baby born under 500kg as a still birth while here they are counted as live births. (The mortality rate for these babies is 869 out of a 1,000)
Its interesting to note that life expectancy at birth the US ranks 23rd and for life expectancy at age 65 we rank 9th. Unless you can find life expectancy numbers from say 5 or 18 years I don't think you can use life expectancy numbers as proof that other countries health outcomes are better then America's.
Total infant mortality has an extremely small effect on life expectancy. Differential infant mortality for babies with less than 500 grams has, of course, an even smaller effect.
http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf
http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_02.pdf
Total deaths in U.S. in 2006 - 2,426,264
Total Infant deaths - 28,384 (deaths under 500 g are a subset of these).
So approximately 1 in every 1000 people die at birth. Yes, they have a disproportional weight in life expectancy, because they die at zero years old. Still, this is not nearly enough to have an influence on LE greater than that of a rounding error.
The U.S. ranks 9th with people over age 65. In other words, LE is pretty good when U.S. citizens have access to the single-payer universal health care system known as Medicare.
medicare, a single payer system that people have forcibly extracted payments into. old people feel they've paid into medicare because it is forcibly extracted from their paychecks, which is not quite the same as an invisible single-payer system.
anyway, macau is not single-payer and has the highest life expectancy. explain that as a justification for single payer.
Minor correction: 1 in every 1000 deaths happen to people who have not yet reached their first birthday. For birth deaths, the statistic you want isn't infant mortality (which is everything prior to 365 days of life, including SIDS/illnesses/accidents/child abuse), but perinatal or neonatal mortality. The current US neonatal mortality rate is 4.5 of every 1000 live births, for N=18,782 per the">http://wonder.cdc.gov/lbd-current.html>the CDC Wonder database.
If you want to talk about live births of small/preterm infants being counted as stillbirths, the statistic you need to use is perinatal mortality, which I've discussed elsewhere in this thread. That includes all stillbirths after 22 weeks gestation, so the kind of category shifting you're talking about doesn't apply.
Nimed's larger point holds, that the absolute numbers of infant/neonatal/perinatal deaths are too small to explain away all the difference.
Nice. Thanks for that, Emma.
if health care is not tied to life expectancy, then we would not live significantly longer or shorter than demographically similar countries. this is in fact the case. i don't know why you think it is connected.
macau, for example, has the world's longest life expectancy. it is a tourist spot reliant on gambling income, among other things. its healthcare is not really a factor in why its people live several years longer on average than, say, swedes.
america gets lambasted for having life expectancy differences of a year or less, but macau towers over the nordic and western european nations so often held up as so much better than the USA.
macau has only a handful of hospitals, and little in the way of doctors, and yet they live longer than anyone anywhere else in aggregate.
healthcare is not what makes a population live longer beyond antibiotics availability, for the most part.
Well, even granting the capability, you still have to exercise diligence. Were you around for Megan's extended screed against the Warren study on bankruptcy, calling it dishonest and misleading? She made a big deal of the fact that the study didn't say anything about bankruptcies falling as a result of the recent reform, or that these were percentages and not absolute amounts:
Then several people pointed out that she did exactly that on the fifth page of a six page paper:
They quoted it again and again, with nary a retraction on her part, or even an acknowledgment that those facts were actually discussed. So if Megan can post thousand-word epistles all revolving around a point she didn't even bother to read on page five of a six page paper . . . then yes, I find it very easy to believe this was the result of laziness and not bad faith.
That was me, among others. What I did was click on the link and go to the source material, since the graph here will only enlarge so far. That was when I noticed that the projected rates were lower after 2010 or thereabouts, and that's when I started looking at the details more closely, like who the source was, and the fact that these were projections. You know, that whole 'scholarship' thing, that discriminates against conservatives, which is why they don't do well in academia.
Oddly enough, no libertarian/conservative thought to do the same thing, which has lead to a bunch of silly statements about some parts of the graph being 'more valid' than others. They could have saved themselves a lot of trouble and well-deserved ridicule if they had just done a little checking for themselves. But that's not how they roll.
Here's how we role. I've got this general strategy for finding the truth. It is: call people on their shyte, and be open to being called out on mine. People are jumping on you because, as you admit, you didn't know that the data for 2004-9 was projected. And, given that you didn't know that, it is just silly to think that the "data" on the left has to be given the same evidential weight as the projections at the right end of the graph. And that is the whole reason why I'm calling you on it.
Megan asks the question: why do those in favor of reform "think" we can control costs?
Let's say Megan is right and these graphs show failure in Massachusettes; even if that is true, there are many more examples of success:every other advanced country has done this and been able to cut costs. So even if MA is a failure, the weight of the evidence says that is can be done. Furthermore, in the places it has been successful, it has been done for a lot longer than in MA; I "think" that looking at systems that have been around for decades makes more sense than looking at a system that is pretty much brand new.
Second, we have a model in the US that works-the Mayo clinic. Doctors are paid well, it provides top notch care and at about half the usual price. Yes, it works within the current health care system; but the way they cut costs is by using evidence based care, coordinating care by using teams of providers, utilizing electronic medical records so tests and such are easily accessible and not repeated, and by paying doctors a salary (a good salary) so that they are not incentivized to do extra, unnecessary stuff. Half the cost! Imagine if, on top of that, we eliminated the administrative burden of working with a gazillion insurance companies, all with different requirements. Recent studies have shown that on average, doctors spend over $60,000 per year per doctor on administrative costs dealing with insurance companies.
So, to answer Megan's question, that is why I, a doctor who has worked in our dysfunctional system for over 10 years, "think" that we can reform and control costs.
Does this mean, also, that if we stopped paying for routine medical care and health maintenance through insurance, and instead had it paid for out of pocket, with insurance limited to catastrophic illnesses, we could cut annual spending on health care by a substantial fraction of [300,000,000 Americans x (2.6 doctors/1,000 Americans) x $60,000/doctor] = $46.8 billion? Because that gives at least some support to the theory that having all health care paid for through insurance companies is raising costs! In which case the current Democratic plan, which forces everyone into the polypoid embrace of Big Insurance, looks less convincing as a cost saving plan.
