Several mainstream bloggers ("mainstream bloggers" - has it already come to that?) have been talking about universal health coverage, the lousy system in the US or some variation on the theme the past 10 days or so. Much of the subject matter may be wonky, but these are not health geeks so it's very interesting to see the debate unfold and it's interesting to note that it's going on now.
The summary version? In both cost and outcomes, the healthcare system in the US compares rather poorly to the systems in other Western countries. Some go the next step, describing the systems in particular countries and, in a couple of cases talking about what to do. We'll pick those up later.
This is a long post, especially if you follow the links - and even better to get the flavor - check some of the comments at those links. That's what happens when you're trying to connect the dots. This is but an introduction.
If nothing else there are some interesting personalities here. So enjoy them. My apologies to those who I left out. Here are some highlights for now.
Mixed in with a bunch of sports talk and triggered by his sister's inability to get coverage, Matt Welch seems to have kicked it off with America's Lousy Insurance System and the Expectation of Wealth.
What I still can't understand, is how anyone -- seriously, anyone -- can think a system where it is extremely difficult for a perfectly healthy young person untethered to an insurance-providing job to obtain health insurance without lying, or without giving up the possibility of having childbirth covered, is a good system. Sure, it can be one helluva system for the folks who can afford it, or who have jobs where these kinds of problems don't come up, or who think that lying is a normal part of everyday life ... but there are reasons other than laziness and lack of imagination that at any given time 10 percent or more of the U.S. population is uninsured.
What I understand even less is how some of these same people will tell you with a straight face how terrible French health care is. Last Thursday-thru-Saturday, we spent a really wonderful time at "Reason Weekend," which is what my employer does in lieu of a celebrity booze cruise. It's a great event, filled with smart donors to the Reason Foundation, various trustees, and a few people from the magazine. Great speakers, panels, walks on the beach, etc. Anyway, we had some small discussion group about De Tocqueville, and someone (naturally) brought up France's high taxes and thick welfare state. "Well, the thing is," Emmanuelle said (quotes are inexact), "some of the things the French state provides are pretty good. For instance health care."
"Wait a minute wait a minute," one guy said. "If you were sick -- I mean, really sick -- where would you rather be? France or the U.S.?"
"Um, France," we both said.
Various sputtering ensued. What about the terrible waiting lists? (There really aren't any.) The shoddy quality? (It's actually quite good.) Finally, to deflect the conversation away, I said "Look, if we made twice as much money, we'd probably prefer American health care for a severe crisis. But we don't, so we don't."
Not to be too much of a classist here, but it struck me then that part of the failure to communicate is a logical consequence of the expectation of wealth. Which is to say, of course the health care is better for people of means, so therefore of course it's better. Expanding beyond health care, this is actually a theme you can see every day, if you look for it -- rich or at least well-off people telling the po' folk how they should behave, and/or how they should interpret the difficult choices they make.
Ted Barlow at Crooked Timber then quoted pretty much the same that I just did in "(cough)," but it generated a lot of comments (over 70 when I looked).
Following the cookie crumbs, we get to Kevin Drum who tees off:
Hell, I make more money than Matt and if I were really sick I'd rather be in France too. I've read quite a bit about France's healthcare system and it's effin great. To put it in a nutshell, you can pick any doctor you want, the quality of care is high, the doctors themselves seem pretty happy with the way it works, and the overall cost per person is half what the American system costs. Plus it covers everyone in the country, not just 70% of them.
But all you hear about in America is that you might have to wait six months for hip replacement surgery. And indeed you might. But that's because hip replacement surgery is usually pretty low priority stuff. On the other hand, if what you need is either routine medical care or else urgent treatment for something like a heart attack — that is, the stuff that makes up 99% of actual real life medical care — France is great.
I've long thought that the spectre of "socialized medicine" is the greatest con ever perpetrated on the American public. Think about it. Suppose you were constructing a healthcare system from scratch. Choice #1 is national healthcare along the lines of France or Sweden. (Not Britain. Their system kind of sucks.)
Choice #2 is this: if you're employed, your employer might provide you with healthcare coverage of some kind. Anytime you change employers or your employer changes plans, your coverage and your doctor will change too. If you're unemployed, or you work for Wal-Mart, you get nothing — though in a pinch you can always show up at an emergency room, which is perhaps the most expensive way of delivering healthcare known to man. If you're poor, there's a shabby government program that will sort of cover your kids, but probably not you. If you're over 65, another government program will cover some but not all of your medical expenses. And all of this will cost us about 14% of GDP, far more than any other industrialized country on the planet.
