Editore"s Note
Tilting at Windmills

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January 12, 2007
By: Kevin Drum

A HEALTHCARE QUESTION....Tyler Cowen has a question for us advocates of universal healthcare:

Let's rate "the paper clip industry" as a 9 out of 10. Paper clips are pretty cheap and usually they work. Let's rate the better federal agencies as a 6.5 out of 10. Let's rate HUD as a 2.5 out of ten.

How will national health insurance do, keeping in mind that U.S. doctors do not wish to have their wages cut, Americans want the right to choose their doctors, and the U.S. is a huge, messy, decentralized, federalistic country with lots of cheats and massive, hard-to-eradicate inequalities at many different levels.

I give it about a 3. How about you?

Let me take a stab at this. Under Medicare, doctors are paid pretty decently, patients get to choose their doctors, and the system currently operates in the United States, messiness and all. So the short answer is that we don't really have to guess at this: national healthcare ought to work at least well as Medicare. And surveys indicate that the group of people who are most satisfied with the healthcare system in the United States are.....

The elderly. Who all use Medicare.

I don't know exactly what number to put to this, but a system that provides good quality care, gets high marks from its customers, covers everyone, and operates at a cost no higher than private healthcare seems like a pretty good deal. Maybe not as good as the paper clip industry, but surely at least a 6 out of 10.

And now a reverse question: how would Tyler rate the patchwork system we have today?

Kevin Drum 12:42 AM Permalink | Trackbacks | Comments (88)

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Comments

Best in the World!!

Posted by: ibc on January 12, 2007 at 1:16 AM | PERMALINK

Medicare for All --

Medicare for Everyone --

Universal Health Care in the USA is spelled MEDICARE --

Posted by: -ck- on January 12, 2007 at 1:17 AM | PERMALINK

How much of a penalty does 'universal' healthcare get for depriving people of the choice to not have health insurance, if they so choose? I'd rather pocket the money, because I'm healthy. Then, I can roll into an HSA and spend it when I need it.

Posted by: American Hawk on January 12, 2007 at 1:17 AM | PERMALINK

Whatever. I don't think anyone can legitimately argue that our Federal arrangment precludes the possibility of a successful national health program. Canada is a cliche example, but, they too are enjoy a Federal arrangement, as do the Germans, and the Austrians, each with publically financed health schematics.

Posted by: Everblue Stater on January 12, 2007 at 1:27 AM | PERMALINK

I'd rather pocket the money, because I'm healthy. Then, I can roll into an HSA and spend it when I need it.

My choice too AH. I don't like having that choice taken away from me.

Posted by: Al on January 12, 2007 at 1:28 AM | PERMALINK

The combination of single-payer Medicare a medicare supplement program is sensational. I've been on Medicare for two years, and the ability to choose pretty much any doc and schedule procedures when convenient can't be beat. Single-source healthcare, such as Britain's National Health service, works pretty well for Brits. Even the Conservatives support it. I'm dubious that the scheduling priorities would be easy for Americans to get used to...those Americans who already have health coverage, that is. Personal experience tells me that the British National Health is a lot more civilized than medicine in the U.S. Emergency Room.

Single payer basic coverage plus insurance top-up coverage should give the health insurers a bone to chew to keep them quiet.

Posted by: Etaoin Shrdlu on January 12, 2007 at 1:30 AM | PERMALINK

A few things.

1. Why would a national system eliminate choice?

Right now, I'm still on my mom's plan--I'm a college senior--and I can only see certain doctors.

2. Doctors wages might decrease, but there's a few things to keep in mind. If we can believe what Dean Baker says, their wages are artificially high because they are shielded from some competition. A true free market system for doctors would probably lower their wages because of the increased competition. It'd be interesting to see some numbers on a how a true free market system (in comparison to what we have now, where they don't face all competition) would compare with a national system. Also, I've been told that most doctors make their money through investments. If that is true, as long as their money isn't cut by absurd levels, like going from $100,000 a year to $30,000 a year, I am not sure why a decrease in pay is going to be the end of the world.

3. I'll admit, I don't know much about the particulars of each health care system, but I do know France has the best rated system in the world and still has a role for private insurance. How has this affected the pay for doctors?

4. Why is HUD so bad? There must be something I've missed out on.

Posted by: Brian on January 12, 2007 at 1:33 AM | PERMALINK

You might also consider the Veterans Health Administration as a model. It seems to get good marks now, but it didn't in the past. It's a good example of how a government agency can be improved when given the proper attention.

Posted by: fostert on January 12, 2007 at 1:33 AM | PERMALINK

Kevin, why do you say Medicare operates at a cost no greater than private health care? What evidence is there?

When Medicare started, it's cost fantastically outstripped the actuarial estimates prepared by the Social Security Administration. I recall discussing this with the then chief actuary of SSA. As I recall, the cost of Medicare was around ten times what the actuaries had predicted.

