You can always make this point about any individual issue, but the problem is that there is a nearly limitless supply of worthwhile causes, obviously they couldn't pay for all of them.
Being bothered by the mere fact that an individual has $5 billion, however, is an entirely different issue.
I admit that I don't see why you're upset.
Singer addresses this, in a way. But Singer takes a moral position, and would have us all giving much more money than we (probably) do.
Your issue might be different. One might say that though there's not a duty to provide such charity, there nevertheless seems to be something wrong with people not stepping up to the plate, as it were.
I would at least suggest that the price tag is likely to be significantly lower for the state than an individual. After all, the state already has people and bureaucracy in place. Still, it would seem that an individual or individuals might work with the state on tackling this problem. Another issue might be that no one has thought of doing so, which brings up the problem of social consciousness, or lack thereof.
I think the fact that 250,000 kids have no health insurance and 12 people each have one billion dollars, in the same state, is enough reason to be upset, even if you don't think the latter should be taking care of the former. (i.e., last paragraph of 1.)
Wait, this is this new plan where Ogged says something reasonable and we all just jerk his chain, isn't it? OK.
I just want to say that if people get tax rebates for Hummers, I should get tax rebates on philosophy books.
Even more awesome is if some billionaire in Illinois decided to buy me my Amazon wish list.
That's probably not up there with getting poor kids health insurance, though.
Is there a universal-health-care grassroots movement, anyway?
I'll just sit around and talk to myself.
dum de doo...
I'm still awake! But I think Ogged is just going to find his heart broken, following this piece of legislation.
I do think there's an argument to be made that perhaps we should be willing to tax those extremely wealthy individuals at a higher rate in order to guarantee the ability to fund programs that make sure children have access to health care, especially if the state is going to make it illegal for children to have a full-time job with benefits.
There was a case made for Universal Heathcare in the Washington Monthly last summer, which proposed, basically, getting rid of medicare and medicaid, and thereby saving billions on bureaucracy. Then a tax is levied instead of paying directly for health insurance. In return, everyone gets a voucher for insurance, and can go with whatever insurance company they like.
I think that the appropriateness of your reaction depends on whether Illinois has a graduated income tax. If it's a flat rate, then it's bothersome, but I think that provision of decent health care is a basic state responsibility which should not be dependent on charity. (There will always be charity at the margins; providing housing for people who need to get specialist treatment in another city is a good example of that.)
One of the criticism of Medicare part D is that it subsidises the middle class and the rich, but that's only a problem, because so many people paying FICA taxes don't have insurance. If we thought of some of our taxes as basic social insurance, it would be fine--put in according to ability to pay, take out according to need (without extra means testing).
Isn't this Rawlsian sorrow, resulting from our judgment of a society by the way it treats the least of its people? Therefore our opinion of its comfortable people drops when we know how its uncomfortable fare?
There was a case made for Universal Heathcare in the Washington Monthly last summer, which proposed, basically, getting rid of medicare and medicaid, and thereby saving billions on bureaucracy.
Right. Because only the government has bureaucracy, while private insurance companies are friction-free conduits of money to health care providers.
And on the main post -- yes, you're absolutely right for it to bother you. It bothering you is not the end of the conversation on how it should be resolved, but it's a disgusting situation.
If your point is "why now? why isn't this take care of already?" I'm with you. Given our cumulative wealth, we should be able to take care of children. And should have done it long ago.
If your point is that these folks should just pony up and fork it over so the state should do it, when did you sign on for libertarian paradise? If it's that people shouldn't be so rich, you've lost me.
I don't mean to derive a specific remedy from the facts. But people sometimes don't want to admit that something is totally fucked up when all possible remedies seem bad. It seems worthwhile to say, "this is fucked up." Being able to articulate what's fucked up about it might be good. It might be that the two facts really don't have anything to do with each other; or that the conditions that make it possible for individuals to be so rick make it more likely that we can solve the lack of health coverage for kids. Open mind, and all that. But it sure seems fucked up.
I can't fathom why universal healthcare for kids would be at all controversial, but then again, I'm a soak-the-rich liberal.
Good thing I can't ever run for public office now, after 16.
Being able to articulate what's fucked up about it might be good.
My favorite way of putting this is, the U.S. spends more on private health insurance than other countries do on public health insurance -- which is to say, we spend more money on a bureaucracy that exists to deny us coverage than other countries do on bureaucracies that exist to extend coverage.
We don't actually need to debate universal health care, do we, unless baa comes back? Our government spends as much per capita on health care as governments in countries that don't have universal health care, and we don't have universal health care. We've just got the worst health care system of any of the advanced democracies. It hurts business too; it even took down Bill Frist. What's notable about the Illinois situation is the way it hits us between the eyes with injustice, not the fact that our health-care situation is in fact suboptimal.
My favorite way of putting this
Damn! That's so well put, I'll be stealing it, thanks.
What if, as I believe, many of the so-called "children" are actually adult midgets? Does that change any of your intuitions, comrades?
tax those extremely wealthy individuals at a higher rate
Hey, good idea! Oh, wait.
This is why I am not a republican.
You know, the universal health care thing is really funny.
I've been out collecting signatures for a ballot initiative in Massachusetts that would significantly expand MassHealth, improve the benefits, and make private health insurance more affordable.
There are all kinds of weird dynamics when it comes to getting people to sign. Young single men usually blow past me, but those accompanied by a girlfriend are wife will generally sign.
Sometimes it's hard to convince really liberal types, because they want to go whole hog and set up a single-payer in Massachusetts. (I think that the existence of Medicare and Federal matching for Medicaid would make this difficult.)
But I also got a really odd answer from one woman who did, ultimately, agree to sign.
BG: Would you like to sign a petition to put affordable healthcare on the ballot?
W: Sure, as long as it's affordable and not universal.
(The bill in question would cover about 350,000 people out of a population of 500,000 uninsured.)
BG: No, it's not, in fact, universal, but why are you opposed to universal coverage?
W: Because those systems ration care.
BG: I'm not sure that that's true. The French get more doctors' visits, and it costs less. (Maybe I should have mentioned Switzerland.)
W: The French system is terrible; they refuse to treat people. I work at Fancy Teaching Hospital and we get smokers from France with lung cancer who are denied treatment under their system.
I got her signature and moved on, but, really, what can you say to that?
Is that true of all (most) systems with universal coverage? And why is that?
In return, everyone gets a voucher for insurance, and can go with whatever insurance company they like.
why should the gov't subsidize private insurance companies? I so don't get this.
The government has to subsidize private insurance companies because otherwise those insurance companies would make it impossible to create a universal system -- because, naturally enough, they don't want to be put out of business.
"Rationing care" is a funny worry. I wonder if those people have ever had a claim denied.
Sam K,
I don't think it is true. She's just met a small sample of very rich people who have chosen to come to the U.S. for treatment.
There are also ethical questions surrounding the aggressiveness of treatment in the U.S. In New York city, there are an awful lot of expensive bypass surgeries performed on very old people who do worse as a result of surgical intervention. For those people pharmaceuticals would probably be a better choice, and it would cost less.
Sam K--According to Ted Barlow, and most other sources I've seen, pretty much every universal system, yes. In comments Lemuel Pitkin says that the problem is that insurance companies create a lot of bureaucracy, take profits, and put a lot of resources into trying to shift costs onto other aspects of the health-care system; he doesn't give evidence, though, so I don't know how true this is. (There's also quite a bit of libertarian and-a-ponyism from other parties in comments.)
