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National health care advocates are feeling pretty s-chipper
Number one item in this post on Graeme Frost:
1) I told y'all this was going to happen. Maybe next time you'll listen, hmmm?
Weirdly triggered angry email from liberal commenters, who offered this as an example of my tendency to make snotty dismissals of liberals. This is weird because, of course, I was talking to conservatives, in re my earlier post on the general political unwiseness of attacking programs that give money to cute children.
Meanwhile, conservatives think I'm nuts, and also maybe a closet liberal, because I think that the battle over S-Chip--whatever the merits of the case--is doing more harm than good to the righteous crusade against government-run health care. But I'm not the only one who thinks this; so do the advocates of national health care. Or at least one of them, anyway:
Granted, MoveOn's support can be a mixed blessing, as the critics of the war found out after the infamous "Betray-us" ad. And, let's face it, health care may never be the kind of galvanizing issue that war is. But the fact that Bush's S-CHIP veto is already sparking protests suggests this may be the beginning of something new--and, for the supporters of universal coverage, something promising. By galvanizing universal health care's advocates, Bush's veto might do a lot more to make universal health care likely than expanding S-CHIP ever would have.
It's for the children!
I've been fairly mystified by the Bush administration's decision to push so hard against the SCHIP bill wending its way through Congress. To be sure, it's not a good bill. The main idea seems to be that we should expand a program aimed at poor children to cover more adults and middle class kids--and pay for it with a highly regressive tobacco tax. It's especially awful from a party trying to reclaim the mantle of fiscal responsibility, since one of the prime effects of tobacco taxes is to reduce smoking, which means that this program's funding stream is self-defeating, and will undoubtedly require more money from general revenues. But is this the hill the Bush administration really wants to die on? Regardless of the underlying merits of the case, it is squandering what little political capital it had left, and positioning Republicans as the party that hates poor kids.
Now Greg Mankiw posts a defense of the veto from inside the White House--and I still don't get it. The administration seems to feel that this is the camel's nose under the tent for some sort of universal government run program, a fear to which I am sympathetic. If poor kids lose their coverage, won't this give the pro-single-payer forces a lot of photogenically unhealthy kids to campaign with next year? That seems like a bigger danger than having New York State cover some portion of health expenses for families up to 400% of the poverty line--particularly since the problems in the financial markets may well damage New York State's revenue stream, and thus its appetite for expensive experiments.
Back to health care blogging
This first sentence is just here for all the bloggers who want to read the first sentence of the post and then go write an angry rebuttal of my claim that poor Americans should have to torture puppies in order to be eligible for Bandaids.
The rest of the post will be for people who want to, well, read the rest of my post.
Continue reading "Back to health care blogging" »
Do everything you can, doctor
During a conversation last night with a Scottish friend, it came up that he cannot recall ever having had a blood test.
This may be the primary argument against preventative medicine saving money. Yes, you save a little when you catch conditions early. But think how much money you save by never giving healthy young people tons of blood tests and other largely unnecessary diagnostic procedures.
And how much good do the broad-spectrum general blood tests do people our age? I've had conditions caught very early by blood tests. Luckily this has allowed me, in consultation with my doctor, to . . . wait for symptoms to appear.
Moreover, overall, it's not clear that the health benefits of catching things early through comprehensive screeening outweigh the health costs of superfluous treatment of conditions that weren't bothering the patient all that much. I'm more than fine with spending a great deal of money on screening if it improves peoples' health, but it's not clear to me that this is the case.
Why does American medicine do so many blood tests, X-Rays, EKGs, and so forth? You can't blame it all on lawsuits; my doctor didn't test me for hyperthyroidism because she was afraid of the malpractice suit that would result from my losing too much weight and getting heart palpitations. Nor can you blame it on money; my doctor doesn't profit from giving me blood tests that all come back normal. And I don't think the lack of rational rationing can be the culprit either. To the extent that insurance companies have bad incentives, it should be to do too little, not too much. They should have incentives to ration this sort of thing, but they don't.
I suspect the ultimate cause is the medical culture, which will make this sort of thing very hard to eradicate in either a single-payer or a private system.
If the petard fits . . .
The Economist's Free Exchange urges caution about the finding that the income-health gradient is even steeper in Canada than it is in America:
If the best evidence is not very good, then we need to be careful about drawing hard conclusions, and more careful still about "screaming them from the rooftop." I thought that the combination of the qualifier "slightly" in the phrase "the health-income gradient is slightly steeper in Canada than it is in the U.S.", along with the questionable nature of the data was sufficient to give us pause before beginning to evangelise. Apparently, that's not the case.
I would suggest that we ought to be very circumspect in analysing the health-income gradient--especially when making cross-country comparisons. For instance, research findings show that the health-income gradient is far flatter among Latinos--in general, Latinos are much healthier than their income levels imply. In America, Latinos make up a far larger share of the population than in Canada, and they are almost certainly overrepresented in the population of the uninsured. Have the NBER paper's authors taken such factors into consideration?
Research also shows that the income-health gradient for the population as a whole depends on the importance of within-group effects of income on health for subpopulations. If within-group effects are strong, then greater economic inequality between population subgroups can actually flatten the income-health gradient for the population as a whole.
It isn't easy to say how these different effects stack up, and that's entirely the point. Screaming from the rooftops inplies certainty of which there is none here. What we do know with certainty is that access to health insurance is more equitable in Canada, and total health outcomes are better in Canada. Without better data on the income-health gradient, I don't believe there is cause to question the arguments of those emphasising the equity benefits of single-payer systems.