Anyhow, the excuse for mandatory governmental health care is supposed to be that it will save money. If it merely breaks even, then I'd rather keep my freedom of choice. Provide welfare for the needy, but please leave me and my family alone.

Posted by: ex-liberal on January 12, 2007 at 1:33 AM | PERMALINK

One more thing.

It doesn't really matter whether or not you want health insurance. 1) If you are the victim of a tragic accident, or develop cancer, you will want health insurance. Chances are, in the case of critical care, you HSA wouldn't even come close to covering your care. Of course, as decent human beings, the rest of us could not tolerate you leaving the hospital with untreated broken bones, bleeding organs, or cancerous growth and would, collectively, be obliged to pay. You, of course, would gladly accept, as the alternative is your unavoidable death. Tell me with a straight face that you would walk out of the hospital and DIE rather than recieve care paid for by others. 2) I would argue (as others have - John Rawls, Martha Nussbaum), that we have an obligation as human beings, and as social contract participants, to ensure a basic standard for everyone. This does not mean a free ride to the middle class, but it does mean basic health care - emergency and preventative. It's not as though these goals are untennable; plenty of similar countries have enacted similar programs, even *better* than the Canadian model which conservatives and neo-libs are so quick to poo-poo (sure, Canadians have to wait in line, but you'd be hard pressed to find a significant proportion of them that would be willing to trade places...).

Posted by: Everblue Stater on January 12, 2007 at 1:35 AM | PERMALINK

Medicare.

Is.

Running.

Out.

Of.

Money.

Just so this sinks in.

Posted by: grunion on January 12, 2007 at 1:36 AM | PERMALINK

American Hawk and Al,

You're welcome to your choice.

And when you fall suddenly ill and burn through you HSA after 12 hours in the hospital, the rest of us are welcome to throw you out of the hospital and let you die in the street.

Deal?

Posted by: trostky on January 12, 2007 at 1:40 AM | PERMALINK

I'd give it a pretty good score. However, I think it's bizzare that decisions on covered procedures requires an act of congress (some of which haven't been revisited since the 1980's). Let's delegate this job to teams of doctors (and administrators) with a little more experience and try to stay on top of the science.

And by all means deny AH medicare.

Posted by: B on January 12, 2007 at 1:40 AM | PERMALINK

Must I remind you that the elderly are pretty content with the jello and apple sauce.

The beauty of HSA's is that when you're old and senile you get to decide how much to spend on viagra and penile implants and how much to save for a possible cancer treatment or a liver transplant. When one's life is at stake one makes remarkably good decisions. It's called game theory. Google it. Bureaucrats in DC looking at tables and charts get paid whether you live or you die.

Posted by: Al's parrot on January 12, 2007 at 1:57 AM | PERMALINK

Al and AH,
Best be quiet and do as you're told. Liberals know what's best for everyone, after all. We all know how efficient federal programs operate and how wonderfully effective they are, so there should really be no debate. Just hand over your taxes and let them decide how to spend it on healthcare for you.

Kevin,
Old people like anything they don't have to pay for, so their favorable view of medicare is not a surprise.

Posted by: Homer on January 12, 2007 at 2:26 AM | PERMALINK

"Kevin,
Old people like anything they don't have to pay for, so their favorable view of medicare is not a surprise."
Old people have already paid for it by contributing taxes during their working years. Is this system too difficult for you to understand?
The fire department and police department work the same way. Doh!

Posted by: DK2 on January 12, 2007 at 2:34 AM | PERMALINK

"It's called game theory. Google it. Bureaucrats in DC looking at tables and charts get paid whether you live or you die."

And which game might that be? Last I checked, game theory involves multiple actors, and (often) multiple rounds. I don't see how this is a game theoretical situation.

Posted by: Everblue Stater on January 12, 2007 at 2:38 AM | PERMALINK

So AH and Al both admit to being free riders?

What a surprise.

Posted by: Disputo on January 12, 2007 at 2:40 AM | PERMALINK

I feel that the satisfaction ratings of all health systems are unfairly biased upwards on account of those most dissatisfied with their treatment being unable to comment due to the fact that they is dead.

Posted by: brooksfoe on January 12, 2007 at 3:28 AM | PERMALINK

First, let's agree that we can stop paying attention to Tyler Cowen, who seems to be blissfully unaware of the world outside America's borders. One wonders if he understands the metric system.

Clearly, given the example presented by pretty much the entire developed world, we could give everyone in the country better care than we're getting now for less money than we're paying now. (Given their example, however, we'd be arguing over how much at what cost pretty much forever, but it would be an issue for citizens and governments instead of, primarily, employers and workers.)

Unfortunately, American exceptionalism instists that American government is uniquely bad, and continues to support the election of Republicans, who tend to confirm the low opinion of government. They want to govern us in the worst way, and they do.

Posted by: bad Jim on January 12, 2007 at 3:40 AM | PERMALINK

I would also like to commend Cowen and many commenters for their hopeful, can-do attitudes. Assholes.