I can't read--I took Sam K to be asking if all universal systems are cheaper, rather than if they all deny care. Of course our system denies care all over the place, starting with the uninsured. What Adam said about the subsidies to insurers--Yglesias has said that the main divide in health care proposals is between those who realize that the current interested parties are evil and must be destroyed, and those who don't.
I find persuasive the argument in Lindert's Growing Public that public health spending improves public health; it's short and runs pp. 257-262, you can flick through it on amazon if you want to. If you really want to get into the nitty gritty of this issue, the OECD data makes a good place to start.
I would vote for you, Joe. Especially after 16.
And I used to work at a health insurance company. We ration care here, too, even if you have insurance. If you get a treatment that must be pre-approved as necessary without getting that pre-approval (and the doctors never know and will advise you anyway that it's fine, it's covered, come in on Tuesday) your claim will be denied and you will be left with the bill.
I quit working in health insurance after a few too many cases like that crossed my desk.
Damn Winna--If the doctor told me that they'd gotten pre-approval and hadn't, I'd tell him that I wouldn't pay his bill.
I've long said that when The Revolution™ comes and I take my rightful place as benevolent despot, the insurance executives will be the first ones up against the wall. Blindfolds and cigarettes will not be covered; those remain out-of-pocket expenses.
You realize, apostropher, that it's only out of love that I'm compelled to note your daily homicidal urges?
Don't make me stab you in the neck, homes.
There was a case made for Universal Heathcare in the Washington Monthly last summer, which proposed, basically, getting rid of medicare and medicaid, and thereby saving billions on bureaucracy. Then a tax is levied instead of paying directly for health insurance. In return, everyone gets a voucher for insurance, and can go with whatever insurance company they like.
That's insane. Medicare/medicaid has around a 3% overhead, the lowest any private insurance company comes in is around 6% (and they go much higher than that). Medicare has no marketing costs, no shareholder profits to pay and enjoys huge economies of scale.
That's exactly right, msw. Health insurance companies are not in the business of providing healthcare. They are in the business of 1) shuffling paperwork, and 2) extracting a layer of profit for their shareholders from said paperwork shuffling. Increasing the role of a fundamentally parasitic industry is an ass-backwards way of containing costs.
Also, re: 32 & 34, it's been my experience that in many cases the doctors themselves are as much to blame.
My 10-year-old sister broke her wrist last year, so my dad, who is uninsured, called several urgent care clinics to find out what an x-ray would cost. They were all comparable, but the place he finally chose said it would cost between $75-100. After the x-ray and the Dr. determined that the wrist was, in fact, broken, the bill came to ~$450 (fuzzy memory). My dad asked for an explanation, reminding them that they had quoted him $75-100 over the phone earlier that day. "Well, sir, the x-ray came back positive." Apparently that makes a difference, now. He found out later that what he was paying for was 90-day "after-care" --but, if you'll recall, this is a broken bone, and THERE IS NO DAMN AFTER-CARE. Urgent care can't set the cast, and the brace won't do.
What's worse is the next Dr. required new x-rays the next day. ugh.
People keep saying "ass-backwards" like it's an obviously bad thing.
msw--I prefer single-payer too, but there is the Alain Enthoven argument which says that true managed care, which is not about cost shifting but actually helping people to manage chronic diseases and get the best care at an effective cost, works best when there's some competition. (He's all for restrictive networks and is having a big argument with Michael Porter on this point.)
I don't think that we can leave everything to the doctors in a fee for service system, and navigating the health care system is extraordinarily complicated on your own.
Back surgery is way overdone, and a lot of the people report that their back pain is worse. So if a back surgeon, who stands to benefit financially from the procedure, tells me that I need back surgery, I'll take advice with a grain of salt.
I've got a question for the rest of you though. Do any of you talk to your friends and family offline about your dissatisfaction with the current system. A lot of my friends aren't quite yet willing to make the leap. Some of them fear the bureaucracy. My godmother's a bit like this, although she's incredibly liberal and will probably come around. She works for Harvard which has its own HMO on site, and she's been very happy with the care she's gotten there. I don't think that medicare for all would have to destroy company specific clinics.
I do think that we need to do a lot more persuading at the local level. There are limits to what we can do at the state level now, but I think that we can work ob pushing the citizenry so that they'll demand something better, and I think that person-to-person interactions are a big part of that.
People keep saying "ass-backwards" like it's an obviously bad thing.
Also, if you fall head-over-heels, exactly how is that different from normal?
They're figures of speech, like "You're sure earning your pay today, peasant."
I'm down on figures of speech this week.
Like head-over-heels. I don't know about you, but I spend most of my time in that position.
This is getting into griping about insurance rather than policy arguments (for the record, slol's 18 and apo's 39 are dead on) but what really burns me about interacting with the system is the way, as described in the last couple of posts, that coverage is made so complex that it can easily be denied because the doctor put in the claim wrong.
I just had a claim for my daughter's yearly physical denied, because they only authorize one physical a year. Of course, this is her first physical this year -- apparently a visit to the pediatrician for an actual illness earlier in the spring was mistakenly billed as a physical. Now, I have no way of straightening this out -- the doctor has to -- and if the doctor tries to bill me for the visit (which she hasn't yet) I plan to point that out to her. I'm not actually out any money on this one, but man am I annoyed.
This summer, we were vacationing down at Hilton Head Island, when Noah (at the time ~6 months old) came down with an obvious case of pinkeye. No problem, Tobramycin drops for a week and it's over. Been there, done that with the first kid. Except we were in South Carolina, which means our North Carolina pediatrician can't just phone in a prescription for the $6 bottle of eyedrops because, you see, the two states only have 11 of 13 letters in common.
So we go to the local Urgent Care, fill out an absurd number of forms, wait an hour or so, and the doctor comes in. He takes one glance at Noah and says, "He has pink eye. Here's a piece of paper I signed so you can go get a six-dollar bottle of Tobramycin drops. That will be $105, please."
I spend most of my time in that position.
You need to spend more time at the Banana Lofts then.
Longtime lurker here...
I'm a grad student who's significantly more liberal & more educated than my parents. I keep trying to convince them that universal healthcare makes economic and moral sense, but I encounter this odd resistance to anything smacking of socialism. As much I tell them costs are lower, quality of care will not decrease, etc, they simply don't believe me. I really don't know what it is, as my parents are really middle-of-the-road politically, and it was Bush's handout to pharmaceutical companies (oops, I mean "prescription drug reform") that finally pushed them into being openly critical of him.
So the implicature is "head directly over heels, with the rest of your body off to the side somewhere," isn't it?
Also, is it used for anything other than falling in love anymore?
I certainly do. People usually tell me to stop talking about healthcare once I roll out some of my stories and ask them why it is that in America, land of plenty, we can't keep people from dying of easily treatable diseases.
Then again, most people tell me to stop talking after about twenty minutes.
And you could tell the doctor you won't pay the bill- many people do. And then it ruins your credit. That is what happens to a lot of bankrupt people- medical bills trigger about 50% of bankruptcies. Of course we've tightened that loophole so that people who get cancer while uninsured are stuck not answering their phones and tearing up bills unread because they can't pay them.