On the other hand, $46.8 billion's a pretty small fraction of GDP. You might not save all that much through either free market or single payer reforms, as a fraction of total medical expenses.
Can you please name those advanced countries that have been able to cut costs?
They don't include the United Kingdom, see for example
http://www.kingsfund.org.uk/what_we_do/articles/economic_growth.html
They don't include New Zealand
http://www.treasury.govt.nz/government/longterm/fiscalposition/2006/20.htm
They don't include Australia
http://www.aihw.gov.au/mediacentre/2006/mr20060929.cfm
They don't include Switzerland or the Netherlands, see http://law.wlu.edu/deptimages/Faculty/Jost%20The%20Experience%20of%20Switzerland%20and%20the%20Netherlands.pdf (page 4 of the pdf)
All these countries have lower costs than the USA, but that's because they started off with lower costs. I don't know of any that has cut costs.
I think you are right in saying how we need to reform things.
Unfortunately none of the proposed reforms from Congress move us towards that. The government could expand its VHA model, but instead its expanding its Medicare model.
You can't take *the Mayo clinic* and extrapolate it to anything. You could duplicate everything at the Mayo clinic from the salaries to the physical plant, and it wouldn't get the same results, because *it wouldn't be the Mayo clinic*. Harvard is not a good model for the rest of american education. Etc.
Here is a better article about that horrible single payer program Medicare- you know, the benighted program that we substituted for free market perfection back in 1965?
What's more, the frightening image of Medicare sucking away nearly a tenth of the national income isn't likely to materialize. Every previous Medicare spending "crisis" has prompted serious and effective efforts to rein in costs without cutting benefits. A number of European countries, moreover, are much farther along the demographic road to gerontocracy than is the United States, yet have still sustained their publicly funded health benefits without having medical spending take a larger share of the national income or restricting access for older patients to a level below Medicare's current coverage.
Lurking beneath claims about affordability is the seemingly fixed American belief that all government programs are less efficient and more costly than their private counterparts. That's simply not true of Medicare. In fact, Medicare has contained its spending better than has private insurance over the past two decades. Nor have politicians given away the bank to older Americans. Medicare is remarkably less generous than typical private health plans. A private plan with Medicare's current benefit package would cost about $2,300 for a single non-aged adult, compared with a current average for private plans of about $3,600 with the sort of benefits negotiated at the typical workplace.
http://goliath.ecnext.com/coms2/gi_0199-2329218/Good-medicine-Medicare-does-need.html
RTWT really. Despite Megan's assertions, the US government has stepped in to reform Medicare and control Medicare costs in the past-and will do so in the future, even if not on Megan's timetable.
Stonetoosl, do you know if the article says which European countries have not had medical spending take a larger share of the national income? I don't know which ones they are, and I don't really want to go through the hassle of registering just to find out the article is still vague.
considering that the source is www.prospect.org, ezra klein's old workplace, i think we can guess pretty well what's in that article without reading beyond the abstract.
http://www.prospect.org/cs/articles?article=good_medicine
that's the link to the article, which doesn't even bother mentioning other countries. it is a stupid article, and represents the kind of shadiness that marks usian single-payer advocates.
Ah, we're into the usual endgame where after having shown a rather thorough ignorance of the subject, the 'personal responsibility' libertarian moves on to declare victory. What's amazing here is that we already know that - per Megan, I haven't checked - part of the graph, the pre-2010 part that they claim is valid because it's about the past . . . has already been proven wrong. Yet, somehow, it's still 'right', and the future predictions are 'wrong'.
I'm guessing that this same individual - being the rugged individualist that he is - doesn't realize that these sorts of studies are statistical in nature, and are subject to revision in the light of more and newer data. I'm also guessing that this poster probably thought the Lancet study was completely wrong and bad and horrible and no good . . .
It's also weird that several people here think predictions are never as good as 'known data'. Uh. let me drop a ball off the roof of my house. I'll try to do a time/distance plot, and I might even get a pretty good one if I have the proper equipment, down to the millisecond and millimeter even. But this data simply won't be as accurate as the prediction that at t=10 seconds, the height above ground will be exactly zero. That's rather more precise and more accurate than anything I could achieve with a set of measurements.
He's done to a blackened crisp. Move along folks, nothing more to see here.
Projections are, by definition, never as good as known data. For all you know a kid could pick up your ball at t=9 seconds. I'm not saying projections are useless or of no evidential value. But they're a very different category of evidence than data. I'm sorry, but that's just a fact.
Mean while, in the real world, Massachusetts actually has already moved to trim its health care program-something that Megan said was impossible, given American political culture:
Overseers of Massachusetts’ trailblazing healthcare program made their first cuts yesterday, trimming $115 million, or 12 percent, from Commonwealth Care, which subsidizes premiums for needy residents and is the centerpiece of the 2006 law.
http://www.boston.com/news/local/massachusetts/articles/2009/06/24/state_cuts_its_health_coverage_by_115m/
Governments have also cut back on Medicaid-the government health insurance program for the poor :
http://www.npr.org/templates/story/story.php?storyId=5195533
I have to wonder-did MM do ANY research before penning this article?
Even more astonishing are fawning comments like this:
Megan's best article ever.
Really? Is this kind of poorly researched filler the most her libertarian admirers expect? Well, I guess it is, really-its what they want to hear , so they uncritically applaud it. .
The largest share of the savings will come from slowing enrollment. An estimated 18,000 poor residents who qualify for full subsidies, but who forget to designate a health plan, will no longer be automatically assigned a plan and enrolled and thus could face delays in getting care.
Savings will also come from eliminating dental coverage for the poorest residents enrolled in Commonwealth Care, roughly 92,000 people who currently are the only ones in the program who receive that care.
So they're controlling costs by rationing care? Why didn't someone think of that?
Also hanging in the balance is the health insurance status of 28,000 legal immigrants whose Commonwealth Care coverage was dropped in the budget lawmakers approved for the fiscal year that begins July 1.
Lawmakers said they cut this class of legal immigrants because they do not qualify for matching federal subsidies. Thus, they are more expensive for the state to insure.