For ten years I was a part owner of a manufacturing concern which, as a matter of course, offered health care to its employees and their dependents. Year after year we paid more and more for worse and worse coverage. The doctors aren't crazy about the situation either, and anyone with a functioning brain realizes that this trend cannot be sustained.

Universal health care, most likely in a single-payer version, obviates a great many problems, and makes many of the remaining problems potentially more tractable. HMO's are already rationing healthcare. Would we rather have our health decisions made for us by private firms with essentially no accountability, or can we make those decisions openly and democratically?

Note that, under single payer, the doctor remains an entrepreneur competing for patients (which would be a freer market than that currently offered by HMO's).

Posted by: bad Jim on January 12, 2007 at 3:52 AM | PERMALINK

More and more of the doctors I've talked with in recent years now favor a national health care system. They feel that any reduction in their incomes is very likely tob e offset by reduced expenses: billing multiple insurance systems gets harder and more complicated all the time, and different private insurers impose more and more restraints on what the doctors they agree to pay for can do. It's as though all federal regulation could be duplicated by half a dozen or more private agencies, and one had to comply with all of them somewhow. They don't like the cost, or the time spent on rival compliance claims, or the wear and tear on their patients' morale (much of which manifests as stress that makes healing harder).

Posted by: Bruce Baugh on January 12, 2007 at 3:56 AM | PERMALINK

How monumentally stupid must you be to compare the market for something as simple and inconsequential as paperclips to providing healthcare?

Posted by: plunge on January 12, 2007 at 4:13 AM | PERMALINK

The only way our present health-care system can be defended is through a mental exercise that draws upon no facts, hence the paper clip metaphor.
The fact is that every other wealthy country on the planet has national health care. That service works for 100% of the people - not 80% to 85% as in the U.S. It delivers the service cheaper than the service is delivered here - not 2% to 3% cheaper, but more than 25% cheaper. The service is of higher quality - not slightly better quality, but substantially better as measured in results like infant mortality and in customer satisfaction.
So if you opposed a measure and had uncomfortable facts like that to call upon, how would you try to carry the debate? You'd play a pretend game. You'd pretend that it is impossible for government to perform well and appeal to an American bias that all government is bad. If you can't deal in facts, you hide behind rhetoric.

Posted by: Ronn Zealot on January 12, 2007 at 4:36 AM | PERMALINK

"How much of a penalty does 'universal' healthcare get for depriving people of the choice to not have health insurance, if they so choose? I'd rather pocket the money, because I'm healthy. Then, I can roll into an HSA and spend it when I need it."

In other words, you want to not pay into the system when you're young and healthy, so the rest of us can support for you when you're old, broke and sick.

You're nothing but a Cadillac-driving welfare queen, American Hawk

Posted by: rea on January 12, 2007 at 5:51 AM | PERMALINK


American Hawk may well be healthy and I hope he stays healthy for many years. But if he has a problem, say a heart attack or some type cancer, isn’t it too late to sign up. My wifes two stents this past May were billed at $54,400. The insurance paid a lot less than that, but someone w/o insurance would pay, at a minimum at least half that.

Disclosure: I’ve been on Medicare for 11.5 months and I do have two other insurances that pick up what Medicare doesn’t. And I had a bypass 5 months ago.

So far “choice” has not been a problem. I have selected the primary care physician I wanted. I selected the hospital and cardiologist and chest surgeon I wanted. I they were not ‘Medicare approved’ maybe I should have avoided them anyway.

Posted by: Chief on January 12, 2007 at 6:19 AM | PERMALINK

Sorry, I tried to say ". If they were not ‘Medicare approved’ maybe I should have avoided them anyway."

Posted by: Chief on January 12, 2007 at 6:29 AM | PERMALINK

Cowen's dishonest little opinion reeks of conservative faith, not fact: He simply won't believe that government can do anything well, let alone as well as business. His entire rating system is therefore bogus.

And frankly, Kevin, so is yours. A six out of ten, for crying out loud? That isn't even a D! What gives?

Posted by: Gregory on January 12, 2007 at 6:35 AM | PERMALINK

ARE YOU KIDDING?

The elderly are the quiet calm pussycats of our nation; if you let loose the nations most corrupt demographic, 15-25 year olds, on a Dept. of Health Care it will be 1 out of 10.

The system today is a 9.0, considering the caliber of people it deals with; maybe you regressives should make some efforts there to make up for your 60s/70s "quagmire".

This is about a tax on the wealthy, in cash and in kind (subjection to this monstrosity), to pay for health care than nearly all uninsured can afford.

And then, what about the staff of this Department? Unionized? Who can go on strike despite whatever law you pass? Who will become part of the Democratic payola/ponzi scheme like the Teachers Union?