We have a great health care system! The best in the world! If you don't ever get sick enough to worry about the lifetime cap on your insurance, if you have it.
Nonscientifically, I'd say no. For actually falling, you do get "arse-over-teakettle" in Britain, which is rather more vivid.
I prefer "ass over teakettle" though I can't for the life of me figure out how it came to have its current meaning. I think it's especially well-used for falling in love.
Oh winna, I know that it could ruin my credit, but I'd get a lawyer to write threatening letters, and I'd contest it, because it was the damn doctor's fault.
Matt: I can't visualize that position -- all I'm coming up with is on your knees, with your head flung back. Which, although certainly abandoned looking, doesn't seem to convey having just fallen in love much.
And SG: That's been one of the greatest victories of the right. Perfectly reasonable, normal people look at social democratic programs and think "Social Democracy=Socialism=Communism=Soviet Russia=Omigod, Joe Stalin's gonna come git me and throw me in the gulag." God only knows how we're going to fix it.
I think you have to in midair for it to work. And what you said in the second half of 56, plus there's this weird belief that private companies are always just more efficient. Well, maybe they are more efficient at some things, but those things are not necessarily connected with delivering service to customers (one day I will be blogging my experiences with U-Haul, hoping that it will do them some harm).
God only knows how we're going to fix it.
Re-education camps.
Which aren't even a little like gulags. (heh heh heh)
LB, regarding your second point: Now that we are starting to see people of voting age who are not old enough to remember a time when the Soviet Union existed, I wonder if this argument will start to loose traction. Socialism ain't the boogeyman that it used to be. For all that I criticize GWB's War on Terror rhetoric, I thank my lucky stars that Osama bin Laden never came out in favor of universal health care.
LOL, apostropher.
We need Tia to write the script for the re-education camps, although that might be in conflict with some ethical duties she'll learn about in her psychology program.
My favorite joke about the health care system comes from Matthew Holt's health care blog. He's been writing up the strike against Sutter Health in California and the fights over whether they ought to be considered a non-profit, since they are raking in more dough than almost anybody and don't actually seem to be offering much in the way of charity care.
This is a real gem:
Meanwhile, on the issue of giving free care to the uninsured (or not, as the case seems to be) Sutter is now pointing out that it thinks it gives lots of charity care because it "writes off" some $40m a year in discounts that it gives Medicaid and Medicare off its charges. After you pick yourself up from rolling on the floor laughing about that one, there is the slightly more serious issue that they raise which is that everyone else does it (or actually, doesn't do it). "Everyone else", in this case, of course means Kaiser.
I love their new definition of charity, and Sutter is known for very aggressive collection practices too. They sued a bunch of people who signed on to a class action related to the excessive fees they charge the uninsured.
These are a little old (10/03), but the American people aren't as against universal coverage as anecdotal evidence might suggest:
"Which of these do you think is more important: providing health care coverage for all Americans, even if it means raising taxes, OR, holding down taxes, even if it means some Americans do not have health care coverage?"
Coverage For All: 79%
Holding Down Taxes: 17%
Unsure: 4%
"Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"
Current System: 33%
Universal Program: 62%
Unsure: 6%
It might be relevant to point out that my parents live in Texas.
Also, I really don't see this knee-jerk negative reaction to socialism getting better in my generation. I think a lot of Reagan's nonsense has trickled down to become conventional wisdom among folks my age (mid-20s). I know people who would argue that private companies are a priori more efficient than government. Maybe being from Texas just makes me pessimistic.
Joe D--Most people support universal health coverage, and they have for a long time. That doesn't seem to be the problem. The problem is getting them to vote out the legislators who won't provide them with something decent and replace them with some who will.
There's also a huge disinformation marketing campaign. I guess there were polls during the Clinton healthcare fiasco where people all said that they were against the Clinton program, but when the details of it were described they all said that they supported that sort of plan.
Bah, Humbug!
Claim denied!
Most people support universal health coverage, and they have for a long time
You'd think there would be some sort of political party that would capitalize on this kind of discontent with our current system.
I think the motivation behind that Washington Monthly keep-the-insurance-companies plan was expressly partly, and probably covertly wholly (how many adverbs can I fit into this sentence?) to try to create a coalition of interests that would unite behind a plan for universal coverage, and they thought that insurance companies would be powerful enough to scuttle anything that did them in.
I've often wondered whether we shouldn't have a period where individuals can buy into medicare and get a tax deduction for the premium. if the drug benefit were a bit better (and I've got a few thousand dollars worth of drug expenses annually myself), I'd totally opt for that. It would make travel within the U.S. a lot less complicated and provide continuity of coverage if I moved somewhere.
Once more people saw that as an option, the insurance sompanies would have a lot less power. They can stick around, but they have to compete with medicare.
This is all a totally theoretical discussion anyway, since we've got to (a) get a Democratic congress and (b) get a Democratic president for any of this to happen, all of which will (c) happen on the 12th.
64: I'm not your generation, but I get that sense too. A friend said that a lot of her students took "But it's socialism!" to be a reductio of any position. This in a bluer place than where I am. I had some students at UWM who were sympathetic to Marx, some very much not, but those were college students, y'know.
Have I complained lately about how Texas doesn't insure its employees for the first three months?
71: I don't get part (c), but otherwise, well, duh, yes. I would hope that more Democrats would make health care the centerpiece of their campaign and win on that. Very few of them seem willing to do that.
It's just a very good idea to provide health care coverage to children. It's cheap, effective, and it's the right thing to do.
As for "universal health care," as my economist friends tell me, it all depends on what 'single payer' means. The desirable aspects of a health care system seem to me to be (in no particular priority):
1. Supports medical innovation
2. Has incentives for cost-effectiveness for both consumers and suppliers, and is efficient at the 'systems' level
3. Minimizes free-rider problems
4. Provides access to care for the poor and unlucky
I get the sense that everyone here thinks the US does not maximize these attributes correctly, and that every other country does it better. I am unsure of this. In particular, I do not believe the evidence supports the proposition that the US health care system is markedly less efficient than other Western nations. And I think we should be very, very concerned about changes in the US health care market that have the potential to reduce medical innovation. (obviously, free well-baby visits do not have that potential)
But OK, let's just stipulate that the French health care system is 20% more efficient than the US one. Does this imply that the US could switch to that system and reap windfall benefits. I suspect the answer is no. By way of anlogy: French public schools are awesome. This accomplioshment, however, is supported by a culture of respect for learning, respect for teachers, and widespread support for central government programs. Further, France is more homogenous demographically, has less immigration, and is (I believe) less rural than the US. This leads me to suspect that merely duplicating French organizational and financial structures would be unlikely to produce similar results in the US.
Of course let's be cautious, but let's not be so cautious as to do nothing. The current system blows donkey.
71: I don't get part (c)
The unspoken conclusion of the phrase is "of never".
baa:
1. I'm curious about efficient at the 'systems' level because (a) I don't know what that means, and (b) I'd think we want it to be efficient at all levels, to the extent possible (i.e., why is the systems level more important than other levels).
2. Also, I'm not sure what "free-rider" means in a scheme of universal healthcare.
And baa--not everybody should be too cost conscious. My Dad stopped taking his heart medicines at one point, because he was symptom free. (The doctor never explained what te drugs were supposed to do.) Of course, he landed in the hospital with a heart attack. The Blue Cross insurance that we had covered the hospital bill, but it didn't pay for the drugs.