Hold on, rationing AND segregation? Can this program get any better? Truly a model for the country.
You realize your post pretty much validates the oft repeated conservative/libertarian bromide that the only why the government has of controlling costs ultimately is rationing, right?
Let's not move the goalposts so obviously, shall we?
Megan's argument was that the American political culture made it impossible to control health care costs by cutting benefits and she cited Massachusetts as an example. I showed how Mass in fact moved to control costs by cutting benefits. She is wrong. Game over.
Now, I don't like the way that they controlled costs through cutting befits and rationing care to the poor and powerless, but they did move to control costs. Could they have found a more just and equitable way? Maybe and they are still working on the problem. We'll see. But Megan's claim has been undermined by the very example she cited.
Ok, if you are proposing that the system slowly implode by throwing more and more people off the rolls, then I'm with you--maybe it can control costs. If you're trying to say that it can control costs by changing delivery systems, etc, then the evidence does not support you.
Megan's theoretical arguments do not seem well grounded.
"American public services culture is, in general, less effective than the Nordic countries, and no, this is not simply an artifact of Republicans criticizing government bureaucrats; the government bureaucrats do a great deal that is worthy of criticism"
A powerful argument if we were comparing America to the Nordic countries. As it is, well not so much ...
"American attitudes toward government: when told they can't have something they want, Americans do not say, oh, okay. They go on the news and call their congressman."
Unlike those passive French who just obediently accept whatever their government tells them?
I can buy some degree of path dependence, some degree of political institutional dynamics. The argument about our being more conservative seems weak - seniors seem to like Medicare well enough.
Tom
One big difference is that the French have never had a system where doctors take super-extraordinary measures to get meager extensions in life. They don't have something being taken away; they've never been offered it.
Of course they love it. They love it even if it bankrupts their children. Find a politician willing to say "y'know, maybe Medicare shouldn't spend so much on end-of-life care, since it offers so little bang for the buck." Tell me ahead of time because I want to bring marshmallows when his house gets torched.
Cruxius,
Your first point is a specific example of Megan's path dependence point. I think the broader point has some legitimacy but is far to weak to stand on its own. We can never change our system because decisions made in the last fifty years are irreversible?
The final point looks to me like a general diatribe about Medicare. OK so you don't like it. But the point is that Americans are not innately opposed to government health care as Megan claims. We simply don't have it now for most people. I don't see how you can reconcile a claim that American's dislike government interventions into health care but love Medicare.
best,
Tom
I don't actually think it's a coincidence that the French have the second most expensive system, after us.
French healthcare is much cheaper than the US though (11% of a smaller GDP per capita relative to 16% for the US).
More broadly, you are trying to explain why American health costs are _much_ greater than everyone else's. To due that you cite factors that make America different.
But the factors you cited are misleading (the US public services are not as good as the best in the world) or apparently wrong (Americans complain more than other people).
Now it is possible that American public services in addition to be worse than the Nordic countries are also substantially worse than average. Do you have any data to support this claim? On public corruption, the US typically ranks middle of the pack.
I don't even know what to make of the claim that US citizens are more likely to demand government action or how to reconcile it with your subsequent claim America's greater innate conservatism will prevent our government from offering health insurance for all.
It seems to me like you went with the kitchen sink approach to argument here.
Tom
If you'd like a metaphor other than the Postal Service for the difference between the public and private sectors, make believe that you're about to undergo a critical operation and that into the room walks, instead of your surgeon....
Christopher Dodd
Cute, but irrelevant. Unless you think this applies to every expert-related situation in which the government is tangentially involved, e.g. your house refi. (And I'm on your side!)
Shelby
The only bills that have a chance to pass are the ones that are worse at cutting expenses while expanding benefits in the least efficient way possible, all with the complicity of the "fiscally responsible", "conservative" party, who screams DEATH PANELS! THEY WANT TO MURDER GRANDMA! every time entitlement cuts are proposed. Meanwhile, big pharma and insurance lobbies are garanteed ever greater favors and handouts by a legally bribed Congress (no lack of bipartisanship here).
Great check against the powerful, politically or otherwise.
Congress is broken. If you have the patience, the reasons are explained in detail here. Google talks rock.
"It's no good saying that well, we should try to be more like the Netherlands--you can't build a system on the assumption that you will, suddenly and for no apparent reason, be able to import someone else's political culture."
Oh if only this impeccable logic was used to avert the Iraq War instead of health care reform...
Question: What makes US culture so incompatible with health care reform?
Answer: Free market idealogues and right-wing hacks.
Oh, we knew this before going into Iraq. Those of us with common sense knew that the job would take 5-10 years to accomplish on the military front, and possibly longer on the Iraqi politicval front. You can't grow a democracy overnight.
But is was and is worth it. Unless you're among those that would prefer to see a American city be nuked before we did anything? Denying Iraq to terrorists is certainly worth the effort.
And your evidence that this amounts to anything is . . . ?
Though I tend to agree with the (so-called) liberals among the responding elite here, I think Megan has made some excellent points. Basically, we have a political problem and recent experience tends to indicate that things are going to get worse before they get better. I mean, how long can any good or service continue to increase at 2-3X the rate of inflation? I suspect that, like, say, oil prices, we will reach a tipping point that will create serious shocks to the system (e.g., expectations, behaviors, budgets, . . .).
I have one slightly off the mark question: It has been stated by all sides of the health-care commenters here that 80% of health-care costs are attributable to the very young (e.g., premies) and those in the final months of life.
As a one-time statistician, I wonder if the latter group is partly an illusion (and, no, don't have the data, please suggest some). Let us suppose that a large variety of life-sustaining procedures are increasingly chosen/prescribed to older Americans. Let's also assume that these procedures "work" 95% of the time, and don't 5% of the time. It may be that a large % of medical costs are attributable to the final months of life, but since that's when you get that kind of health care, why is this a surprise? Or even a problem?
I would be REALLY surprised if a large chunk of our health care costs were attributable to the 20-30 year old group, wouldn't you?