Point well taken. Except . . . how come advocates for single-payer are so rarely interested in exploring these holes in the data when they support the argument for equity? Why don't we hear about the problems in cross-country comparisons of commonly used metrics such as infant mortality? Moreover, why doesn't the blogger mention that America also has a much higher percentage of African Americans, who, for reasons that are not clear, have higher mortality and premature birth rates even when things like income and education are controlled for?
You cannot argue, on the one hand, that cross country comparisons make it hard to really know whether Canada's income-health gradient is steeper; and then turn around and say that "for half what we spend, Canada offers insurance to all its citizens and produces better outcomes in practically every category listed: life expectancy at several ages, infant mortality, mortality from chronic conditions, mortality from various other diseases (including respiratory diseases, despite a higher rate of smoking), and so on." I agree that cross-country comparisons are fraught, though also, unfortunately, the best we have. But either you rely on that sort of data, or you don't; you can't use general arguments about the reliability of international data to dismiss specific studies that don't bolster your case.
Which half?
There's a lot of very good stuff in Robin Hanson's provocative essay arguing that half the money we spend on health care is wasted. Overall, I think he has the better of the argument; probably, excess health spending doesn't much change outcomes. But I'm less sanguine than he is at the notion that we could simply slash our spending in half.
Mr Hanson's argument is that above a certain basic level, there's no evidence that extra spending improves health. Some procedures above that make you healthier, but other unnecessary procedures make you less healthy; the overall effect is a wash. I'm fine with that conclusion, too. But he argues that cutting those extra expenditures wouldn't impact innovation. There, I'm less convinced.
It would seem natural that the procedures most likely to have dubious health value are the newest procedures, where benefits and side effects have yet to be fully explored. So while current spending might not do you any good, it is providing the knowledge that will do others good in the future.
This suggests that on health costs, Americans are leaning in to the strike zone and taking one for the global team: spending a lot on procedures of dubious value, so that others can incorporate the valuable ones into their health systems. Yet another reason that I think my European friends, if they know what's good for them, will stop extolling the virtues of a cheaper single-payer system to us, and start telling us how awful it is, nothing we'd ever want to try.
Driven consumers
Ezra says that consumer-based medicine is a red herring:
Indeed, the reason people get medical care -- in particular expensive medical care -- is because their doctors tell them to. I have never in my life sat up in bed and thought, "huh, I should really get some laparoscopic surgery." If I get a surgery, it's because my doctor told me to. And if I can't afford it, I have to ignore his diagnosis.
For that reason, if you want to safely cut back on care patients buy, you need to get doctors to stop recommending so much wasted care. You can do that in a few ways: Put them on salary rather than on fee-for-service deals, so they don't make more money when they recommend treatment. Create new research institutions that test the cost effectiveness of care so they have a better idea of which treatments are worth recommending. Offer bonuses for using proven therapies. Etc, etc. But this idea that the way to better run medical care is to rejigger the financial incentives so patients have to ignore their doctor's advice is really quite bizarre.
I actually agree with Ezra that consumer-driven medicine is unlikely to be much of a panacea. But I think he's wrong about the way that it reduces costs. Yes, it can save costs by forcing patients to forego useful procedures, but most consumer-driven advocates don't envision patients being uninsured; they just envision high deductibles to make them cost-conscious. More to the point, consumer costs don't just make patients attentive to cost-benefit analysis; they also change the way that doctors think about them. Doctors are much more willing to order tests charged to a faceless insurance company (generally one they've had unpleasant financial negotiations with) than they are to a live patient sitting right there in their office.
During the years that I was uninsured, I saw expensive East Side doctors, and doctors running Medicaid mills for the local housing projects. The common denominator was that as long as they assumed that I was insured, either by an employer or the government, they tended to order a lot of tests and procedures. The magic words "I'm uninsured" revealed that most of those tests had a very, very slim marginal benefit. We still ordered tests that were likely to yield useful information: thyroid function, breathing tests, and various other things that for reasons of age or previous medical history seemed likely to yield useful results. But given that I am not overweight and had none of the symptoms of diabetes, we canned the blood sugar tests. Likewise the EKG for my nonexistant heart symptoms, the assorted tests for incredibly rare autoimmune diseases, the hormone levels, and the cholesterol screen.
Since becoming insured, I've had all those tests, and more. They always come back fine, even my thyroid, which I've been waiting to lose to an autoimmune disease for almost ten years now. Meanwhile, I've had three disease scares from tests that showed borderline positive, five EKGs, three electrocardiograms, two chest x-rays (to be fair, one was at the behest of the WTC workers program), and probably more useless procedures that I can't remember. They haven't made me healthier; they've made doctors more secure, and test companies richer. Those categories of expenditures are ruthlessly trimmed by cost-sharing patients without much apparent cost in health.
There's another category that I'm not sure who is best equipped to deal with: the borderline useful. For example, I've had a camera stuck down my throat in order to discover that I had, not an exciting ulcer or scary stomach cancer, but boring acid reflux. Had I still been uninsured, I probably would have gotten a dose of antibiotics and antacids for the putative ulcer, and orders to come back if the problem didn't go away. Had it actually been stomach cancer, of course, that would have been bad . . . but almost no one at the age of 30 has stomach cancer. And the risks of general anaethesia may outweigh the benefits of finding that one-in-a-million cancer.