All right so far.
That same day Krugman weighed in with Ailing Health Care (sorry, excerpt only). He says we're facing a crisis. In particular he notes that the costs of Medicare and Medicaid are rising faster than GDP per capita (we believe that to be an exceeding important point). He also challenges the belief that "government is always the problem and market competition is always the solution."
Stirling Newbury welcomed Krugman to the fray with another economic perspective:
The basic reality that Democrats should be taking on is this: competition is good, the health care system, because it lives in the protected economy is not facing the same competitive pressures that manufacturing and high tech are. Where the market cannot provide competition because of immobility of service, the government must enforce competitive levels of cost reduction. Right now, health care is not facing competition from abroad, and this means that health care providers have much more pricing power than anyone else.
I can remember when the Decembrist was writing about almost nothing but medicare costs and health care costs. The present situation of health care in the US is a complete vindication of his view that this is the critical service delivery problem over the next decade. Mark was right, and finally the public debate is recognizing it. A lot of people should be thanking him for being ahead of the curve.
Tim Worstall at Tech Central Station took a different course in Health in the Balance, criticizing Krugman for what he considers to be obvious regarding employer health costs.
Referring to General Motors' health benefit costs, Worstall says:
Now assuming that the CFO of a company is both sentient and honest when a man walks into the office and says we're going to stick the taxpayer for one of your major costs, of course they will say yes..
That may be true today, though most of those CFOs still won't fess up to it in public. But it was certainly untrue for decades. This is likely to be one of the key changed vulnerabilities of those who would rather go without some form of universal coverage. It will also be interesting to see how this issue plays out with small business.
Unfortunately Worstall goes on in this manner:
This is where I think the bait and switch will come in, for he (Krugman) has, as above rightly praised the French system. Yet the French system is not a single payer at all. The compulsory insurance element collected through pay packets pays for only a portion of treatment costs (35-65% on prescriptions, 70% in general, except in some exceptional circumstances like cancer treatment). There are myriad private insurers who offer a variety of plans to cover un-reimbursed costs and sometimes the extra costs that can be charged over the prixe fixe. One could with a straight face actually state this is less generous than the current Medicare and Medicaid systems in the US ...
What worries me is that the Professor will point to a decent system, that of France, and use it to propose a terrible system, that of the UK.
Well he winds up in an interesting position, praising the French system. But accusing someone of a "bait and switch" based on what you think they're going to do is pretty chintzy.
Worstall also noted that "as soon as Krugman's article came out the left side of the blogosphere lit up (health reform is, as we know, one of the great hopes of liberal and progressive America)." That, he got right.
Krugman followed up (on tax day of course) with The Medical Money Pit.
A dozen years ago, everyone was talking about a health care crisis. But then the issue faded from view: a few years of good data led many people to conclude that H.M.O.'s and other innovations had ended the historic trend of rising medical costs. Before I get to the numbers, let me deal with the usual problem one encounters when trying to draw lessons from foreign experience: somebody is sure to bring up the supposed horrors of Britain's government-run system, which historically had long waiting lists for elective surgery. In fact, Britain's system isn't as bad as its reputation - especially for lower-paid workers, whose counterparts in the United States often have no health insurance at all. And the waiting lists have gotten shorter. But in any case, Britain isn't the country we want to look at, because its health care system is run on the cheap, with total spending per person only 40 percent as high as ours. The countries that have something to teach us are the nations that don't pinch pennies to the same extent - like France, Germany or Canada - but still spend far less than we do.
Triggering over 100 comments, Kash at Angry Bear pointed to Krugman's op-ed and began a series of postings on how poorly the US compares to other healthcare systems:
The data very consistently shows that the US does not have a very good health care system when measured in terms of the health of its people, or when measured in terms of how its citizens feel about the health care they get... and it has a horrible health care system when these mediocre outcomes are juxtaposed with its astronomical costs.
He provided one table ...
But this is just a sample; there's virtually no metric in which the US health care system provides better care than those of other countries, other than in care for the very rich. The reality is that the average person in the US receives mediocre care that is extremely expensive.
And he followed up with this on the performance of the US healthcare system. Kash's third post, on what do we spend the money on, provided LOTS of comparative data presented graphically. Good stuff.