Uh-huh. And here's I I roll: I use facts, evidence, quotes, cites. Something that seems completely alien to your type:
No, the only people who are 'jumping' on me are complete blithering imbeciles who can't admit that the graph does not support Megan's statements. Ignoramuses who don't have any idea of how science works, or data collection on large sets, or basic notions of evidence. But say whatever you've got to say so you can live with yourself. Like this piece of work I'm calling you on:
God, what a putz! I just gave you an example where that was not the case!!!! Your response? To say 'never' followed immediately by 'may'. And look . . . I just picked up a sharpie off the desk tossed it in the air, and projected that it would be a distance d=0 off the ground at t=3 seconds. Gee, I couldn't tell you what the position/time time was to the inch or tenth of a second, but, somehow, my prediction was accurate to five decimal places.
So much for never. So much for intellectual honesty or personal responsibility. (Dusts hands) Another crispy critter.
Do you really not understand this? You sound so confident in yourself that it is hard to even know how to respectfully disagree with you. I have no idea what this response is supposed to amount to. There are many true sentences that use 'never' followed by 'may'. Like, you can never be sure that you'll wake up tomorrow, since you may die in the night. And it is this very fact about projections - that you can never be sure of them - that makes them have a different evidential weight than collected data. You can be sure - dead sure - that the facts about the past won't change. But you can't be sure that your projections for the future will be correct. This really is just basic common sense.
I'm not sure what your point is about evidence. My type doesn't use evidence? Megan was most certainly using evidence to make her point, although, as we have seen, she may have inadvertently misused the evidence. But our dispute is about a more theoretical claim, that collected data is better evidence than projections. I suppose I could present evidence for that claim - obviously, there is a much higher proportion of true bits of collected data than true projections - but it seems unnecessary, since no one arguing in earnest could really doubt this. In any case, I'll mention some evidence that has just come to my attention. People who call their opponents names and insult them are rarely interested in the truth, they're simply interested in scoring points and winning. Unless further evidence comes to my attention, I have to conclude from the evidence at my disposal that you are simply not in earnest, and will take everything you say with the according number of grains of salt.
Medicare/Medicaid exist precisely to cover the worst possible risk pool so why one wouldn't expect their per capita costs to be higher and why would it make sense to extrapolate those costs to the population as a whole?
And frankly the argument that we couldn't replicate health care systems that work in other countries because.... well.... we're just too different. is stunningly weak.
I've only posted this eight or nine times now, but what the hey. Here are the WHO life tables. And as I've also explained many times before, no, from these tables, differential infant mortality stats don't explain the differences in life expectancy.
So comparing Canada to the US, the US loses on life expectancy in every age bracket (except a tie at 100+)...including the 65+ brackets, where Americans are all on single-payer. Sure, you can talk about how 80.6 over 78.0 at birth proves the superiority of the Canadian system, but 19.7 over 18.8 at 65-69, when the two are on a fundamentally identical system(except that the American doesn't have to worry about doctor shortages) would seem to indicate that there's an actual difference in the populations, not just in the systems.
Unless you're going to claim that American Medicare is run enough worse than Canadian to knock a year of life expectancy off American seniors, which wouldn't seem to bolster the case for Obamacare, you might want to accept the thesis that there may be actual differences in the populations.
Sorry, one more thing. Just how "homogenous" are those European populations? I lived in Germany for a year and saw a lot of non-Aryans. I just got back from a week in Paris, and there were a whole lot of non-homogenous Parisians walking around (aside from chubby Americans, of course). Ditto, my many trips to London.
Does anybody have data on the claim of European physiological/cultural uniformity?
According to the CIA world factbook, Germany is 91.5% German ethnicity, 2.4% Turkish, other 6.1% (made up largely of Greek, Italian, Polish, Russian, Serbo-Croatian, Spanish).
UK is: white 92.1%, black 2%, Indian 1.8%, Pakistani 1.3%, mixed 1.2%, other 1.6% (2001 census)
USA is: white 79.96%, black 12.85%, Asian 4.43%, Amerindian and Alaska native 0.97%, native Hawaiian and other Pacific islander 0.18%, two or more races 1.61% (July 2007 estimate)
You can't honestly have this discussion without acknowledging that white Americans have a life expectancy 8 years longer than black Americans. Certainly that has something to do with our healthcare system, but it has a lot to do with genetic predispositions to heart disease. We have been addressing that and narrowing the gap, but you can hardly blame our system for genetic differences.
Once you control for ethnic differences, US life expectancy exceeds most European nations.
Thanks, Mark. Good reference. I note that they don't break the numbers down for France, Italy, or Spain. France, in particular, probably has a minority composition closer to ours. Switzerland is (predictably) nearly all white Europeans. Netherlands is not *too* different than the US in terms of ethnic mix.
Netherlands ethnic composition from CIA worldbook:
"Dutch 80.7%, EU 5%, Indonesian 2.4%, Turkish 2.2%, Surinamese 2%, Moroccan 2%, Netherlands Antilles & Aruba 0.8%, other 4.8% (2008 est.)"
That would equate to 89.9% white using the standard USA was calculated (including Turks and Hispanics as white).
I've found that American travelers vastly overestimate the relative percentage of minorities in Europe. I think this is because cities tend to have hugely disproportionate immigrant populations, and also the 'sticking out' factor. IE- you see many dark skinned people in Amsterdam and it is remarkable. You wouldn't even notice in New York much less try to count. Its an observation bias.
"I've found that American travelers vastly overestimate the relative percentage of minorities in Europe"
I appreciate that, but I actually lived in Europe twice and my travels are often outside the big city. I still suspect that the French ethnic composition is similar to ours . . . though the use of health care may differ among ethnicities, don't know. Not sure I'd lump Turkish in with "whites", though the EU slice probably is.
In any event, I think some of the arguments being made above are implying that cultural uniformity (not ethnicity) has helped bring about consensus on medical care choices/politics. Spain's politics (as one example) tend to reflect regional differences (and frictions), so I'm not sure I entirely buy the consensus theory.
black people are not genetically predisposed to heart disease. nutrient deficiency is the most likely cause of shorter life, and secondly environmental factors.
but let's not get into eugenics territory when diet and environment are both more measurable and more likely relevant factors.