Also Weiner, that sucks about Texas not covering its employees for the first three months. How are people supposed to maintain continuity of coverage?
Also, I'm not sure what "free-rider" means in a scheme of universal healthcare.
I swear, there's a woman living in Chicago who goes by a dozen different names, visits a dozen different doctors when she has a cold, riding around in a Cadillac that she paid for with the reimbursement checks she receives from her HMO.
I think that the appropriateness of your reaction depends on whether Illinois has a graduated income tax.
It's my understanding that tax wonks have some time now accepted that we effectively have a flat tax in this country. Dick Gephardt has been talking about this for awhile, and the case was also made by David Johnston in his Perfectly Legal.
Right. Because only the government has bureaucracy, while private insurance companies are friction-free conduits of money to health care providers.
I think you misunderstand. There are extesnive medicare and medicaid bureaucracies a big part of whose job is to decide who gets covered, who doesn't, and for what. This is the money that would be saved under universal health care.
79: Beats me. I could probably get supplemental insurance if I weren't disorganized and irresponsible, and I don't have any preexistings, but if you or someone in your family is sick I think you can't afford to take a job at a Texas school (except UT, which seems to have a workaround). Another new faculty type thinks this is designed to break continuity of coverage.
and that every other country does it better
Every? No. Many? Undeniably.
I do not believe the evidence supports the proposition that the US health care system is markedly less efficient than other Western nations
We rank first by a wide margin in per capita health care expenses and near the bottom of first world nations for pretty much every health care-related measure. What evidence would it take for you to support the notion that other countries are getting markedly more health care bang for their buck?
Or other Texas state job, natch. Well, I guess you extend COBRA beyond the summer till December (adjust as necessary for non-academic-year employees).
I should note that I'm probably more sympathetic to (what I assume is) baa's position than many people here. There are significant problems with our health care system, but there are also a lot of good things about it, too. It represents something like 15 percent of our economy (early '90s figures), and we should tread really, really lightly when dicking around with it.
One of the good things about some the Il. proposal is that its incremental; also, it covers kittens, so it's hard to be against it. (Isn't this precisely what Dean proposed? He gets less credit for being right about pretty much everything than I would have thought possible.)
Nationally televised primal screams sometimes make people want to redirect due credit.
Presumably you should be able to get COBRA from your last job?
And Michael: If the private insurance companies are doing anything at all in the Wash Mo universal-coverage-through-vouchers system, they're making decisions about who gets covered by them for what. (If they aren't making such decisions, they aren't doing anything at all -- just taking a cut of the voucher as it goes from the gov't to the health care provider). Those decisions are going to require bureacracy, which will be just as wasteful as the one they currently have. I think Tia's probably right -- the only policy reason to involve private insurance companies in universal health care is as a bribe to them not to prevent it.
LB--Sure COBRA's an option if your previous employer was big enough, but if Weiner had gone to Texas straight out of graduate school and been covered by a non-employer student plan, then COBRA wouldn't have applied.
Plus you'd have all these non-network coverage issues. Me, I don't think that I can live anywhere other than Mass or NY where you can buy community rated coverage.
There are significant problems with our health care system, but there are also a lot of good things about it, too.
Compared to the systems in other industrialized countries, what? My understanding of the facts (I'm not claiming a lot of knowledge here, and could be convinced I was wrong with data) is that we don't have a lock on technical innovation compared to other countries. What else do we get that they don't, that you worry about losing?
we should be very, very concerned about changes in the US health care market that have the potential to reduce medical innovation
Well, speaking as a fellow who works in the pharmaceutical development field, let me toss out some figures, because I hear that objection raised all the time in my industry.
CMR International estimates that worldwide pharmaceutical R&D rose to a record $53 billion last year, representing about 17% of worldwide pharmaceutical sales. This is the highest percentage of any industry (computer software and services runs about 10-11% of total sales).
53B is a big figure, but in perspective, that's a bit over half a year's spending on Iraq for us to completely subsidize the entire global pharmaceutical industry. Needless to say, even under the very most generous national health plan, we won't be required to subsidize the entire planet's pharma industry, or even just the American one.
I'm wholly unconvinced that setting up a single-payer health plan is going to pose a problem regarding medical innovation.
You can't get COBRA for school-related insurance? That stinks. I had no idea.
"completely subsidize" [R&D for] "the entire global pharmaceutical industry"
RE 74
The canadian healthcare system is probably the best we can hope for because of the geographic issues you mention. It is still way better than the US system.
Support of medical innovation has two parts: development of new medical technologies and spread of new medical technologies. The first part needs to be strongly supported but the second part need only be supported if the new medical technologies work well for the costs. Just as agricultural credits for biofuel isn't really energy innovation, misallocation of healthcare money to marginally effective high tech solutions isn't really medical innovation.
I don't thionk that France is more ethnically homogeneous than the US. They have Algerians and other colonials, Bretons, Alsatians, Basques, provincials, and refugees from verious areas. The long-time minorities are pretty suppressed and assimilated, though.
Re: COBRA.
That shit ain't cheap. Even when offered, a hefty chunk of working America can't afford it. We couldn't when the missus took an extra two months off beyond the approved period after the baby was born, because it was something along the lines of $400/month, and we were down a salary to begin with.
Luckily, no car crashes or serious illnesses before she went back to work.
And I never understood the 'ethnically homogenous' argument, anyway. How does the existence of Hmong refugees make universal health-care unworkable? Are we literally talking about the expense of hiring translators, or what? Because the health-care system we have now doesn't have all that many Hmong translators, and universal coverage, even with insufficiently culturally/linguistically sensitive providers would still be an improvement.
(My tone here is dismissive, because I don't understand the argument at all. I'm sure there's something substantial to it, I just don't get what.)
Well, I didn't come straight out of grad school, but I could've got COBRA from my last job if I'd applied. A lot of this is irresponsibility (and adverse selection, market proponents)--in this case I had taken the assurances that benefits were more or less normal and was shocked to find out that they didn't cover me for three months. By that time the COBRA deadline was past. Plus what BG said, Wisconsin insurance doesn't travel well to Lubbock. Also, COBRA costs money, and I didn't get paid between June 1 and Oct. 3, while incurring a lot of moving expenses (this is pretty typical when you switch academic jobs).
Not that I'm saying Texas is doing anything uniquely horrible--just a bit of sneaky cost-shifting, if you're on the ball enough to get your own insurance bought. As I said, I bear a lot of responsibility for not buying insurance. It's just mega-chintzy, and an insult, and really could hurt people who are coming from jobs where for whatever reason they don't have COBRA. Also, note the adverse selection.
students took "But it's socialism!" to be a reductio of any position.
I can relate my experiences from the student side: In classes where Marx was actually read, there was near uniformity against, but mostly on the grounds that his arguments are really bad and don't support his conclusions without false suppressed premises.
But support for Rawls or quasi-Rawlsian welfare stat liberalism was very high, even in the class where the professor suggested that a lot of Rawl's support comes from the timing of the publication of Theory of Justice, rather than what it actually says.
I really should read me some Rawls.
Read Political Liberalism, it's short and clear, and gives you all the basic ideas in Theory of Justice.
I really should read me some Rawls.
You should just book him for your next corporate event.