TOH

Posted by: The Objective Historian on January 12, 2007 at 6:56 AM | PERMALINK

It seems to me a smart liberal would not talk about the governments efficiency in the abstract, but would argue that the private sector's inefficiencies counterbalance the bureaucracy inherent in government programs. Compare and contrast the VA with HealthSouth or some of the other embezzlers, or point to CEOs making obscene incomes on their patient's $1600 physical therapy session.

An analogous situation is car insurance rates: if the Dems would argue that we should raise gas taxes 50 cents, but all the illegal aliens and scofflaws that aren't insured now will have to contribute to the insurance pool and honest people's costs will drop = and then you followed through with demonstrable savings for the middle class on their total balance sheet - you might start to get people to believe government is the right institution to solve some problems. The big obstical for Dems would be how to curb the trial laywers and insurance lobby gutting the program, or standing it on it's head, in the same way Repub's lobbies bastardized deregulation in many instances.

Posted by: ex-minion on January 12, 2007 at 7:07 AM | PERMALINK

I'm a long time proponent of universal coverage and think that single payer is the way to go. However, Cowen's post did spark a question in my mind.

I don't know what the objective evidence says about reimbursement but my admittedly unscientific survey is that 100% of the Doctors I know complain about reimbursement rates. I don't know if that's legit or not, but how many will drop out of the system to pursue other occupations if 100% of their patients go to medicare sized reimbursements? And, are those with private insurance effectively sunsidizing medicare by paying higher reimbursements. This subsidy will disappear in a single payer system causing reimbursement rates to need to increase and lowering any cost savings. (OK, 2 questions)

Posted by: Bob on January 12, 2007 at 7:18 AM | PERMALINK

My wife went from corporate healthcare to Medicare, and Medicare is by far the best. One sees that even Medicare is quite inefficient, however, and could be made cheaper by computerizing records and tests, etc.

Posted by: bob h on January 12, 2007 at 7:24 AM | PERMALINK

At this point, I can't see how anyone with half a brain and the remnants of a scruple could defend our system, especially now that consolidation in the industry has created a healthcare oligopoly that can get away with anything. Case in point,
William McGuire, CEO of United Healthcare, with $1.8 billion in exercisable stock options (yes, Billion, with a "B"). Their greed and contempt for principle is so boundless that $1.4 billion was too paltry, so he and the company are now under investigation by the SEC for backdating his stock options to more favorable prices. (Regardless, he just "retired" with $6.4 million lump sum gift, a $5.4 million supplemental pension, and an office, secretary, paid life and disability insurance premiums and health care for his family, etc., etc.)

A couple of comments in an online discussion with WaPo business columnist Steven Pearlstein put this in perspective (worth reading the whole thing):
From a doctor: As a local MD practicing in Arlington I have found United Healthcare to be completely disinterested in the needs of patients or physicians. United has repeatedly reduced payments for services and ultimately we dropped United as of October 1st since the company had no desire to even discuss reimbursement with us... United Healthcare was interested in only one thing: an increased stock price and the massive options deals offered to the top executives.

From a businessman:the folks in our Chicago office had MAJOR headaches a couple years back when all their area hospitals started refusing United coverage. You can imagine what headaches that created for our HR people.

And from Pearlstein, regarding United Healthcare's extensive relationships with Medicare and Medicaid: Its fair to say that at least a third, if not more, of the UnitedHealth's excessive compensation came at the expense of taxpayers.

Posted by: R. Porrofatto on January 12, 2007 at 7:34 AM | PERMALINK

The one thing I learn from Tyler Cowen is that having a pricey education really doesn't mean anything. This is also true of the 'choice' he's so eager to exercise in healthcare. Happily, Tyler will be paid out in his own coin, spending his time visiting doctors who will prescribe expensive and unnecessary drugs because they see no point in explaining to him that his health is normal and he should get on with life.

If you want to improve your life, don't get any medical treatment (other than dental care) that Medicare won't pay for. As the years pass and you learn how useless the "new" treatments were and how many side-effects the drugs had, you will be increasingly happy about all the time you did not spend in a doctor's office.

As for the trolls, someone should go undercover and find out how they get paid for regurging the old AMA propaganda that even doctors don't believe anymore. My god, it's like having old Reader's Digests around posting here all the time.

Posted by: serial catowner on January 12, 2007 at 8:04 AM | PERMALINK

I challenge the assumptions that doctors would oppose a single payer plan, or would experience a reduction in income. Every doctor I know would prefer a single payer plan, and is very unhappy with the labor requirements that come with dealing with insurance companies. Not to mention slowness of payment and endless disputes over reimbursement.

The frustating experiences that we as patients have only happens when we interact with the health care system. Imagine interacting with it every working day. That's what doctors have to put up with.

Posted by: jayackroyd on January 12, 2007 at 8:16 AM | PERMALINK

Anyhow, the excuse for mandatory governmental health care is supposed to be that it will save money. If it merely breaks even, then I'd rather keep my freedom of choice.