There's some evidence that the underlying biological mechanisms DO work differently in certain ethnicities -- "black" people respond differently to certain cardiac drugs than do other races, for example. (I'm not sure I've ever seen this broken out according to the many ethnicities that are grouped under the "black" checkmark, but it wouldn't surprise me if that's a factor too. We expect Mediterranean populations to be distinct from Nordic ones, so why shouldn't we expect Somalian heritage to diverge from South African?)
It's not eugenics to talk about ethnic composition being important in some contexts where genetics does have a disparate impact. In fact, it's racist if we ignore legitimate and meaningful distinctions, like testing Ashkenazi Jews for Tay-Sachs or black people for sickle cell anemia, and thereby don't treat people with the appropriate protocols for their heritage. It's only eugenics if we use those distinctions for non-medical purposes like determining their social status or civil rights.
In the book "Survival of the Sickest" by Dr Sharon Maolem raises a depressing hypothesis about American blacks' health status. The key concept of the whole book, which covers a lot of other health situations, is that it can make sense to have a gene that gives you a higher likelihood of death when you're old as long as it increases your odds of reaching that older age.
That the Atlantic Crossing part of the slave trade had such a high fatality rate that it counted as a genetic bottleneck. For example the slaves were not given much water on the ships, so those slaves who had a genetic tendency to retain salt would have been more likely to survive the crossing and thus their descendents have disproportionate rates of hypertension.
Another example of how it's genetics and environment, not either separately.
there's actual research regarding vitamin d deficiency being related to the cluster of problems that affect black mortality in america. the retain salt gene thing is a just-so story and a very stupid one at that that doesn't even pass a basic smell test.
"Medicare/Medicaid exist precisely to cover the worst possible risk pool so why one wouldn't expect their per capita costs to be higher and why would it make sense to extrapolate those costs to the population as a whole?"
Again, you aren't understanding the statistic.
The US government spends more per capita on health care than the UK or Canada.
All they get for spending more per capita than the UK or Canada is coverage of 27% of the population, most of them on Medicare.
That is per capita for the whole United States.
NOT per capita just for the people who are covered by Medicare.
I've asked this question before, and I realize the political obstacles, but . . . why don't they just up the Medicare payroll tax deduction? A fraction of a percent more would hardly raise a fuss, would it? And all most of those retired voting seniors don't pay in at this point anyway . . .
And look . . . I just picked up a sharpie off the desk tossed it in the air, and projected that it would be a distance d=0 off the ground at t=3 seconds...
Merely for clarity's sake, is it your position that the practice of forecasting increases in health insurance premiums is comparable, in complexity, reliability, and depth of understanding required, as estimating the time it takes a tossed marker to hit the floor?
One more time: health insurance is NOT the same thing as health care. Consider Medicare, a single-payer system that we already have. It pays a low amount for many procedures, so low that many doctors will not accept Medicare patients. "But I have medical insurance!", says the over-65 person. "I am not an indentured servant", replies the doctor who is free to decide who to accept as a patient.
I think that people under 65 should be allowed to "buy in" to Medicare. In addition to any Medicare premiums from wages, they should be able to pay an extra monthly premium to have access to Medicare. This would satisfy the people yelling for a single-payer option while leaving the rest of us alone.
The other thing we MUST keep in mind is the demographics bomb that is about to go off. Medicare in its current state is simply and irreparably untenable. Extending entitlements to millions of more Americans is little short of lunatic when we have absolutely no prospect of paying for the current obligations.
This is such the largest elephant ever ignored. Nobody even wants to speculate on how we're going to pay for medicare in even 10 years. Its simply too vast of a problem to complicate. We're not just rearranging deckchairs on the Titanic with these new plans, we're burning life rafts.
True, Mark. Which is why I wonder why a proposed Medicare tax hike isn't on the table. With total national AGI of almost $9 trillion, a two percent hike on earned income yields $180 billion more a year. Though still not enough to cover the projected $37 trillion deficit over the next 75 years, it's a start.
I think because an across the board tax during this recession is not only economically bad news, but politically impossible.
What is going to be done is means testing for Medicare and SS. Its not if, its when. We could start smaller now and it would hurt less in the end, but we won't. Nobody has the political courage to take on entitlements. We are going to see a historically unparalleled transfer of wealth from the young and working to the elderly and retired over the next few decades. The irony is that the oldsters a demographically much wealthier than the young, and aside from healthcare their needs for disposable income is much lower (buying your first house, weddings, kids, college, etc).
At some point (sooner than we think Im betting) the taxpayers will have had enough with the huge payroll tax hikes we're destined for and somehow sanity will be returned to the system. But its probably going to be very messy and its certainly going to create a net drag on the economy as taxes rise.
The problem, of course, is that the elderly not only vote more often and reliably than the young, but that they will almost outnumber them. The fact that taxpayers will be upset will be irrelevant - the recipients will still be voting to keep their benefits.
Speaking as a person who will be eligible for Medicare in five years, and will be getting Social Security in ten, I think this development is not only unavoidable but desirable. I have little enthusiasm for the AARP's growing role as a lobby for giving old people government handouts regardless of the cost to the rest of the country.
Though the problem could be much reduced by increasing all the age thresholds by one year, automatically, for every two years that pass, until we get back to the situation that existed when Social Security was created, where only a minority of people ever collect it, and only for the last few years of their lives.
Sigh. Merely for clarity's sake, is it your position that predictions are never as accurate as the previously accepted measurements?
Not a hard question.
And - merely for clarity's sake - is it your position that Megan was not using projected data when she made the claim:
Or shall I just assume that you think predictions are never as good as the measurements, and that Megan's data was empirical and factual from 2004 to 2009? I'm sorry, but this constitutional inability of libertarians to admit to the most obvious mistakes makes them a laughingstock. Well, that and their self-assessments of expertise when coupled with statements that clearly show that they have little if any on the subject.
Bub, you haven't been 'respectfully disagreeing' with me.
Ah, playing the stupid card. You said:
And I just gave you an example where that was not the case. But why don't you just go an and continue to pretend that you don't get it.