1) My parents are much like singular girl's; moderate on some things, but puzzlingly resistant to the idea of universal health care, even though throughout their own lives they've often had no or minimal health coverage. One of the specific points of resistance is the scary stories out of Canada and the UK of long, long waits for MRIs and knee replacements.
And there are shortages and long waits; but these aren't due to rationing or the inability to pay for it, but due to a shortage of nurses and doctors. (Admittedly, perhaps indirectly caused because those nurses and doctors can make more in the U.S., but that's not what's frightening my parents.)
One of my friends was amused by an American friend who was afraid to go to a UK hospital because of 'socialized medicine'.
2) baa's 100% right that people will be more thrifty if they have to spend their own money to go to the doctor (rather than clogging up emergency rooms). What it means is you wait. If the kid has a 103 degree fever, you bathe them with rubbing alcohol and give them water and popsicles and wait.
I am unconvinced, however, that this is a good thing; like apostropher's pink-eye story, there are many illnesses that do require a doctor, and treatment isn't the result of someone's mommy panicking. $105! for a normal childhood illness! And really, it is sad hearing your sister cry and apologize to your mom for going to the university clinic (tons of pain, possible flipped ovary) because she knew it cost mom money.
Cost-consciousness may end up costing you overall in the long run; if you're feeling fine and skip your physical, then the doctor doesn't catch that your cholesterol is high, so you don't catch the problem early enough to prevent the heart attack.
3) The Canadian system relies heavily on subsidies of pharmaceuticals; one of the reason it gets away with this is because the drug companies have a big market just to the south with protective patents and such. I'm a little leery of plans that assume we can emulate another country given that their systems sort of rely on having the U.S. to buy their drugs.
You know, I bought A Theory of Justice on the grounds that I'd seen it brought up around the blogosphere enough that I should read it, and I can't say I got all that much out of it more than I had from reading summaries of the main arguments (veil of ignorance, etc.). Very, very dense and unengaging.
You may be less of a lightweight than I am (many people are) but I wouldn't unreservedly recommend going out and buying a copy.
puzzlingly resistant to the idea of universal health care
My guess is that people figure, in the current system, if they really need care, or need the best care, they can max out their credit cards, live, and worry about the rest later. They fear that if the government controls healthcare, there will be no backdoors. If the government says you have to wait, you have to wait. Frankly, I have this fear too, and it's pretty powerful.
All of my friends in college read it, because they all took this huge core course called JUSTICE where it was required reading. I think that's where most of my classmates learned about Kant's categorical imperative.
Me, I took a class called autonomy and alientation which was only so-so. I'd have preferred a class that was offered later about morality and theism. Does theism even allow for morality etc.? It went by the catchy title, "If there is No God, All is Permitted."
Frankly, I have this fear too, and it's pretty powerful.
Moderately nuts, though, isn't it? The kind of "best care" that people worry about not being able to get is well more expensive than the limits on my credit cards -- I'm not going to successfully buy myself a new liver, for example, and neither is 99% of the population.
Also, why would gov't care shut down backdoors? Isn't there a co-existing luxury private care system in most universal health care countries?
Re: 104
But, but, but, no one's suggesting prohibiting private supplemental insurance or other private health care expenditures, are they?
But once you have maxed out your credit cards? What do you do then, hope no one else in your family needs hospitalization? Which kid doesn't get to go to college because of the family's medical bills? A night in a hospital costs on average $14,000. I don't know about your credit cards, but we don't have to be talking catastrophic car wreck or stroke to have this start to hurt big-time.
I agree that fear is probably part of it. Canada's 'UHS' is actually provincially administered, and Alberta is considering going to a two-tier system, where if you have the money, you can pay for priority. It has not been a universally popular notion, but those who are behind it usually cite something about not wanting to wait when they can clearly pay for it.
104: I think that in a universal system, there will still be inequities, but they will be more related to education and knowing the right people than the ability to pay. The selfish part of me knows that I would do better under a system like that.
In Alberta, most people have insurance through their jobs, just like in the U.S., that covers prescriptions and so forth. The provinicial health care is deducted out of your paycheck, just like an HMO or PPO monthly fee.
The difference is largely that if you're unemployed or in a job that doesn't provide health care, you have this basic care. (If you don't pay anything for a year, you can still go to the doctor; if you're overdue on your payments for a year, you will be cutoff until you make some kind of payment arrangements.)
In particular, I do not believe the evidence supports the proposition that the US health care system is markedly less efficient than other Western nations.
From The World Bank:
2002 Per Capita HC Spending, in US Dollars:
Canada: $2163
US: $4887
France: $2109
(note - that's "per capita", not "per-insured person", so even the shitty numbers above under-represent the US costs)
2002 Child Mortality at Birth (per 1000 births):
Canada: 5
US: 7
France: 4
2002 Life expectancy at Birth:
Canada: 79
US: 77
France: 79
Seems as clear a case of inefficiency as one can imagine. We pay more than twice as much as comparable nations (I don't have the numbers handy, but I'm pretty sure that Canada has a larger number of immigrants than the US) and we are significantly less healthy. Even though the average frenchman smokes 87 packs of cigarrettes a day. I guess I don't understand the "it works for everyone else, but that doesn't mean it would work here" argument.
I unreservedly recommend Kymlicka's Contemporary Political Philosophy: An Introduction. If you're interested in the area, it's a great work, even if you've already read some of the authors discussed: I read it after having read a good chunk of Rawls and all of Anarchy, State, and Utopia, and got so much out of the book. I now await one of the philosophy professor commenters to explain the error of my ways.
My ex-roomate who is currently a TF (that's the weird Harvard term for teaching assistant, right?) in the above-mentioned Justice class is also using this book for counterarguments to the pieces the class is reading.
And I never understood the 'ethnically homogenous' argument, anyway.
Me too. I think the subtext of that argument is something like "Those People have a lot of children and also keep getting their arms caught in the machinery".
I didn't much dig Autonomy and Alienation either, though maybe I shouldn't admit that, since it was taught in Philosophy while Justice was in (gasp!) Government. Of course if I'd known I was going to be a philosophy major I should've just taken Rawls's course. Feel very stupid for not having done that.
Anyway, Justice as Fairness is less of a doorstop than Theory, though Rawls will be dry no matter how you slice him.
106, 107--I think I've seen it said that a lot of the problems in the UK system come from the pervasiveness of the two-tiered public/private system. So I think some people have suggested restricting private care. But what 106 says. And, you know, besides the rest of what 106 said, if your doctor has no appointments you also have to wait.
washerdreyer--yup. TF stands for Teaching Fellow. I think it's easier to say than TA.
Weiner--I knew someone who took a class from Rawls during his last semester of teaching. He didn't talk about his own philosophy at all.
The messeed up thing about the UK is that you're either in the public system in which case care is free at the point of use or you go private and pay the surgeon the full cost of your hip replacement. (There's also BUPA which operates its own hospitals and seems to be like an HMO. The big difference is that if your employer provides other health coverage, you have to pay taxes on the benefit.
There's no supplementary insurance that allows for little extras or for a more expensive doctor. Canada does ban private medicine. (This was declared unconstitutional in Quebec by the Supreme Court, but that ruling only applies to Quebec, and I believe that it was temporarily vetoed by a legislative over-ride.)
I'd be okay with a certain level of supplementary insurance and allowing people to pay for certain upgrades out of pocket. We've had this here for people who chose to purchase medigap insurance.