It seems obvious that consumer-driven care is the only shot we have at eliminating those kinds of expenditures, which could trim a lot off our health care bills. Either the government, or private insurers, are self-evidently willing to pay for couture medicine in a way that other countries are not. What I don't know is whether we should be interested in eliminating this last category.
Standing on the shoulders of giants
Derek Lowe continues to swat down the canard that all the real drug research is done in academic labs, while drug companies unfairly reap the rewards:
I also mentioned recently that I’d come across a good example of an academic compound with interesting activity but no chance of being a drug. Try this one out, from Organic Letters. Yes, there aren’t many other compounds that do what this one does (inhibit the production of TNF-alpha). And no, it’s not going to be a drug – well, at least the odds are very, very long against it.
Why so negative? Several reasons. For one thing, this molecule is extremely greasy. This is not a killer in and of itself, but it’s inviting trouble, for the reasons noted here. The second problem is that this thing looks like it’s going to have some trouble dissolving. That’s trouble both from both the thermodynamic (eventual amount in solution) and kinetic (speed of dissolution) senses. That greasiness will be the problem with the former, since a lot of this molecule’s surface area gives water molecules no incentives to join in on anything. And all those aryl rings (along with the symmetric structure) are asking for trouble with the latter. Those features make the structure look like it’ll form a very good, very happy crystal, with its aromatic rings stacked onto each other like ornamental bricks. “Brick” is the very word that comes to mind, actually.
But solubility is only the beginning. The real problem is that quinone functionality in the center of the molecule. In medicinal chemistry, no one wants quinones; no one likes them. They’re just too reactive. It would not surprise me for a minute to learn that this group, though, is the reason for the compound’s activity. It’s probably reacting with some functional group on the surface of the target protein and gumming up the works that way. It’ll do that to others, too, if it gets the chance. There are all sorts of weird little quinones in the literature that hit proteins that nothing else will touch, but none of them are going anywhere.
No, it’s safe to say that any experienced drug-company chemist would draw a red X through this one on sight. Plenty of reasonable-looking compounds turn up with unanticipated problems, so we don’t need to go looking for trouble. That’s not to say that it can’t be a research tool (although I’d be careful interpreting the data from complex systems – there’s no telling how many other things that quinone is going to react with).
But all this brings up another thing that we were talking about around here – how much do drug companies owe academia for working out fundamental biochemistry and molecular biology? What if someone uses this very compound, for example, as a research tool and discovers something about its target that could be used to develop an actual drug? What do we call that?
Well, we call that “science”, as far as I can see. Everything is built on top of something else. In a case like this, the discoverers of this current compound, even if they’ve patented it, do not have a claim on what discoveries might come from it later on.
Coverage for thee, but not for me
Ezra blogs about a modest proposal to get universal health coverage passed:
My ace reporting reveals that one element of the health reform strategy Edwards will announce today is a bill, to be submitted on his first day in office, ending health care coverage for the president, the Congress, and all political appointees on July 20th, 2009, unless they've passed health reform that accords with four non-negotiable principles Edwards will detail in the speech. If they don't pass comprehensive health reform, they lose their coverage until they do.
The populists got direct election of senators passed by reforming local state legislature procedures to force support for the 17th amendment in the Senate. In this case, however, methinks that this act would have trouble getting passage. And if it did, that the affected politicians would have little difficulty obtaining coverage from insurance companies fearful of change. But it would probably make good political theater.
Hold the line
Matt says Britain can spend so little on health care because its system really is socialized:
Be that as it may, I think Hanson's observation that "humans long ago evolved a tendency to use medicine to 'show that we care,' rather than just to get healthy" partially explains why things like the UK's National Health Service generate so much bang for the buck. In effect, a highly centralized state run health care system is able to put a cap on how much demonstrative caring can be done through the health care system. Nobody's going to say to his or her spouse, "well, sure we could afford the procedure, but it doesn't really stand up to cost-benefit analysis compared to spending the money on organic produce for the kids" but if bureaucrats stand in your way well, then, that's hardly your fault.
That doesn't actually strike me as a very good model of how American government services work. It is, to be sure, how they used to work; American public goods in the 1950's look a lot like British ones, except nicer, because we were richer. People largely accepted what they got at the pleasure of the government.
But after the legal revolution of the 1970's, American public services look, well, like American ones: unable to deny anything to anyone. What would actually happen in the case Matt describes is that the patient would form an activist group, sue, get the treatment, and use the government settlement to buy the kids organic fruit and a trip to Disneyland.
Harder than it looks
It's rather common to hear those in favor of price controls on prescription drugs argue that the government does all the real research anyway, and the pharmas just steal it and slap their name on the resulting pill; or that the cost of R&D is wildly overblown.
As a counterexample to these two claims, I (well, Derek Lowe, really) give you: Renin inhibitors.
I notice that the first marketed renin inhibitor seems to be doing fairly well. That's an interesting phrase, "first marketed renin inhibitor". . .
This is a good example of what drug discovery can be like. Renin is a fine drug target – it’s been known for a long time as a key component of blood pressure regulation, and that’s a condition affecting a huge market whose treatment provides a real medical benefit. What more do you want?