It's hard to address this level of ignorance by someone who thinks he knows something . . . particularly when it's "just common sense". To name but one of your many errors, you are confusing 'measurements' with 'actual data'. Whether you are doing this on purpose or not I won't bother to hazard a guess.
Since I don't believe you are in earnest, I'm really just writing this for any impressionable youngsters who read through the comments. But here goes. you wrote:
"Ah, playing the stupid card. You said:
Projections are, by definition, never as good as known data.
And I just gave you an example where that was not the case. But why don't you just go an and continue to pretend that you don't get it."
Do you mean to suggestion that you interpreted my comment to mean that projections are never true? That would be a pretty uncharitable interpretation. Being true is one way of being good, but I was actually talking about a different sense of goodness: reliability. Projections are by definition not completely reliable. Recorded facts are reliable. As far as my ignorance goes, please tell me how I am confusing measurements with actual data? Data refers to "facts and statistics collected together for reference or analysis". And facts, dear friend, are true.
Your point is probably that our estimations of the facts are not always correct. But I completely agree with that. In theory, we can't be completely certain that we're not in the matrix, and then our "data" would be an illusion. But that doesn't mean that there are not any recorded facts, and the subject of our exchange was whether a graph representing recorded facts on the left and projections on the right must be accepted or rejected wholesale. And the answer to that question is no.
is it your position that predictions are never as accurate as the previously accepted measurements?
I'm not sure precisely what this means, but suffice to say that I think highly accurate predictions are possible in some fields of endeavor, Newtonian dynamics being one of them. However, I think predictions--even in predictable fields--are inherently inferior from an evidentiary standpoint to actual measurements. A wise man once told me "Evidence trumps theory...every time." I've taken that to heart.
I'm inclined to regard economic predictions--and health insurance premiums fall into that category--extending more than a year or two into the future as about as accurate as what the weatherblond says is going to happen 10 days out: any relationship to reality is pure coincidence.
Now, it seems to me that muzzybelly has raised two very important objections: 1) the first graph does not show actual data, and 2) to the extent that we have actual data, it is only for a single year. Both of those indicate a lack of support for the claim that RomneyCare has caused costs to rise.
And now its your turn to answer my question.
Ok everyone, Meghan is correct. Massachusetts health care costs have gotten out of control. Premiums at my firm went up 30% last year - we brought the increase down to only 17% with a high deductible policy. This is not a statistic this is fact.
That being said, I think it's great Massachusetts is trying something, but god forbid the Fed's try and do this.
Temporary agencies and retailers have had huge problems that have been hard to work out with state bureaucrats, what would this be like at the federal level ?
We have No Choice, but to Controlled our Healthcare Costs.
For years, Microsoft's Desktop Applications have Increased Productivity, Efficiency, and Costs Savings in the Work Place.
Proper Deployment of Health Information Technology (HIT) Solutions can Increased Productivity (i,e, medical data mining, risks treatment and service delivery), Efficiency (i,e, medical errors, redundant and inappropiate care), and Costs Savings of around 20-30% of our Annual National Healthcare Expenditures ($2.4 Trillions).
We can start by Deploying a pure Packet-based, All Optical/IP, Multi-Service National Transport Network Infrastructure, using Ethernet throughout the National Networks.
This of Investment is like the Investments that were made in the past in the National Transportation Inter-State Highways, which Increased Productivity, and our GDP.
Also, the this Next Generation/21st Century All optical/IP National "Network of Networks" can Serve as a Business Driver for: e-Healthcare, e-Commerce, e-Education, Energy Systems, Transportation Systems, Social Networking, Entertainment, etc.
Please See: www.gkquoquoi.blogspot.com for Summary Deployment Plan for the Nationwide Health Information Network (NHIN).
Gadema Korboi Quoquoi
President & CEO
COMPULINE INMTERNATIONAL, INC.
The spammers are becoming ever more surreal.
Korboi -
Why on earth would we need to deploy a *new* network when there's a perfectly good, robust, diverse, fault-tolerant, and redundant system in place already?
Is there something special about e-healthcare packets and/or frames that they need this "Nationwide Health Information Network" on which to run?
Korboi -
I just read your blog.
Nevermind - you don't need to try to answer my question.
kthx.
Megan,
Meidcare's administrative costs per patient are clearly HIGHER than private health insurance, and with regards to administrative costs as a percentage of total costs, if you do a close examination of Medicare administrative costs, that is close to a wash:
Medicare Administrative Costs Are Higher, Not Lower, Than for Private Insurance
Medicare's Hidden Administrative Costs
Moreover, if you assume that health insurance companies spend money on administration to reduce fraudulent payouts, one could argue it is better to have less fraud. Since private health insurance companies have very low profit margins (~3%), those reduced fraud costs are reflected in lower premiums.
Lol, your "theoretical" points are laughable.
Wrong:
There high wage inequality in the United States, therefore we cannot enact a policy that *might* decrease wage inequality in healthcare.
Wrong:
We can't cut costs because Republicans made a fuss in the media about end of life issues.
Wrong:
Americans demand more of their government than complacent Europeans. Perhaps you've never read a British tabloid? There is plenty of drama and fussing in European Nations.
Wrong:
Americans can't expect effective government programs because we can expect that Republicans will sabotage government programs when they come into power.*
I struggle to believe that you aren't aware of the massive cognitive dissonance in your worldviews. It is almost as if you believe that your political ideology somehow fiats reality.
*Note, It isn't Republican criticism that makes government ineffective, it is Republican incompetence at managing government.
Well, I'm glad to see my lessons aren't entirely wasted! The problem I am speaking of is confusing measurements with 'actual' measurements or 'real data'. Yes, if you have real data, then one would say that in certain cases, they will be more reliable - and more accurate - than a prediction(or perhaps more precisely, an extrapolation.) One thinks of counting dollar and cents out of a store register at the end of the day and then using the accumulated data to predict sales next week or next year.