Right now, the United States government spends more on health care per capita than any other country. Then, you add on the other 55% of private health care expenditure, to arrive at the US spending more than twice as much than any other country. There is no doubt that a federal single payer plan would be cheaper.

Freedom of frickin' choice? What health care plan are you on? The people who now are operating out of network and paying cash to doctors who refuse to participate in the insurance racket will still be able to do that under an single payer plan. You're creating a doubly false dichotomy. Anybody on a health care plan has very limited freedom of choice, and under any single payer plan, there will always be the opportunity to pay that Park Avenue opthamologist 300 dollars for an eye exam. (Real world example. All the eye doctors in network also sold glasses and/or performed Lasik surgery. I wanted an independent opinion. Won't happen again.)

Posted by: jayackroyd on January 12, 2007 at 8:24 AM | PERMALINK

The one thing I learn from Tyler Cowen is that having a pricey education really doesn't mean anything. This is also true of the 'choice' he's so eager to exercise in healthcare. Happily, Tyler will be paid out in his own coin, spending his time visiting doctors who will prescribe expensive and unnecessary drugs because they see no point in explaining to him that his health is normal and he should get on with life.

This is a point that doesn't get made often enough. The reason we have the current diastrous system is because the fee for service medical system was studded with incentives for overtreatment. Unnecessary operation, like tonsilectomies and hysterectomies, were the norm.

The idea behind HMOs was that they would create incentives for doctors to engage in preventative care (which didn't generate much in the way of fees in the old system). The notion was shifting incentives toward keeping people healthy rather than treating them when they got sick.

It didn't really work out that way. It turned out that all HMOs did was create an incentive to exclude sick people from coverage and added a huge incentive to undertreat--confounding the original plan. Your doctor is better off if you don't have an annual physical, don't make office visits, don't take care of yourself.

Posted by: jayackroyd on January 12, 2007 at 8:32 AM | PERMALINK

“Most of it involves transfers from the young to the old. Down the road, most medical care will be for people over age 65, and most of the payments will be from taxes on younger people.” - Victor R. Fuchs, economist, Stanford

Posted by: MsNThrope on January 12, 2007 at 8:34 AM | PERMALINK

The first question should be.. who is Tyler Cowen and how much money is he getting from the health insurance lobby.

Posted by: underseige on January 12, 2007 at 8:44 AM | PERMALINK

From a Canadian point of view, I would guess that future universal health care in the US should logically be rated at 9 to 9.5/10. Why? Because it is coming in now, in the Internet Age. There are no vested interests in "the bureaucracy" who are afraid of online efficiencies, so it can be efficient from day one.

By waiting so long to implement universal health care, the United States lucks out big time, since it can design its system from the ground up with Internet architecture. No public or private insurer can compete. It can be a model for the rest of the world.

Posted by: Bob M on January 12, 2007 at 8:47 AM | PERMALINK

It seems to me a smart liberal would not talk about the governments efficiency in the abstract, but would argue that the private sector's inefficiencies counterbalance the bureaucracy inherent in government programs. Compare and contrast the VA with HealthSouth or some of the other embezzlers, or point to CEOs making obscene incomes on their patient's $1600 physical therapy session.

Yeah, gee, it's amazing no one's made those arguments before! [/snark] I'm grateful to not-at-all-ex-minion for revealing his ignorance of this issue, but that's hardly surprising for someone whose misguided worldview seems to be sprung from a rancid swamp of Rush Limbaugh bloviating, National Review intellectual dishonesty and RNC blast-faxes.

you might start to get people to believe government is the right institution to solve some problems

People already believe that. Intelectually dishonest, faith-based so-called conservatives like Cowen and yourself don't, based on nothing but faith, cynicism and the fact that when people like you get in power, you screw evertyhing up. As P.J. O'Rourke said (before the Katrina debacle, back in the '80s, yet!), Republicans claim government doesn't work, then get elected and prove it.

Posted by: Gregory on January 12, 2007 at 9:44 AM | PERMALINK

I'm ok with the paperclip analogy. Let's compare US paperclips (health care) with about 20 comparable suppliers.

US paper clips are 30% more expensive than the next most expensive (Switzerland) and 40% more expensive than the third most expensive (Germany). Only four other suppliers (Iceland, Canada, Denmark, and France) cost even half as much as the US paper clips.

15% of US paper clips require special "emergency maintenance" to keep them working, where clips from other suppliers get by with regular maintenance and only require emergency service in cases that are actual emergencies (15% of US citizens get no insurance and must seek healthcare in emergency rooms, vs 0% for the other suppliers).

7.1 US paperclips, out of a thousand, fail within their first year of use. No other comparable paperclip supplier has such a high failure rate; theirs are typically below 6, and often below 4. Surprisingly, a budget competitor (Cuba) manages to deliver paperclips with a failure rate (6.45) below that of US paperclips. (Infant mortality).