Off the top of my head -
1. Ethnically homogeneous - I think that's a reference to the fact that different racial groups have different risk profiles. African-Americans need to worry about sickle-cell anemia in a way that I don't. Creating a system that handles a greater number of risk profile, one might think, is more expensive than creating one that only has to deal with a smaller number of problems.
2. I don't know how much of the work being done in other countries is done by other factors. Japan is better than us - could some of that be diet? More generally, if obesity does have bad health outcomes (directly or indirectly), does the fact that we, as a nation, are fat-asses make us more expensive to treat than other countries?
3. I prefer market solutions wherever possible. I look at my cellphone and think that under an AT&T monopoly, I'd be paying approximately 500 million dollars a month for my current service.
4. I'm not sure how strongly I believe this, but I do believe that government bureaucracies are more entrenched than company bureaucracy. So Jim, who's nice but an idiot, keeps his job (which, it turns out, is frustrating the hell out of you) for life.
5. I think there are possibilities for innovation everywhere, theoretically - not just in drugs and medical procedures, but in delivery of service, etc.
6. All that said, I liked the outlines of the Clinton plan for managed competition. Let the government set a base rate, and anyone who wants in can compete against it (IIRC).
I think the 'ethnically homogenous' argument is usually used to mean something like 'not a lot of recent, poor immigrants who will not be earning a lot of money but using just as much health care'.
The funny thing is that immigrants generally use a lot less healthcare than native borns, and they pay a lot of taxes.
Cala-
If that's it (and I think there's a good shot that that's what people do mean), then it doesn't make any sense at all. Any such effect would be totally accounted for by stats like the percentage of poverty, rather than ethnicity. If that's the argument, then ethnicity hasn't got anything to do with it.
Tim- If you're right, how big an effect can that really be? Our doctors have to be a little more broadly trained, a few more diseases are common -- is this really going to be a significant cost effect when considered against the size of the health care system as a whole?
Ethnic homogeneity normally correlates with a polity's willingness to vote for social welfare benefits, i.e., I will pay taxes so that someone like me can get welfare but I wouldn't do it for someone not like me; this is the "there but for the grace of God go I" principle.
Yes, LB, but I suspect it's a term with more than a hint of racism; "them people move here, don't do no work, then take our health care." And the implication is supposed to be immigrant --> poor, less integrated, harder to make into a contributing member.
But you're right that I haven't heard of one that can't be accounted for by poverty rather than race. I'm not buying into the genetic predilections for certain diseases as being an overwhelming factor, at least one that would be brought up more than obesity, gender, or age of population (90% of health care expenses are spent within the last six months of life).
That ignores, of course, that plenty of countries are ethnically diverse.
Slol- that's a plausible explanation for what the story is behind the U.S. not instituting universal health care, but people here are asking what weight it has normatively, aren't they?
Tim- If you're right, how big an effect can that really be?
I don't know, though I'm sure there are studies on this. The larger point is that there are lots of little things that could make the services we need to deliver more expensive than the ones France needs to deliver. I'd guess that we have to treat more gunshot wounds than France per capita, and that gunshot wounds are more expensive to treat than injuries from a cutting literary remark.
I do think you're right, which is why I was picking at the argument. I think the 'ethnic homogenity' gets used in an unexamined fashion by people who don't mean anything racist by it (that is, I don't think ill of anyone for relying on it), but I haven't ever seen an explanation of it that makes any sense at all.
Whoops, that was to Cala. To Tim's latest -- crime is way down lately, and that doesn't seem to be having much of an effect on our health care costs, does it? This:
The larger point is that there are lots of little things that could make the services we need to deliver more expensive than the ones France needs to deliver.
isn't an argument that universal health care wouldn't work here, it's a statement that empirical research (which I don't believe has been done) might possibly show that universal health care wouldn't work here. Maybe the French have a lot of lung cancer and cheese poisoning, which drives up their costs compared to ours? It could be true.
J'accuse!
It might be the case that health care is more expensive to provide in a country with large rural populations; less centralized, less people per provider, etc. That might explain the difference between France (more urban) and the U.S., but perhaps not between the U.S. and Canada (though I'm not certain of the percentage of Canadians in or near big cities.)
I'm not suggesting that it indicates that universal care wouldn't work here; I'm suggesting that it makes efficiency arguments much more difficult to make. And I think you might be surprised at how large a field health economics is.
And I think you might be surprised at how large a field health economics is.
I know work has been done in this field, I just haven't ever seen the "It wouldn't work in the US because of our heterogenous/geographically spread out population" back it up with research. People I've seen making the argument have stated it as self-evident, rather than as the result of empirical investigation. (I should say that there may be good solid research supporting it, but I haven't seen it cited.)
Sorry in advance if I don't answer everyone. But here goes a whirlwind tour:
This is undoubtedly a bad venue to talk about international comparisons of health care efficiency.
Yes, the US spends more per capita and the crude measures of outcome are moving the wrong way. But it's important to recognize that these crude measures -- life expectancy, infant mortality -- are not just *very* crude, but are also sensitive to non health care factors (like economic inequality and lifestyle).
On innovation, it's not the dollars, it's the process. A system of profit hungry biotechs, device companies, pharma cos and VCs has produced enormous value for all of us. I don't believe that this can be replicated by shutting down the industry and replacing it by directly funded research. It's like proposing to replace silicon valley with more NASA funding.
What's good about our health care system? It's the leader in innovation, bar none. At the highest end, it's simply the best. Try getting TNFa blockade drugs in Canada. You can't, because they cost 15k a year. If I had arthritis, however, I would pay 15K for these drugs.
On homogeneity, I had in mind people who have language and cultural barriers to health care access. I suspect that's a more of a problem in the US than in, say, Norway.
Bostoniangirl, I'n in the NHS and with BUPA (which for me is like private medical insurance but my -- cheap -- policy kicks in if getting NHS treatment would take too long). I do though know what you mean, but the system here is changing (the systems here are changing?) to offer more flexibility. Right now if I want a "more expensive doctor" (= top doctor?) I ask to be referred to them under the NHS; privately I'd have to go to my local hospital. Luckily my local BUPA hospital is staffed by the top doctors at the national NHS teaching hospital anyway.
That's how it is now. By the time Blair has privatised it, who knows?
(On your point about universal systems favouring people on educational grounds etc.: yes indeed. When I worked at London I often went straight to the front of the -- then very small -- queues, and got very pleasant treatment. And I didn't complain... .)
LB:
"It wouldn't work in the US because of our heterogenous/geographically spread out population"
Ah, OK. I don't think anyone can make the argument that universal care wouldn't work in the US, in the sense that it's physically impossible to have such a system. But universal care isn't really a health discussion or an economics discussion. It's a political discussion informed by those other fields. So, baa might be right above - we lose certain arthritic drugs. Who cares? Maybe not that many people, so as a political matter we decide to go in a different direction.
baa:
It's like proposing to replace silicon valley with more NASA funding.
But it's silly to pretend that a lot of that Silicon Valley innovation wasn't spurred on my DoD funding for darpanet etc.
jayann--Thanks for the info. I think that in France you can get supplementary insurance to pay for a more expensive GP, but all of your GPs get capitated payments. Oh the saga of foundation hospitals.