OK, let’s make it even more attractive. It’s not that hard to set up a renin assay, and the protein is well-studied. The counterscreens and secondary assays are not a problem; hypertension is fairly well understood. And if you screen for renin inhibitors, you generally find chemical matter to start off with, too. Protease inhibitors vary quite a bit in their drug-likeness, but they’re certainly not impossible on the face of them.
But even after all this, I would not like to be asked to count how many renin inhibitors have been reported over the years, never to be seen again. The first reports I can find go back to the early 1980s. Given the lead time for these things, I can safely assume that these compounds were being made around the time I went the my high school Junior Prom (theme: “Saturday Night Fever”, natch – it was 1978, after all). And here we are in 2007, and the first one has finally made it to market. It wasn't easy, either - the compound was left for dead years ago, and was only kept going by some ex-Novartis people who started their own company and licensed the compound back to Novartis when it finally made it through the rough spots.
So, what’s the problem? Many compounds have been done in by poor behavior in living models (distribution, absorption, and so on). Getting oral bioavailability in this area has been a lot harder than anyone thought, and even the current drug is no great winner in that category. Projects start and stop, difficulties occur, and the years go by. And other mechanisms for going after hypertension have, of course, come to market, starting with the ACE inhibitors (which come from roughly the same disco era as the first run of renin compounds). They took the gigantic market that an early-1980s renin inhibitor would have had, but even so, I don’t think a year has gone by since that someone in the industry hasn’t been working on one. (There's still room to think that a renin compound would have a better profile than the existing drugs, though). And here we are: 2007. A sobering thought, that is.
You think too much
I very much enjoyed Jerome Groopman's book, How Doctors Think. I love his writing at the New Yorker. But I am afraid I didn't think very much of the book's thesis, which is that doctors need to improve their clinical judgement rather than relying on evidence based medicines and statistics. "People are not statistics" is sloppy thinking; most of the time, we are. And there's substantial evidence that doctors do best when they treat their patients by the numbers.
Over at eSkeptic, Charles Lambdin voices the same criticism:
Groopman tells us he is troubled that new doctors seem to be trained to “think like computers,” that they rely on diagnostic decision aids and some seductive “boiler-plate scheme” called evidence-based medicine. Groopman’s position, when his various arguments are gathered and assembled, becomes untenable. He admits doctors suffer from innumerable biases that diminish the accuracy of diagnosis, reducing many diagnoses to idiosyncratic responses fueled by mood, whether the patient is liked or disliked, advertisements recently seen, etc. Thus Groopman agrees with decision scientists’ diagnosis of doctor decision making; but then he goes on to wantonly dismiss what many of the very same researchers claim is the best (and perhaps only) remedy, the way to “debias” diagnosis: evidence-based medicine and the use of decision aids. In place of statistics what does Groopman suggest doctors rely on? Clinical intuition of course, the very source of the cognitive biases he pays lip service to throughout his book.
. . .
Most doctors do not like decision aids. They rob them of much of their power and prestige. Why go through medical school and accrue a six-figure debt if you’re simply going to use a computer to make diagnoses? One study famously showed that a successful predictive instrument for acute ischemic heart disease (which reduced the false positive rate from 71% to 0) was, after its use in randomized trials, all but discarded by doctors (only 2.8% of the sample continued to use it). It is no secret many doctors despise evidence-based medicine. It is impersonal “cookbook medicine.” It is “dehumanizing,” treating people like statistics. Patients do not like it either. They think less of doctors’ abilities who rely on such aids.
The problem is that it is usually in patients’ best interest to be treated like a “statistic.” Doctors cannot outperform mechanical diagnoses because their own diagnoses are inconsistent. An algorithm guarantees the same input results in the same output, and whether one likes this or not, this maximizes accuracy. If the exact same information results in variable and individual output, error will increase. However, the psychological baggage associated with the use of statistics in medicine (doctors’ pride and patients’ insistence on “certainty”) makes this a difficult issue to overcome.
The statistics vs. clinical intuition debate has ensued for decades in psychology. Where one sides in the debate is largely determined by what one makes of a single phrase: “Group statistics don’t apply to individuals.” This claim, widely believed, ignores many of the most basic concepts of probability and statistics, such as error. Yes, individuals possess unique qualities, but they also share many features that allow for predictive power.8 If 95% of a sample with quality X has quality Y, insisting that someone with quality X may not have Y because “statistics don’t apply to individuals” will only decrease accuracy. Insistence on certainty decreases accuracy. As Groopman himself says, the perfect is the enemy of the good.
. . .
Physicians who allow themselves to think in such discretionary ways can find “exceptions” everywhere they look, and, augmenting a decision aid as they see fit, will only end up lowering its overall diagnostic accuracy. Why? Because human beings do not apply rules consistently. Mechanical procedures always lead to the same conclusion from the same input. Doctors are subject to random fluctuations in diagnosis caused by judgmentally-irrelevant factors including availability, priming, recency effects, inconsistent weighting of information, fatigue, etc., all of which reduce accuracy. What leads to a correct decision for one case may not for another, and variables that contribute to the diagnosis made may actually be uncorrelated with it.
This is hardly restricted to doctors. Every profession resists being told that there is a standard way to do things, that a cookie cutter can cut better than their skilled hand. Journalists famously hate the "inverted U" style of writing a news story, even though it really does seem to work better than anything else; it's boring to write, and leaves no room for individual style. Teachers don't like "teaching to the test" or rigidly programmed phonics curricula, even though the latter produces measurably better results than all but the very best teachers. Unfortunately, for many of us, it may be time to welcome our new robot overlords.