But in point of fact, a lot of data simply isn't like that; it's statistical in nature and what is called 'data' is actually reduction on the raw measurements themselves. An easy example would be to sample one store in fifty out of, say, 1,000 stores, and then say that over the weekend, average sales were 'x'. The 'data' here is the average sale; what the actual measurements are are the register tapes from 200 stores. Now, that's an easy example, but a surprisingly diverse set of phenomena are subject to this - recording particle interaction events in an accelerator, for example, or figuring out cosmological red shifts, to get the other end of the size scale. In cases like those, it's quite possible to have 'data' that simply don't accord with the real world. And in certain cases, the predictions from these 'data' will be more accurate than the data themselves.
But my objection is of a different sort: Megan was quite happy to introduce this graph when she thought it supported her case. And when it turned out that in fact, it didn't, that it projected a lower rate of increase for Massachusetts as opposed to the U.S. overall, then the refrain was well, you can't use the graph for that.
Even though the part that she thought supported her case was also a projection. And a wrong one, as it turns out (if the other sources are correct, I didn't click on them[1].
Not yet, for you still haven't answered mine. Did Megan quote projected data from the graph to back her argument? And if so, can she plausibly dismiss the part of the graph that undercuts her case on the grounds that it is a projection? That's what I'm pointing out, and that's what my initial comment was referring to.
[1]The funny part was that the only reason I clicked on the link and actually read the thing was because in the one shown in the posting, the the print was too small, even after enlarging it. If that wasn't the case, I probably would have missed both the lower than national average increase, and the fact that the 'data' was projected.
And I've already explained the difference between raw measurements and data reduction. You're equating the two, and you can't do that. Further, my example was to show that data can be inaccurate and imprecise, and yet the prediction can be both more accurate and more precise than the data. This isn't a difficult concept.
Point one: the 'facts on the left' were not facts, they were projections, which has been pointed out I don't know how many times now, and they were used in the service of making a point. So, no, you can't do anything but accept or reject wholesale, even in this narrow example.
Point two: It strikes me that you don't really have any idea how much 'known data' is statistical and provisional in nature, or how often what is referred to as 'data' is actually 'data reduction' on a set of raw measurements.
Point three: "It's just common sense" is a good proxy for someone who tries to speak from authority when it's painfully obvious he doesn't have the faintest idea what he's talking about. "It's just common sense" that raising the minimum wage will increase unemployment. "It's just common sense" that raising the price on any given commodity will decrease the demand for that commodity. "It's just common sense" that the offspring of cats are cats, not dogs or alligators, and that there is no such thing as the creation of new species.
I don't know why, but this last post made me feel like we were making a little bit of progress.
"Point one: the 'facts on the left' were not facts, they were projections, which has been pointed out I don't know how many times now, and they were used in the service of making a point."
Granted. But this was never the point of my complaint. As you yourself have admitted, you thought that the left of the graph represented recorded data, and the right represented projections, and that one could not rationally think that the data were evidence and that the projections were not. And I think that this is false, hence our dispute. It turns out our dispute isn't all that relevant since, as you note, the left of the (relevant portion of) the graph was also projections. But we're arguing about a conceptual point.
"Point two: It strikes me that you don't really have any idea how much 'known data' is statistical and provisional in nature, or how often what is referred to as 'data' is actually 'data reduction' on a set of raw measurements."
If data reduction is done properly, it should inherit the evidential status of "raw data". Else there would be no point in doing it.
Humans very often think they know more than they do - I'm aware of the difference between knowledge and merely apparent knowledge. I didn't think that our discussion required this level of nuance, but I'll state my position in a way that should avert any misunderstandings: not only is known data more reliable than projections, but widely accepted measurements and widely accepted reductions of those measurements to useable statistics are more reliable than projections, especially projections that are NOT widely accepted. (Here I'm using 'widely accepted' to mean something like "most people on both sides of the debate accept it".)
"Point three: "It's just common sense" is a good proxy for someone who tries to speak from authority when it's painfully obvious he doesn't have the faintest idea what he's talking about."
Are you saying that common sense is never right? Are you saying that we should conduct inquiry by disregarding common sense? Of course sometimes prejudice etc. masquerades as common sense. But there are very good arguments that there is no rational alternative to appealing to common sense. The debate is a big one, so I won't try to have it here, but here is a link to one nice paper:
http://www.princeton.edu/~tkelly/papers/Common%20Sense.doc
By the way, it is impossible for the offspring of a cat to be a dog or an alligator. But I'm not sure who could have thought there was no such thing as the creation of new species: someone who thought that every species had existed for all eternity? That's certainly not common sense.
Really? I 'admitted' this, eh? Care to point to exactly where I 'admitted' this? In fact, let's look at the wayback machine:
Note the time and date. Next:
Note the time and date. Iow, even if you want to dismiss the smiley and the 'assumptions', even then if you want to insist that "I didn't know it" I would have known this about ten minutes later. Poof!
I think what you mean to say is that (a)other people - such as yourself - missed this repeatedly, and (b)as a matter of general principle, yes, I think that you're not free to pick and choose out of a cite, declaring that the parts that support you are valid, but the ones that don't are not valid[1].
And unless you can point to somewhere where you've actually said that Megan (and everyone else who did the same thing) are selectively accepting and dismissing parts of this graph by whether it supports them or not - and condemning them for it - well, I just don't believe you.
I think you've argued yourself into a corner, and you just can't admit that you're wrong. Because, after all, that's how libertarians roll ;-) Like I said, I'm a believer in evidence, so you can either produce what I described above, or you can go ahead and reaffirm my impressions of your tribe.
Translation: John just very late in the day figured it out . . . but still won't condemn the selective use of this graph to make points. Even though he had the perfect opportunity just now, as he himself has admitted.
Gee, then you must agree with the Lancet report about how many excess deaths have occurred in Iraq since the occupation ;-} No, John, you're just flat-out wrong on this one, and I can give you example after example where this is the case. Since this sort of thing is widely known amongst scientists and statisticians, I'm guessing that neither science nor statistics are your forte. In fact, you're still doing it with 'known data' bit. But you 'know' better, don't you? It's just "common sense".