I knew the widow of the Rector of Exeter College, Oxford. They were thoroughly middle class people, but I'm sure that he got better treatment at the Radcliffe Infirmary, because he was on the Board of Trustees there. And his widow is a thorough-going Labour supporter and probably never considered that fact.
When her daughter nearly died giving birth in a Catholic hospital, the family made her husband transfer her to the Radcliffe Infirmary. And the poor infant lasted 6 months in intensive care.
The NHS is pretty much crap for mental health, but pretty much everywhere seems to be that way.
A system of profit hungry biotechs, device companies, pharma cos and VCs has produced enormous value for all of us. I don't believe that this can be replicated by shutting down the industry and replacing it by directly funded research.
Maybe we're talking past each other, or maybe I just don't understand what you're saying. We don't have to shut down private pharma research to change the way that health care payments are negotiated and delivered from consumers to providers. I think we can probably move straight to a single-payer system without that being much of an issue, since the two are only tangentially related. People will still have their diseases, doctors will still prescribe medicines, better ones will still supplant less effective ones. My point was that even if we did effectively nationalize domestic pharma R&D (which would never happen even under the most ambitious plan imaginable), that's completely doable. Fortunately, it's also completely unnecessary.
What I'd like to see is not UK-style socialized medicine, but Canadian-style socialized insurance. We can all point to snags in that system, but at some point everybody needs to stop and ask whether those shortcomings outweigh the shortcomings in the current US system, because it isn't like ours is some marvel.
baa? Humbug.
</baa>
Look, baa, you're not being careful.
these crude measures -- life expectancy, infant mortality -- are not just *very* crude, but are also sensitive to non health care factors (like economic inequality and lifestyle).
If you hold constant for these factors, and pollution, and total spent on healthcare, you still get better results from a more-publicly funded healthcare system. I gave the cite upthread, here's a table and here's a paper.
This is just one of those areas where a reasonable conservative is going to have to admit there's something to this whole public welfare thing.
baa,
Try getting TNFa blockade drugs in Canada. You can't, because they cost 15k a year. If I had arthritis, however, I would pay 15K for these drugs.
So you are saying physicians in Canada are not allowed to prescribe this drug, and not for safety reasons?
If I had arthritis, I don't think I'd pay $15K a year for the drugs. The money just isn't there.
That's one thing to keep in mind; it doesn't matter if the high end things aren't affordable under a UHS because they're not affordable now under a non-UHS.
To some extent I think this generalizes further. The six-month knee replacement waiting period doesn't scare me as much as it does some, largely because without insurance in the U.S., that knee replacement isn't even on the table, let alone waiting for it.
Cala makes a key point -- we'll probably never make John Edwards' Two Health Care Systems totally equal, but we can certainly make them less unequal. The wealthy, if they can afford it, will always be able to find extra special care that normal folks can't get. But the normal folks should have access to some level of care, as opposed to no level of care. I think the fears of those $15K arthritis drugs becoming totally unavailable are unfounded. If you're the type with $15K to spend on arthritis medicine, you'll be able to get your hands on some, I have no doubt.
You know, next to pop music, healthcare consistently gets the most comments around here. It's amazing that the Democrats haven't been able to make any hay out of this.
The non-crude measures of healthcare system efficiency would break toward single payer healthcare. A non-crude measure of healthcare system efficiency would be some sort of measurement of improvements in life expectancy and quality of life attributable to healthcare intervention versus healthcare expenses. $12,000 arthritis medicines can pay for a lot of effective interventions for the 40% of american that don't have healthcare insurance.
And the $752 more per person per year of healthcare administration costs that the US pays over Canada does not help matters.
As the Unfogged commenters go...
Because your commenters are clearly a representative cross-section of the American electorate.
But seriously, you're right. I think someone coming out strongly for single-payer gov't health insurance (Medicare for everyone!) would get a lot of interest.
Are you counting sex as healthcare?
I don't think they've tried. They all say that they want universal coverage, and most of them have some sort of plan, but you never get the sense that it's really their top priority.
I supported Dean in the primary in large part because of his commitment to healthcare coverage expansion. I didn't love the details of his plan (Lieberman's looked better) but I knew that he was committed to the issue, and that his might even pass a Republican Congress.
Are you counting sex as healthcare?
How would you emulate the French system? What would a single-payer plan look like?
It's amazing that the Democrats haven't been able to make any hay out of this.
The big money is against it. Oh, wait, I mean the BIG money.
And what money is for it? What BIG money wins by switching to universal health care?
The entire American economy presumably. It'a diffuse benefits/ concentrated burden problem.
We shouldn't lose sight of the point that Blagojevich's proposal is a really good idea! Universal coverage for kids is the way to kill America's horrible "private" health system. As Ogged notes, health care for children is really, really cheap. And once all kids are covered, then parents start saying "but what'll happen to poor Johnny when he turns 19!" So you extend it to cover everyone up to 25 (which costs practically nothing since twentysomethings are very healthy and twentysomething men won't go to the doctor even if they're sick and have insurance) and then the slope keeps on slipping until you hit the 65-and-over crowd on Medicare.
Everyone should get on board. We can soak the rich later.
You're an evil genius. I like that in a Democrat.
That is brilliant Matt, but the HSA evangelists (ask Ezra about Ron Grenier) will tell you that the kid will get sick and then get cut off of the program, as happens now with SCHIP. Or they'll be unable to purchase insurance on the individual market.
So long as you let me buy into medicare, I'd be okay with that though.
Here's a question: do costs associated with childbirth get covered under Blagojevich's plan, since they're related to the health of the child, or not, since they're also related to the health of the mother?
Blagojevich's plan rewards teenage pregnancy!
If the point of it is the camel's nose effect, pregnancy related/ childbirth care isn't all that urgent. It's pretty cheap, and I have the impression it's well-covered by most insurance plans, and that there's a fair amount of gov't funded care in that area for the uninsured. Not that it's not a problem, but it's not urgent enough that it makes just covering kids first a bad first step.
If you travel abroad and buy some sort of travel insurance, you have to payt quite a bit extra for maternity coverage. The same goes for people buying individual coverage with HSAs. Pregnancy coverage is quite a bit more. I think this is because men of the same age don't, as Matt says, go to the doctor.
117.4: 4. I'm not sure how strongly I believe this, but I do believe that government bureaucracies are more entrenched than company bureaucracy. So Jim, who's nice but an idiot, keeps his job (which, it turns out, is frustrating the hell out of you) for life.
But in private health insurance bureaucracies, Jim's job actually is frustrating the hell out of you. So you'll give up on the health care, or your claim, or something. This is particularly likely to happen because the person who's getting frustrated is by and large not the HR person who is deciding who your company buys insurance from. Anyway, the company has an incentive to find people who are really, really good at frustrating the hell out of you, and to replace actual human beings with even better smiling obstructionists--remember what happened to Mr. Incredible?
Respect to Chopper.
To build on 157. I also think that it would be easier to figure out how to work the system to get what you need. Chronic disease support groups could all discuss their strategies, who was helpful etc., whereas now everybody's insurance is different, and it's completely impenetrable.
If the mother is under 14, childbirth is covered.