The good news and the bad news
Peoples' incomes improved markedly in 2006; the poverty rate dropped, and household income marched upwards.
On the down side, the percentage of Americans with health insurance dropped rather precipitously, from 84.7% to 84.2%. What happened?
Well, the numbers do tend to jump arund, especially with the business cycle. But we're in the very late phases of an expansion, if not a recession; why should insurance coverage still be falling? Forget the fluffy AP stories; let's go to the tape.
The percentage of Americans covered by private insurance has been falling for a while, now. That's not some grand conspiracy of business owners. In part it's due to companies dropping people, but a sizeable chunk of the change is simply due to programmes like S-Chip, which encourage families to drop their coverage; and an ageing population transitioning into Medicare.
The public sector dropped pretty sharply last year, but not nearly as steeply as the government. After rising steadily since 1999, the percentage of people with government coverage dropped by 30 basis points. Out of a total increase in population of roughly 3 million, the private sector, which usually insures about 800,000 new patients a year, only insured a little over 500,000 new patients last year. That's a big drop. Meanwhile, the government, which generally insures a million or more new patients last year, this year took on . . . about 53,000.
The big slowdowns were in military healthcare, and in Medicaid. So at a glance, we're looking at two factors: state governments cutting back on Medicare spending, and the recruitment and retention shortfalls in the military, which mean fewer soldiers and dependents in the military healthcare system.
The other interesting detail confirms an ongoing story: immigrants. The percentage of native born americans with coverage dropped by 40 basis points last year; but the percentage of the foreign born without coverage dropped twice as fast.
What about public health?
I was going to get to this later, but a couple of people have brought it up, so let's get it out of the way now: what about the sewers? Or vaccination? Or the many other public efforts that have made people well?
Those efforts are justified on a completely different moral logic than something like single payer. Because of the way that disease spreads, things like sewers and vaccinations are a genuine public good. That is, they have significant positive externalities from which your neighbours cannot be excluded. If I get vaccinated, that lowers your chance of disease, even if you don't get a vaccination. Likewise, if I treat my sewage, you become less likely to get cholera, even if you don't treat yours.
As long-time readers of my old blog know, I'm pretty harsh on people who don't vaccinate (or use sewers, either, though that one hasn't really come up). The problem with vaccines is that they've been too effective; effective enough that parents are (rightly) more worried about a small risk of side effects from a measles or polio shot, than they are about the risk of blindness, heart disease, or paralysis. That tempts them to free ride on other parents who do vaccinate.
As an individual, that's the smart strategy, but socially it's disastrous, since it destroys the compact by which we keep infectious disease at bay. Also, once there's a new reservoir of unvaccinated kids, their free ride becomes not that free.
But treating infectious disease to keep it from spreading is in a different moral category from a universal health care system. Curing my asthma will not protect the people across the street, or America, from danger.
Sick of being sick
A commenter responds to my last post thus:
People don't have a right to money from society simply because they have gotten sick.
I disagree. Now what?
Well, obviously, at some level we're just going to have to agree to disagree.
But it raises some interesting questions. Why do you disagree? If we should give money to sick people regardless of need, is it because being sick sucks and we're giving people bonus payments for having sucky things happen to them? If that's the case, why don't we give people bonus payments for, say, being really ugly, or being severely socially awkward, both of which seem at least arguably worse than, say, having chronic asthma.
Also, if they deserve money just for being sick, why give them the money in the form of healthcare? Wouldn't a cash transfer be even better? Then the people who wanted to be treated could spend the money on healthcare, and other people could spend the money on something they valued even more than healthcare. It seems like a Pareto improvement in net happiness over a simple single-payer system.
Finally, if they deserve money just for being sick, why don't we peg the money to the suffering the disease causes, rather than the cost of treating the disease? Inquiring minds want to know.
Attack on all fronts . . .
Brian Beutler doesn't understand why I find flipping back and forth between arguments so annoying:
See, I don't find this tendency annoying at all. In fact, one of the things I like best about being in an argument is when I can win that argument on a handful of different grounds. For instance, I can make both efficiency and morality claims about torture, the death penalty, profiling, health care, and the Brian-deserves-more-free-money initiative now making its way through Congress, and my argument is all the firmer for it. And I should add that keeping in mind both efficiency and morality is an obviously excellent way of picking a health care system, or for that matter any other system that depends on both efficiency and morality to be effective.
What actually is annoying is the tendency of one's opponents in a multi-flanked argument to complain that the war is being fought on too many fronts instead of either hitting back strongly, or, more preferably, ceding the point altogether.
The problem is not that the arguments are multi-flanked; it is that the multi-flanked argument becomes a way of avoiding conceding any particular point. Just as you have pinned down the crux of some particular efficiency argument, your opponent says "Well that doesn't really matter, because what I'm worried about is the morality of it." Then, when you look like you might be winning a point about morality, your opponent suddenly says, "Well, that doesn't really matter, because my system is more efficient!" Aggregate claims have to consist of propositions that are individually true, but this sort of argumentative style prevents us from ever determining whether they are, or not.
Obviously, if you're trying to defend a predetermined position, this is a feature, not a bug. And it's certainly a bipartisan vice. But it makes the debate pointless, especially since I can play, too! The result is that we go around in circles, reassuring our echo chambers of like minded supporters without ever having any sort of productive discussion.