Ezra Klein pointed to Kash's postings and said:
Kash has a great post comparing America's health care with those of other developed nations. As you all know by now, our system's report card lands us in the remedial classes. There's virtually no metric that, when compared to other wealthy nations, we don't languish on the tail-end of. Kevin follows Kash with another great post comparing our house-of-horrors system with the far-superior French model. France is the way to go if you want to sidestep the (way overblown) pitfalls of Canadia Care (as I like to call it) and the total mess that is Britain.
In the same post, Klein also pointed to Kevin Drum and added:
As a final point, Kevin's post touches one of the deep fissures in the health care debate. 43,000,000 Americans lack health insurance. That's 70% of Bush's total vote. Now, a bunch of them are children, but even so, that's an enormous constituency. Were they voting as any sort of a bloc, which you'd expect a group tied to the enactment of a certain policy to do, they'd own the political system. But since they're mostly poor and disproportionately young, nobody listens. (Sorry to say Ezra, but the numbers and the politics may not quite work that way. The uninsured may be equivalent to 70 percent of Bush's vote. And it's true that there are a lot of red states with high proportions of uninsured - start with Texas which has the highest percentage, but it wasn't likely 70 percent of Bush's actual vote. Nevertheless, there may be some political potential here. There are over 36 million uninsured adults. That's over 84 thousand per Congressional District. They're not distributed evenly and they're not all voters. So the challenge is to find districts in which uninsured adults can be registered, be organized on this issue and vote in elections where their voting will make a difference. JWR)
Matthew Holt also followed Krugman, saying it was great that Krugman was weighing in:
There's nothing new or original that THCB readers or Health Affairs readers won't already know. We spend more and basically get less, but we lead the league in surgeons driving Porsches. But it's very good that someone is raising this issue outside of pure policy wonk circles. Even Krugman seems stunned that our government spends so much more per head than other governments which cover all their people, and all we get for it is Medicare for seniors and crappy coverage for the very poor. And by the way those numbers don't count the role of the Feds and states as employers paying for health care coverage for 10 million government workers--if you add that in, the government share of spending is higher (although that math doesn't really matter as we don't cover any more people because of which column you put the spending in).
Don Johnson at the Business word blasted Krugman saying:
Paul and his friend Uwe see the world from the perspective of hard left socialists. I see it from the perspective of someone who has written about health care markets for almost 30 years and believes in regulated free and diversified markets. We get our health care from a collection of industries. There is no health care system, which is one of the great things about health care in this country. We have choices and the freedom to experiment that are not seen in any other country.
Such choices and freedoms add to our costs and the added cost is worth it in so many ways. (There is no health care crisis. Health care is a booming industry, people have the money to buy care, they’re getting great care and health care is labor intensive. It creates jobs, only a few of which can be outsourced to India.)
As usual, Paul picks the stats that build his case and ignores reality.
He says that Krugman ignores:
- The high pay of health care workers, "not just docs" which accounts for 60 percent of health care expenses and the effectiveness of medical professionals.
- The "strong correlation between individual and national wealth and health care spending and consumption.
- America's "politics and geography are so different from the rest of the world that comparing our economy and health care markets to those in other countries tells us little, if anything.
He closes by saying that Krugman may be an economist, but "he
doesn't believe in markets" and ... he knows nothing about them. He
goes on to say that Krugman is a "propagandist determined to bring Bush
and the GOP down, but he's so blatant about it nobody but the hard left
gives him any credibility. And he closes by talking about how unhappy
Canadians are with their health care and that "no country is happy with
its health care."
Ummm. Where to start with that? Let's start with Matthew Holt criticizing Johnson, in a fashion that was more restrained than I probably would have been.
I like Don Johnson's blog Businessword but sadly when you really push him, as I've done in his comments over the last couple of years, he either won't answer or his answers reveal a political philosophy that is downright mean. So in his criticism of Krugman's analysis on his blog and in comments at THCB here, Don essentially says that if you're poor or sick in America, well that's just tough titties. And, as a by product, it's OK for the insurance market to screw over those who really need individual insurance because, well, because it's a "market". Same way it's OK for Enron to defraud the California rate payer, or same way it's OK for Healthsouth to defraud its shareholders. After all they're operating in "markets" too. But Don misses the wider point. Because of the way the US system is set up -- because we're a richer country than any in Europe, and because the majority of people can afford to pay way too much for our health care -- we systematically overpay for things that no rational market would value. That does not help our economy, it hurts it as most health care spending is non-productive to the overall economy.