1. Slolerner, I'll read the paper later. But I do not believe that there's a working consensus of health economists saying that the US going to EU or Canada style care will save money and improve care and keep the same level of medical innovation. The reason I believe this is direct reports from health care economists. The data, they say, is simply not such to support this conclusion. So Slolerner, if you are suggesting that it is simply a black letter economic fact that switching the US to a UK, Canadian, French or Japanese system will just generate free money and better health, I think that's simply not so. Interestingly, the paper you reference also suggests that the there is no correlation between tax+transfer levels, and GDP growth. Maybe this is true, but it's anything but uncotroversial.
2. This is all off point to the 'insure all children' plan, which, as everyone says, is a fine plan. I would prefer a 'insure cheap children' plan, but whatever.
3. Point taken, Apostropher, that the mechanism of how we pay need not determine what we pay for. I do think that in designing a health care system, however, we want to make sure there is a very robust incentive for medical innovation. Right now, as you know, the majority of that incentive (in pharmaceuticals, at least, but I bet in devices as well) comes from the US market. So it's not crazy to have worries on that score.
4. TNFa blockade drugs are not reimbursed in Canada. In the US, they are reimbursed, by private insurance plans that have a -- dare I say -- insurance function. We aren't all going to get arthritis, we pool our $, the unlucky get Enbrel. The very unlucky -- the uninsured and arthritic -- do not. My answer would be: have the government buy poor people Enbrel.
5. Joe O. Yes, $12,000 for Remicade would pay for lots of well baby visits. But this does not mean the presence of $12,000 remicade implies inefficiency in our health care market. It only means that people's preferences do not match up with a utility maximizing strategy for society as a whole. Arguably, I should want to buy well-baby visits for poor children before I spend $12,000 bucks on a drug to cure my cancer: more expected utility! More years saved! Maybe you think this is how government should be allocating money. But it's not how people want to allocate their money.
6. Ultimately, this is an empirical issue. I suppose in some vague way I prefer people to have more control, and cede less of it to government. But if I knew that moving to some form of single payer would increase input/outout efficiency of the US heatlhcare system two fold, I'd be all for it. But I do not beleive that because a) the direct data are inconclusive, b) it seems improbable that any system can be as inefficient as the argument claims the US system is, c) if we screw up the US market, we can kill medical innovation, d) short-term focused political actors are poor shepherds of an industry based on innovation, and d) it seems unlikely to me that a system which *increases* the prevalence of third party payment and *decreases* competition among payers is likely to increase efficiency.
Your point 5 doesn't actually contradict what Joe O said. Joe O said that $12,000 arthritis medicine doesn't generate as much utility as well baby visits. You concede this point and say that the individual actors with $12,000 may want to spend it on money for their arthritis (or does Remicade treat cancer as well) rather than on well baby visits for other babies. So government perhaps should allocate money away from Remicade to well baby visits, but individuals won't.
IOW, utility will be increased if the government interferes in the health care market, so that more money gets spent on well baby visits rather than Remicade. That's exactly what we're all advocating.
I think you may not be using "efficient" in the same way as Joe O is--you're using it in the sense in which markets are efficient. But a perfectly efficient market underweights the utility of the poor. (e.g., suppose someone starts out with $0, in a perfectly efficient market they'll starve.) We're interested in maximizing utility rather than efficiency, because we don't think money corresponds to desert, or that the most important human right is the right to spend what's in your bank account how you like tax-free.
robust incentive
I read up to here and then suffered corporeal death. It's a pity, because I'm sure the rest of your comment was crisp and persuasive.
Waitaminnit:
My answer would be: have the government buy poor people Enbrel.
Isn't that universal health insurance? What are we arguing about?
Or do you mean poor-quality Enbrel, made from people? Puppy-blood drinker!
I would prefer a 'insure cheap children' plan, but whatever.
You mean the ones you can get at the Dollar Store, or what?
Looks like I was wrong twice in one comment.
I suppose in some vague way I prefer people to have more control, and cede less of it to government.
Except the available alternative to government control is HMO control, not "people control".
Matt:
I think we're using 'inefficient' differently. Americans spent $22mm watching 'Deuce Bigalow, European Gigalo" -- that could have paid for well child visits for half the kids in Illinois! Is this a sign of inefficiency in the US health care system? No, obviously. Would taking that money away from people and giving it to poor children make overall resource utilization in the US better. Yes!
The question at stake is precisely what kind of government involvement in the health care system will amount to directing monies otherwise used for Deuce Bigalow (or its health care equivalent) to poor children. If our worry is poor children not getting well-baby checkup, we should pay for their well baby checkups. We should not monkey with the entire health care system, or replace the highly regulated (and admittedly crappy and ill-functioning) health care market with a even more regulated and likely to be more crappy health care government monopoly/monopsony. I don't want every physician to be an employee of a huge staff HMO. I don't want the return on every new drug decided by a single pricing decisions made by short-term minded political actors.
On the "give poor people Enbrel" idea, think food stamps. Some people can't get enough to eat. That's terrible. So we should levy a tax and give them food stamps. We should not respond by having the government set the price of bread or making every supermarket employee a government employee. Right?
cheap children
see, this is what happens when I rush to get to a ballgame. Cheap, poor -- they all blend together when viewed through my ruby-lensed spectacles.
very robust incentive
Ok, what I really want is for everyone in biotech to get so filthy rich they can pay hobos, or perhaps "the least advantaged" to duel bears. Happy now?
baa, at this point I think you're basically on our side and we're basically talking empirically about the details (well, aside from Yglesias's point that insurance and pharma are evil and must be destroyed). I mean, I think food stamps, except that food stamps work by giving everyone a little bit of money, which won't work here because you have to pool risk, so basically we're talking about giving poor people the money to buy insurance. And you've got to make sure companies will sell insurance to all those poor sick people, or there's no point in the exercise. Then as I understand you have to take care of adverse selection: make sure that healthy people like me buy insurance, because if only sick people buy insurance the insurance companies are going to go broke doublequick. So we have universal mandated insurance with subsidies for the poor, working through the already existing insurance companies. Isn't this HillaryCare, give or take a Regional Health Alliance?
I don't think the experience of other countries shows that single-payer schemes will be more crappy, though the prospect of Republicans being in charge half the time should give me pause. But anyway, I think at this point we're basically arguing details (and Holt says to quit it!)
(Note: I do not necessarily endorse the sentiments expressed in Holt's last paragraph.)
It sounds like a lot of what baa's criticizing is a British-style system where the government runs the hospitals, but as far as I know that isn't what most single-payer advocates are advocating. Most people seem to prefer a more Canadian-style system where the hospitals stay but the government takes over the functions currently performed by insurance companies (although I strongly doubt anyone is going to ban private insurance the way Canada does). That is, it's single-payer, not single-provider. "Medicare for All" (however it's specifically structured) is along these lines.
Re:157. I think that I support single payer, but if I were the one choosing the insurer, and not the HR people, it might be better. So, basically I'm saying that a voucher type system might be okay.
Of course, I have to be able to switch insurers, if I'm not happy with the one I have, and that means that if I'm sick, the premium that accompanies the voucher has to be adjusted. And nobody's really figured out how to do that well. Actuaries are pretty good at predicting claims costs for large groups, but they're not so good at doing it with small ones. (That's one of the huge problems with the individual market in states without community rating. They jack up your rates in a way that doesn't relate to your risk. Mention that you've used Flonase and your premium could go through the roof.)
So, on the whole, I'm still for single-payer providing Cadillac coverage, but I'd let people pay for Lamborghini coverage out of pocket or with supplementary insurance.
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