US paper clips fail earlier than others. Japanese paperclips have an expected lifetime of 81.25 years, though this is widely believed to be partly caused by the use of special Japanese paper with special fish-oil and tea-leaf additives. US paper clips fail (on average) at 77.85 years. There's 16 other brands with measured average liftimes of 79-80 years and 7 brands expected to last between 80 and 81 years. Some of these paperclip suppliers are niche brands, but most of them supply large numbers of paperclips, like the US. One explanation for the poor performance of American paperclips is that American paper is fatter than any other paper, and this puts an unusual strain on the paperclips, but casual tests reveal no particular correlation (http://www.nationmaster.com/correlations/hea_obe-health-obesity), and other countries also have paper that is nearly as thick. Furthermore, it turns out that paper thickness measurements cannot reliably be compared between countries; three of the six countries with the thickest paper measure it with special paper examiners, whereas the rest are "self-reported", and self-reported paper measurements are typically thinner, and less accurate. So, other countries' paper may not be as thin as claimed.

During their lifetime, paperclips sometimes suffer periods of "ill health" when they do not work very well. Again, the US paperclips fall short of their competitors, compounding their already shorter lifetime and higher initial failure rate. Of the 29 paperclip suppliers for which this statistic is reported, the average percentage of time spent in "ill health" is 9.8; the US falls below the average, at 10.8 (20 other suppliers do better). Comparable suppliers, UK, Spain, and France, produce clips that are only ill for 8.8% of their life. It's possible to combine both expected lifetime and percentage in ill health to obtain the expected years of healthy lifetime; here, again, the US falls short, with only 67.6 working years, versus 73.6 for Japan. 21 suppliers deliver paperclips that will be useful for more years than US paperclips.

Using these objective measurements, US paperclips have lower quality on every single metric, and are also more expensive. Paperclip purchasers seeking comparable quality at a lower cost could save 2/3 of their money by buying paperclips from Portugal or Greece. Customers seeking premium paperclips could still save money by trying the French, Canadian, or Australian brands. Customers in search of the very best paperclips should look hard at both Japanese paperclips, and Japanse paper manufacture; it appears that their exceptional performance may be partly due to their fish and tea paper additives. In any cases, it's clear that paper clip customers have a world of choices that are superior, both in price and performance, to the US suppliers. It's a mystery why any rational person would buy US paperclips.

Posted by: dr2chase on January 12, 2007 at 10:02 AM | PERMALINK

It's a mystery why any rational person would buy US paperclips.

...which says a lot about Cowen for his enthusiastic support of US paperclips and disdain for any alternative, no?

Posted by: Gregory on January 12, 2007 at 10:09 AM | PERMALINK

I think it's important that the discussion focus on the availability of health care rather than on the availability of health insurance. It may seem a distinction without a difference, but focusing on providing care rather than on insurance rates, payment schedules, and profits might help to bring the issue home to more voters.

Second, someone above reminded us that Medicare is running out of money. This is an issue now and it will become even more severe as we boomers get old and sick. However, all money issues involving public services boil down to priorities rather than actual dollars.

So, for example, it might become some administration's priority to cut funds from somewhere else - I'd say we could find $100 billion or so in the Defense Department alone - and send it to Medicare. If the voters make their own priorities clear, politicians will follow.

Posted by: Jack Lindahl on January 12, 2007 at 10:16 AM | PERMALINK

> keeping in mind that U.S. doctors do
> not wish to have their wages cut,

I think it is really important to keep in mind that if you talk to primary care physicians, PAs, nurses, internal medicine providers, etc. you will get a very different take on fees, salaries, insurance companies, etc than you will talking to specialists.

Having had occasion to sit in my primary care physician's office for a while (yes! - even here in the good ole USA, home of the Best Medical Care Ever(tm) people sometimes have to wait) I have tried to calculate out his (and his small group's) income and expenses. I really can't figure out how he makes a profit, much less take home a decent salary.

Cranky

Posted by: Cranky Observer on January 12, 2007 at 10:16 AM | PERMALINK

> Second, someone above reminded us that
> Medicare is running out of money. This
> is an issue now and it will become even
> more severe as we boomers get old and sick.

Of course, all that care for the old and sick will create new jobs and opportunities for the young. Admittedly we will have to dial back the war spending quite a bit to make the shift.

Cranky

Posted by: Cranky Observer on January 12, 2007 at 10:17 AM | PERMALINK

I may as well give a pointer to the story my brother wrote about insurance which appeared last summer in Analog You can read it on-line at his blog:
http://petcalls.typepad.com/pet_calls/2006/12/total_loss.html
(I posted a bunch of links to reviews of the stories in the comments on the story)

Posted by: Don Hosek on January 12, 2007 at 10:18 AM | PERMALINK

I really can't figure out how he makes a profit, much less take home a decent salary.

Short answer: Drug company kickbacks. It is not unusual for a company like Merck or Pfizer to unsolicited send checks for ten grand or even more to physician office, with the unwritten understanding that the physician will prescribe their brand-name drugs that have no generic equivalent.