Well, maybe he wasn't that restrained. Right as usual though.
Matt Singer from Left in the West talks about Mandatory Health Insurance: The Libertarian Solution. Referring back to Welch, he says: "he doesn’t really think socialist health care or socialist health insurance works better than a good system could work, merely that it works better than our crappy system." There are a number of important points in that post. But most of them have to do with what to do. So we're going to return to them in another post.
Kieran Healy at Crooked Timber reposts some data that he had previously commented on and noted that:
... these data do not include (his emphasis) any health-related Research and Development spending, so it’s not the case that the U.S. is way up in the top left simply because it’s generously subsidizing everyone else’s research costs.
The figure doesn’t show it, but it’s worth noting that despite not having a national health system, U.S. public expenditure on health in the 1990s was higher in terms of GDP than in Ireland, Switzerland, Spain, Austria, Japan, Australia and Britain.
Both are useful points.
He also drops a political zinger:
It’s easy to see that mainstream debate about health care in the U.S. happens inside a self-contained bubble, and that one of its main conservative tropes—the inevitable expense and inefficiency of some kind of universal health care system—is wholly divorced from the data.
So I guess we're left with a battle of anecdotes. Data reliant geeks like me are doomed.
Dr. Roy Poses offers a different angle on Canada, one that has more to do with governance than money
In Ontario, hospitals often have to guess what the government will set as their budgets, then run for most of the fiscal year based on the guess, only to find out at the end of the year that their guess was wrong. The provincial government may then blame the hospital for running a deficit based on a budget the hospital had never actually seen. So that's one reason why the head of the Ontario Hospital Association called for a new system, claiming the current one "would be better suited to a Monty Python movie." This is just a reminder that organization and governance of health care may be even more important than financing. But in the US, financing receives much more attention.
Pandagon in No Market started by saying "healthcare is not a true market ... and it shouldn't be treated like one." I used to say things like that. Now no. First off, it's not a single market. It's a complex interacting set of markets. It's impaired It's flawed. Much of the market competition is distorted by insurance and other factors. But there are markets here and the competition is fierce. He goes on:
But healthcare is entirely premised on this idea - those with money deserve a better quality of life in a system where having money actually allows you to reduce the cost of attaining it. If you have enough money, you can purchase insurance which allows you to reduce the cost of healthcare drastically, whether in absolute dollars or as a percentage of your income.
Correct. And add the following ... while your costs are being reduced because you have insurance, the total prices of medical services are being bid up making them more difficult to afford for the uninsured. Then as the cascade continues, the cost of coverage goes up, creating an even higher barrier for those outside the system.
Kevin Drum returned to the fray with a link to Kevin Healy's review of the new book by Susan Sered and Rushika Fernandopulle, MD, Uninsured in America: Life and Death in the Land of Opportunity (Amazon Link). A couple of months ago I colleague I respect asked why dropping dental coverage from Medicaid was such a big deal. Let's start with Drum's quoting from the review:
Rotting teeth are a consistent motif among their interviewees, and with a poignancy not often found in policy books, the authors peg tooth decay as a reliable barometer of ones employability and caste status. As one uninsured woman who works part-time in a call center (and therefore out of public view), tells them: "I've gotten toothaches so bad, so that I just literally pull my own teeth. They'll break off after a while, and then you just grab ahold of them, and they work their way out ... The hole closes itself up anyway." As the insured reader guiltily and involuntarily runs his tongue over his teeth upon reading these lines, the authors' caste argument essentially proves itself.
And there's plenty more where that came from, as the authors present through their subjects a laundry list of ominous examples of untreated suffering, ranging from gallbladder disease to diabetes to asthma, addressed alternately by hopeful neglect and homemade cocktails of alcohol and over-the-counter pain medication — or in the harrowing case of an Idaho man with recurring bone spurs in his feet, a power sander.
Even from a purely physical perspective, it's not as if our teeth were disconnected from the rest of us. But even though I've worked on these issues for more than 25 years and had been aware of employability issues, I hadn't thought about it in terms of "caste status." Drum has another post a couple of days later, but here he then goes on to say with considerable irony, "good old American healthcare. Best in the world, baby, best in the world."