Multi-flanked arguments are fine. In the case of health care, they're even necessary; health care, after all, is only a means, so you have to know what ends you mean to establish. But to make a sound aggregate argument, you need to examine each of the pieces separately before you aggregate them, particularly if not all of the pieces have buy in from the other side.
At this point, I'm simply trying to nail down some small priors before proceeding. Those priors are:
1) People don't have a right to money from society simply because they have gotten sick; to the extent that they have a right to health care, it is that they have a right not to die or suffer from lack of funds.
2) The distributive justice claims for single payer are, on the advocates side, stronger than the efficiency claims. They would prefer a single payer system that is less efficient than the current American system, to efficiency improvements in the current system that did not cover the 45 million uninsured people. I know (I KNOW!) you think that single payer is both more efficient and more just. I'm simply trying to establish a rank ordering of priorities.
These are the first building blocks of an argument about single payer. I don't actually think they're really controversial, if you stop thinking eight moves ahead. Does anyone prefer their efficiency claims to their distributive justice claims? Do you think that we should give Warren Buffett money for health care, not as a side effect of arranging the most efficient transfer of resources to the needy or otherwise deserving, but as a moral end in itself? Is anyone prepared to argue that Warren Buffett deserves a special bonus from society--tens of thousands of dollars worth of health care--just because he's old?
I don't think anyone does believe these things; or certainly not many people. People are treating fairly straightforward propositions as if they were trick questions. They're not. I'm just trying to frame the argument in a pretty neutral way.
People are also acting as if I believe that, by nailing down these first points, I have made some sort of comprehensive argument against single payer. Obviously not. Such an argument is far larger than a blog post could manage (which is why I'm doing it in baby steps). Thus, many of them respond "But single payer is awesome!", when I haven't gotten anywhere near a discussion of its relative awesomeness to other possible systems. At this point, I'm just trying to lay out the criteria by which we might one day evaluate its awesomeness.
Let us agree (how) to disagree
Says Ezra of my health care posts:
It relies on unproven and incorrect premises ("Most advocates of single payer, I think, care most about this justice claim. They may also think that they can make the system more efficient, but if one could somehow prove scientifically that a private system would be cheaper and better, they would still favor a public system as long as a substantial population remained uninsured); brackets the argument about efficiency then pretends it doesn't figure into reformer's claims; radically overstates individual culpability for illnesses; elides the fact that living a healthier life just means you die from something expensive later; mistakes an intergenerational compact (wherein each generation pays for the next, rather than making a one-time transfer) for charity; and appears to miss the fact that Medicare already exists, and so single-payer would not mean more resources would be transferred to the old, thus obviating the central point. And that's just a partial list!
It's hard to argue with vague generalities, but here goes,.
I could be wrong about the first claim, but if so, I would like to hear from a large number of single-payer advocates who will say that if the American system could be proven to provide higher quality care per dollar on average than other industrialised system, then they would be content to leave 40 million people uninsured.
The second claim isn't so; I don't pretend that efficiency doesn't factor into reformer's claims. I just left it off because health care is too big a topic to be attacked in one post. I have, as Ezra knows, in the past addressed efficiency claims; I will again in the near future.
But in health care, as with so many arguments, there is an annoying tendency on all sides to shift back and forth between arguments. One starts by arguing about morality (when is society entitled to take money from one group of people to give to another, and how much), and your earnest young policy reformers says "But what really matters is that it's more efficient!" Then you start to argue about efficiency, and suddenly your opponent says "But what about the suffering old people?"
This is not a good way to pick a health care system, or much of anything else. One should establish some first principles, and then use them to generate a health system which will hopefully maximise them. If you simply accept, as received wisdom, that a single payer system is either good or bad, and that people who disagree with you are immoral cretins, then there's not much point in our arguing.
But if you don't accept that then presumably the object of this discussion is (at least theoretically), not to simply find which argument is tactically most superior at the given moment to support your position; it is to establish the first principles and empirical data from which we will reason to a conclusion. And then try to reason to a conclusion.
Which is not to say that we will agree. Ezra and I will almost certainly not agree; we hold different priors about things like autonomy, individual rights, and government efficiency. Both of us have already reasoned to a conclusion from which, barring substantial new evidence, we will probably not budge. But we can at least flesh out our areas of agreement.
So that post was an attempt to establish, at perhaps unfortunate length, the first prior of my argument: that the old and/or sick are not entitled to get money from other people simply by virtue of being old and or sick. They may be entitled to get money for health care for other reasons: because they are needy, or because they were promised that care (or should have been promised that care) in exchange for joining the military. Or other reasons we might argue. But merely having aged, or gotten sick, does not in and of itself give you a moral claim on society; as I said in a prior post, Warren Buffet doesn't deserve to have my dry cleaner buy him health care simply because he is older and sicker.
That does not, as I think I repeatedly said, necessarily mean we shouldn't have single payer. It simply undercuts a particular argument in favor of single payer: that society has a duty to care for the sick, full stop. Society also has a duty to clothe the naked and feed the hungry, but we have successfully outsourced most of that duty to Green Giant and Calvin Klein.
But I am not claiming that this is the only, or even the main, argument deployed by advocates of single payer. I'm just trying to put it behind us, so that once we are talking about something else, I don't have to deal with someone saying "But . . . but . . . they're sick!." I am laying the burden on my opponents to convince me that the people we are helping are not merely sick, but also meet some other condition, such as need, that entitles them to the transfer.