Posted by: Blue Girl, Red State on January 12, 2007 at 10:21 AM | PERMALINK

Isn't that quid pro quo?

And isn't quid pro quo illegal?

Posted by: Blue Girl, Red State on January 12, 2007 at 10:24 AM | PERMALINK

Tyler Cowen is an idiot for many reasons on the subject of national health insurance, particularly when he talks about paper clips instead of comparing how real-live private sector insurance companies operate. The privte insurance industry takes your money, provides crappy service (Ever deal with them over the phone? It's worse than the DMV. Really), and when you need them most, they say "no" to coverage. That's the real experience many people have with insurance companies, who each have an army of lawyers, marketers, accountants, sales folks, and obscenely paid CEOs--and we wonder why their admin costs are 20-30% compared to Medicare's 2%.

And for anyone who is worried about Medicare's relatively low reimbursement rates, let's recall that Medicare currently covers ONLY the MOST at-risk population: the elderly. This puts a strain on the system that requires more cost containment than insuring the rest of the population. When we consider that one fact, the rest of the positives about Medicare's performance that Kevin noted become that much more amazing.

A Medicare for all program would create far more efficiencies in administrative paperwork and lowering medication prices. Most single pay programs also promote choice for individual doctors and hospitals, unlike the private sector captive HMO programs.

Again, Tyler Cowen is an idiot. He should be ignored like someone who works at some communist rag newspaper that is handed out for free at college campuses.

Posted by: Mitchell Freedman on January 12, 2007 at 10:30 AM | PERMALINK

ex-minion: Compare and contrast the VA with HealthSouth

Right you are, ex-minion. If we have to move toward socialized medicine, let's model it after the VA, not Medicare. Medicare is atrociously expensive. Those getting benefits like it, but those paying in are getting hosed.

OTOH the VA really does deliver decent medical care at a reasonable cost.

Posted by: ex-liberal on January 12, 2007 at 10:35 AM | PERMALINK

If we have to move toward socialized medicine, let's model it after the VA, not Medicare.

I'm sure you get bonus points with your neocon ilk for working the phrase "socialized medicine" into your dishonest and erroneous analysis, but to the rest of the world, it just marks your post as more "ex-liberal" bullshit.

Medicare is atrociously expensive. Those getting benefits like it, but those paying in are getting hosed.

Medicare pays for medical care for the elderly, who naturally consume more health care, you dolt. Those who pay in receive the same benefit later -- as long as we can keep you Republicans hands off it, which should be no problem, because to your eternal vexation, it's an enormously popular program, and years of dishonest Republican propaganda -- but i repeat myself -- has done nothing but delude faith-based conservatives such as yourself. Suck on that, you feckless turd.

Posted by: Gregory on January 12, 2007 at 10:49 AM | PERMALINK

Kevin: exactly the right question to ask.

Posted by: Dammitman on January 12, 2007 at 11:05 AM | PERMALINK

I will reiterate my theory about universal health insurance (Medicare for all). My father, aged 69, easily the most right wing person I know, is as big a fan of Medicare as I know.

If it works for crusty, but loveable, Republicans, then it will certainly be popular with crazy liberals.

Posted by: swarty on January 12, 2007 at 11:53 AM | PERMALINK

How much of a penalty does 'universal' healthcare get for depriving people of the choice to not have health insurance, if they so choose?

American Hawk: a number of different universal health insurance models in existence are characterized by significant participation by private insurance companies and private sector healthcare providers. The French system -- arguably the world's gold standard in universal healthcare -- is one such example.

Posted by: Jasper on January 12, 2007 at 12:06 PM | PERMALINK

Kevin,

The elderly rate Medicare highly because they are not paying for it. I suppose many of the people paying Medicare taxes today, and resenting it, will rate Medicare highly in the future when they are drawing benefits. I would rate the Ford Expedition as excellent if they gave me one for free, or even at half the cost.

Also, on the issue of whether or not doctors are well paid by Medicare, the relevant point is whether these doctors are paid better by private insurance companies for service or better paid by Medicare. Doctors who treat both types of patients, and are reading this thread may have some information to offer in this regard.

And I make the following point repeatedly, but it seems to never sink in with this crowd: it does not follow that universal healthcare in the United States, based on the model of any of the countries frequently cited, will produce the same outcomes and levels of expenditures those countries have. The history, the demography, and the expectations of US citizens is quite different than that of other countries. The arguments that universal care will bring more healthcare to the uninsured who need it are much stronger than the arguments (completely unsupported by actual evidence) that it will be cheaper overall and give better outcomes to the average American.

Posted by: Yancey Ward on January 12, 2007 at 12:13 PM | PERMALINK

Paper clips seem like a 9 out of 10 because their unit costs are low. If the industry were inefficient and monopolized the cost per unit might be .05 cents instead of .04 cents. It's a 25% increase, but you wouldn't really notice that, would you?