Uh-huh. "Common sense" says that time passes at the same rate for everyone. Relativity says it doesn't. Unlike you, I'll go with what relativity says, and not "common sense". But your appeal to "philosophy" is interesting; I've had extensive training in physics, I teach math - including undergraduate statistics - and I've actually done some statistical work for the university where I am employed as well as some stuff for the CDC a while back. Iow, I'm very aware of the provisional nature of knowledge, types of data and measurement, data reduction on large sets of measurements, etc. You, otoh, don't seem to know very much about this, as both your initial statements and your continual revisions of them suggest. Do you have any sort scientific training, or are your objections stemming from an education in something other than the sciences, say philosophy? Because everything I've said is pretty standard stuff.
[1]Let me quote something from a few posts back about doing the same thing with the CBO:
So, no, this has been a sore point with me for time, that libertarians just aren't that literate scientifically, and really don't understand how the scientific method, evidentiary requirements, burden of proof standards, etc really work.
Professor Levenson (assuming this is you), I think you need to get out more. This is all a big waste of your time.
Well, on October 8th, at 9:44 you said that you initially didn't realize that the numbers on the left were projections. I interpreted that to mean that during your initial foray here you hadn't realized that. If you deny this, I guess I will simply believe you, but it seems surprising that you wouldn't have mentioned the point earlier. But, as I said, the dispute is about a conceptual issue. And when it comes to the conceptual issue, I have to say that it is you who are in over your head, or else simply not arguing in earnest (as I have said before). Do you have a scientific argument that life on earth doesn't originate from the visit of a tribe of dancing gnomes? Of course not. But it is a very silly idea nonetheless, and I shouldn't think much of someone who put much stock in it. Likewise with the idea that if one appeals to something as evidence one must appeal to it in toto. It is just a very silly idea, since, for example, all sorts of things might be represented on one graph, including established facts, measurements, projections, hunches, etc.
Did Megan quote projected data from the graph to back her argument?
Yes. My suspicion is that she thought she was quoting measurements, not data, that is, that she didn't see the footnote. I didn't see it until Shelby pointed it out. Those projections are still useful--we can compare them to the real results to see if the projectors knew what we were doing--but they aren't evidence of anything.
And if so, can she plausibly dismiss the part of the graph that undercuts her case on the grounds that it is a projection?
Maybe, depending on the purpose for which she uses it. Surely you are familiar with the phenomenon of the "10-day forecast." I don't think that weatherblonds are actually capable of predicting anything 10 days out. So while I might buy 2 or 3 days worth of weather forecasts, I certainly don't think they can tell me what to expect a week from now. Economic forecasts are similar. A year or two maybe, but much beyond that it's basically a guess. Heck, that famous graph of "unemployment with and without the stimulus" suggests that even a few months out its basically a guess.
However, for the purpose of saying what is happening in MA's health care costs right now, it is utterly pointless to use projections apparently made in 2003. That's why I think it was a mistake rather than an effort to mislead.
And if you'll permit me to say it, you could have been a bit clearer about your objection. It was clear to me, at least, that a bunch of us had not read that footnote, and were nonplussed by your seeming insistence that projections and data (measurements, whatever) were as equally valid, when in fact what you meant was that early projections are as valid as later projections. The first point is nuts, the second is sensible.
Sorry, but I emphatically disagree. As would most of the people I work with, I would imagine.
Megan has a bad habit of not vetting her sources, and when called on here mistakes, refusing to admit them. It's the refusal to admit to obvious whoppers that lead a lot of people to suspect an effort to mislead rather than a mistake.
No, I still hold with both of them (which may have led to some confusion.) Look, you can't simply say that all predictions generically are less accurate and reliable than the measurements(data reduction) they are based on. It's just not true as a general principle. If you want to talk about, say, taking a runner and training him up, plotting his times on a graph and doing some sort of curve fitting to extrapolate his running times six months from now, hen yes, you're probably correct, and I think that people have got an implicit assumption that social statistical data is like that. Very often, it's not. But yes, I was deflected from the more immediate point that in this instance, the 'data' Megan was using was in fact a projection.
I think that people have got an implicit assumption that social statistical data is like that. Very often, it's not.
If you want to talk about marriage rates or birth rates or the distribution of heights or some such, then I can believe that sound predictions can be made. But economic predictions--and health care premiums are a form of economic prediction--are notoriously unreliable (again, check out the "with and without stimulus" unemployment graph). That isn't surprising given how economics is a branch of applied psychology, the squishiest of the squishy sciences.
Controlling Healthcare Costs The American Way:
Not Doing It
Rob Lyman:
economic predictions on health care premiums
are notoriously unreliable; Unsurprising given
economics is applied psychology, the squishiest
of the squishy sciences.
Correctomundo. When in doubt:
A) Run in circles, scream and shout.
B) Don't. Choose wisely.
Adding zeroes does not produce a sum.
Analyzing a signal buried beyond recovery
in noise does not produce data, rather the
conclusion that one wishes were true.
@ MM Q4 predictors: Would you bet your life ?
The State doesn't hesitate to bet for you.
Sorry, but I emphatically disagree. As would most of the people I work with, I would imagine.
Are you saying that you and the majority of the people you work with believe the 10-day weather forecast, or that you believe the 10-year economic forecast? Neither has a particularly good record.
I should have bit a bit clearer immediately above. Microeconomics has a decent level of predictive power. Macroeconomics has some interesting things to say, but has the predictive power of Vegas bookies: OK for this year, worthless long-term.
No, I'm saying they would disagree with the idea that predictions are always less accurate and less reliable than the underlying (raw)data. You have to take it on a case by case basis. Sometimes they will be, sometimes they won't.
Don't cheat - no one was talking about particular raw initial measurements being more reliable than projections based on analyses of such measurements. The question is essentially this: which is more reliable, our beliefs about the past or our beliefs about the future. Answer: beliefs about the past. This is true even for scientists.
Fiance'?
You're spoken for?
There's already too few tall, smart women!
Excuse me.
I meant to say "There are already to few tall, smart women!"
Back to the health care issue; why is it that I so seldom hear anyone stand up and say that they are unable to care for themselves and that they would like the rest of us to provide for them? But I DAILY hear someone talk about "the masses" who will perish if we don't surrender a huge portion of our earned incomes to the gov't - which will of course (faithfully and efficiently) direct our dollars toward those masses.