I am well aware that Ezra and others are trying to make a sort of "Sick+" argument in favor of single payer. In order to help those who are needy, they say, we have to have single payer, because of problems with the way that medical markets work. I disagree, for reasons I will lay out presently. But I am certainly not under the impression that I have already refuted those arguments (at least not on this blog. I've just tried to map the boundaries of the dispute. Because I do, fairly frequently, have single payer advocates pounding on the table asking why I don't want to help sick people?
As for the rest of it, it confuses sufficient with necessary conditions (I don't need a lot of sick people to be very responsible for their conditions; I just need a few to be partially responsible, since in aggregate, the unsick are not at all responsible). The bonus random reference to healthy lifestyles is a rejoinder to another, different argument about cost-benefit analysis that I was not making.
It assumes an agreement about intergenerational compacts that I find dubious and do not share--to the extent that there are society-wide intergenerational duties, I think they run one way, from present to future, and involve a) conserving a common stock of resources and b) not bequeathing them debts. That means the government shouldn't run a deficit other than in times of war, and it also shouldn't promise expensive benefits to be paid out of the pockets of people who can't yet vote, or indeed breathe.
And it ends with a claim about Medicare that I've seen before, but which I find extremely odd. People don't magically start getting sick when they turn 65. The near old, those in their late fifties and early sixties, also consume a decent amount of care. Moreover, any single payer system I'd envision would cover nursing home care and prescription drugs and home health care workers, for which many seniors currently pay a substantial sum out of pocket. It's hard to envision how a single-payer system could fail to increase the net social transfer from young to old, though I agree with Ezra that that transfer is already large.
How low can you go?
In discussing health care, one often hears about how low America ranks on the WHO survey--37th in the world! This is true. But there are a couple of problems with it.
First of all, that survey is getting a little elderly; it hails from 2000. In the normal course of economics writing, that's pretty dated; my editors at The Economist would never have let me discuss health systems using a ranking that outdated. In general, an economics writer has to have a pretty darn good reason for using data more than a couple of years old.
Also, as John Stossel notes, many of the measures it uses, such as life expectancy, may be exogenous to the health system:
The WHO judged a country's quality of health on life expectancy. But that's a lousy measure of a health-care system. Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That's not a health-care problem.
Similarly, our homicide rate is 10 times higher than in the U.K., eight times higher than in France, and five times greater than in Canada.
When you adjust for these "fatal injury" rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation.
Now a liberal might argue that crime and auto accidents could be resolved by other items on the progressive agenda. I disagree (for starters, from what I understand, America's higher homicide rate long predates the emergence of the European welfare states), but that's a legitimate argument in favour of a broader progressive platform. However, it undercuts the belief that single payer is going to magically improve things.
Other indicators seem almost cherry-picked to make America drop down on the rankings. Equality of distribution, for example, is heavily weighted; so heavily weighted that quality of basic care suffers in comparison. That's why places like Morocco, the Dominican Republic, and Costa Rica clean our clocks.
Now, personally, I don't really care about equality of distribution per se. I don't care if Bill Gates gets super-awesome treatment; what I want to know is, are people suffering and dying from lack of care?
Obviously, those things are linked, and it's not unreasonable that an egalitarian would put that on their list of criteria. But one would hope that the WHO rankings would reflect, to a first approximation, where you'd rather get sick. Does anyone really think that they'd rather be the average consumer of health care in Colombia, than in Columbus, Ohio?
But what about the worst off, you might say? What about them? The WHO table isn't even a good ranking of where I'd prefer to be poor. I'd far rather be an uninsured day laborer in San Francisco, than in the Dominican Republic. For that matter, I'd rather be uninsured anywhere in the United States than an average citizen in Costa Rica.
This is a problem for those touting our low ranking. I can't say I know what our ranking should be; a lot depends on value judgements that it would be hard to gather consensus for. But whatever our true ranking is, I'm pretty sure we're not behind a significant chunk of Latin America. You don't see a lot of uninsured illegal immigrants trying to get home for the awesome health coverage.
Another bad argument in favor of single payer
Many of my commenters have responded to my posts on single payer by saying: but the young and healthy will someday be old and sick!
Why, yes, they will. But why is that a good argument for taking money from them to give to old sick people, on the promise that some future young healthy people will give them money?
Morally, I don't see how the fact that I will be old and sick gives currently old and sick people a moral claim on me. Had I known, a year ago, that I was going to move permanently to DC, would that have justified the DC government in taxing me last August, on the grounds that in the future, I would be a resident of DC?
As an argument for single payer, this is even worse; at least some of the people who would have benefitted from my taxes last August will be paying taxes this August to help give me roads. The transfer inherent in single payer, on the other hand, is largely non-overlapping. The class of currently old and sick people (Class A) is justifying a transfer from the class of currently young and healthy (Class B) on the grounds that a future class of young and healthy people (Class C) will eventually make a similar transfer? So can I demand that you buy me lunch, on the grounds that at some point in the future, someone, somewhere, will probably do as much for you?
Now, let's think about those transfers. One of three things must be true:
1) The transfers from Class B will be the same size as the transfers from Class B. This is lunatic; Class B could simply spend the money on themselves.
There is a question of what to do if you live in a society that has, for whatever reason, already implemented such a stupid scheme. Morally, I think it is obvious that you do not dump those who contributed to it in good faith; but morally, I think it decidedly unobvious that the right thing is to keep the thing going. In general, the current generation should minimise the binding committments it hands to future generations, not least because what if the future generation decides it isn't so binding?
2) The transfers from Class B will be bigger than the transfers from Class C. Given that Class A seems no more deserving than Class B, this seems straighforwardly immoral.
3) The transfers from Class B will be smaller than the transfers from Class C. This is more complicated, because economic growth enters the picture . . . but by what right does Class A claim resources from Class B by committing Class C to repay its claims, with interest?1 Particularly since current trends show health care expenditure growing much faster than the economy as a whole.
In other words, either we are trying to get rich by picking our own pockets, or we are unfairly taking from someone in order to give goodies to those who are now old and sick.
I want to emphasize something though: I'm talking specifically about a moral argument in favor of a single-payer financing arrangements. I'm not talking about "the morality of providing healthcare" or "the morality of caring for those who cannot help themselves". I think that the debate over single payer healthcare frequently features an underlying assumption that the old and sick are, by virtue of being old and sick, thereby automatically entitled to have someone else give them the rather large amount of money implied by a mandatory single payer subsidy. This seems unconvincing to me.
There are good arguments in favor of single payer, most of them having to do with market structures, which ultimately try to prove that we cannot accomplish moral ends that I think are at least arguably justified without erecting a giant single payer system. I find those arguments ultimately unconvincing, for reasons I'll elaborate next week. But I think they are at least arguable, unlike the premise that Warren Buffet is entitled to have his prescriptions paid for by my dry cleaner simply because Warren Buffet happens to be in worse health.
1 But what about the budget deficit, I hear you cry? Yes, I quite agree. Except insofar as Classes A & B are using the money to secure the vital interests of Class C . . . by, say, fighting World War II . . . I'm against deficit financing. I don't think it mattes economically very much, but morally, I'm with you.
Good question
Medpundit asks:
Why do people think that a single-payer system would be any better than Medicare or Medicaid? The way things work now, Medicare gets the gold (more political clout in the over-65 population) and Medicaid gets the shaft (absolutely no political clout in that population).
The morality of health care finance
I think this post wins the prize for boringest title ever. Also, it seems to be roughly one squintillion words long. But stay with me. This is important.
A post from my old blog on the morality of healthcare transfers has attracted an amazing amount of ire from the liberal bloggers and commenters flocking to complain about how evil I am. Most of them, in the course of criticising it, display what seems to me like an Olympic-caliber ability to miss the point. However, given how many of them did not understand what I was saying, it seems likely that I was more in error. Let me see if I can clarify.
There are some arguments that the market for health insurance is different and special, and therefore can be best provided by the government; I find those arguments unconvincing, for reasons I will explain another time. But that is not really an argument about the moral merits of the system; it is a claim about efficiency.
In discussing the morality of a single-payer system, those efficiency considerations are irrelevant. In discussing the morality, one thing matters1: who is made better off, and who worse off, by the system?
Most advocates of single payer, I think, care most about this justice claim. They may also think that they can make the system more efficient, but if one could somehow prove scientifically that a private system would be cheaper and better, they would still favor a public system as long as a substantial population remained uninsured.
But wholesale transfers to large classes, from large classes, are not good moral philosophy unless those classes are very well specified to the moral effect you are trying to achieve.
For example, we could take money from taxi drivers and give it to surfers. Some of the taxi drivers would be bad people who don't deserve their money; some of the surfers would be sterling chaps whom society has failed to justly reward. But still, we all2 recognize that this would be moronic, because virtue and vice are fairly randomly distributed within and between the two populations. There is no reason to think that on net, we would have enhanced social justice.
Now, Ezra's original post criticized Giuliani's health care plan on the grounds that it will transfer less money from young, healthy people to old sick people:
If you're healthy, a world in which Giuliani's plan was law would be a world in which it was economically foolish of you to purchase high quality, comprehensive coverage. And that would be fine -- for the healthy individual. But insurance works based on risk pooling. If our hypothetical 23-year-old only uses $10 of health care a year, but is now paying $80 rather than $100 for his plan, that's less money that can subsidize someone with a chronic illness.
This post makes what I think is a very common assumption among single-payer advocates.
A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick. It does not distinguish much more finely than that between the deserving and undeserving within that class. This is why discussions of particularly deserving or undeserving people within the larger class, such as your fine old Uncle Bob who served his country in two wars before becoming a minister, are irrelevant; as with the surfers and taxi drivers, almost any class we can specify will contain some very worthy members who deserve more from society than they have gotten. What we need to know is whether the class of old and sick people as a whole are much more deserving than the class of young and healthy people; whether our transfers do more good than harm.
Single payer advocates seem to invariably assume that the answer is yes. This is a natural reaction; the old and sick inspire our sympathy. But I am not sure that, as a group, they should also summon our sense of social injustice.
How do we decide which class is more "deserving"? Our intuitions offer dozens of ways, but I think these are the major metrics:
1. They are needy. The class we propose to benefit has greater need for the money than the class from whom we propose to take.
2. It's not fair. The class we propose to benefit has been unluckier than the class from whom we propose to take.
3. They are responsible. The class from whom we propose to take has in some way contributed to the problems we are trying to rectify.
How well do any of these describe the old and sick en masse?
Continue reading "The morality of health care finance" »
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