Posted by: Saam Barrager on January 12, 2007 at 12:19 PM | PERMALINK

I make the following point repeatedly, but it seems to never sink in with this crowd: it does not follow that universal healthcare in the United States, based on the model of any of the countries frequently cited, will produce the same outcomes and levels of expenditures those countries have.

Not to speak for "this crowd," but especially given the sorry-ass state of our current health care system and the fact that every other industrial nation on Earth seems to do better, your argument that it maybe might not work here isn't as impressive as you think it is, Yancey.

But then again, your arguments never are as impressive as you think they are. But they are ruggedly individualistic, so that's okay, then.

Posted by: Gregory on January 12, 2007 at 12:22 PM | PERMALINK

I imagine that a single payer system would also absorb or completely eliminate a lot of insurance-related costs that are currently externalities for the insurers themselves.

For example: My employer, a medium-sized business, spends hundreds of work hours per year dealing with health insurance. Shopping for a plan every year, hiring an insurance broker, negotiating with insurers, administrating the benefit for employees, etc. etc. Hell, rounding up all of the employees for the annual health insurance explanation meeting takes about 125 work hours right there.

Posted by: Joe Bob on January 12, 2007 at 12:31 PM | PERMALINK

If medicare pays so well, why are so many physicians opting out of the system?

Posted by: Doc on January 12, 2007 at 12:34 PM | PERMALINK

Yancey, I suspect that it would create better outcomes for the "average American," who is typically tied to his or her job because of the rapidly-declining health-insurance benefits.

However, it would probably have outcomes not in line with the health care expectations of upper-middle class residents of Manhattan's upper west side and the surrounding suburbs, whom I suspect is that audience that Mr. Cowen is writing for.

Posted by: Tyro on January 12, 2007 at 12:40 PM | PERMALINK

If retired people in this country had to wait for their bypasses and joint replacements, or, heaven forbid, were told that they would not be paid for, in a similar fashion to what occurs in the systems Kevin touts, they would revolt. In fact, the greatest single barrier to adoption of such a system is that those who oppose such an adoption, for either selfish or altruistic reasons, will be very sure to educate Medicare recipients as to how the typical 75 year old, overweight, diabetic who desires a knee replacement or a heart procedure in such systems is provided for. Given that this is the demographic in our electoral system which is most highly sought by our major political parties, such a change will not happen.

Posted by: Will Allen on January 12, 2007 at 12:41 PM | PERMALINK

Actually, tyro, the desires of middle class retirees are the people who largely drive domestic political decisonmaking in this country. Which is why the systems Kevin touts will not be adopted here.

Posted by: Will Allen on January 12, 2007 at 12:44 PM | PERMALINK

"I'd rather pocket the money, because I'm healthy. Then, I can roll into an HSA and spend it when I need it."

Good idea! Because viruses and bacteria only infect unhealthy people! *rolls eyes at conservative magical thinking*

Posted by: Pocket Rocket on January 12, 2007 at 1:13 PM | PERMALINK

Like Kevin, I'm a huge proponent of universal healthcare, but unlike him, I took off the Medicare blinders long ago.

Unlike Social Security, which it's often unfairly compared to, Medicare IS going broke.

Medicare does not reimburse fairly. That's why a lot of doctors stopped accepting Medicare patients altogether, and virtually NO doctors accept Medicare reimbursement as payment-in-full.

Seniors that cannot afford [often] expensive supplemental policies are forced into Medicare HMOs. Many of these programs offer decent care, but are fraught with administrative nightmares that many seniors are not capable of understanding and navagating. This resuts in access and denial of service issues.

If you scrol through the comments, you will see that the seniors that are positive about Medicare are those with one or more supplemental policies. Because of their income, and their ability to purchase additional health insurance, Medicare works out great for them. I would wager that Seniors who rely solely on Medicare for the totality of their health care would not be so positive.

Posted by: SteveK on January 12, 2007 at 1:22 PM | PERMALINK

Whoa Momma! The elderly SHOULD like the Medicare system, because it is highly subsidized by the rest of us. In fact, it is subsidized with borrowed money right now, because we aren't willing to raise enough taxes to pay for it.

If you extend Medicare to everyone, you will have a medical system that we are TOTALLY unable to pay for except by rationing access and cutting reimbursements. That means absolutely no one will like it.

This is not to say that government has no role in the solution, just that the solution is not simple. Medicare is not the model for a better health care system.

Posted by: RWC on January 12, 2007 at 1:26 PM | PERMALINK

If retired people in this country had to wait for their bypasses and joint replacements, or, heaven forbid, were told that they would not be paid for, in a similar fashion to what occurs in the systems Kevin touts, they would revolt.

It seems to me that waiting for a needed bypass is one of those things that would negatively influence either expected lifetime, or percentage of life in ill health. How would explain the discrepancy between your claimed delays, and other countries' superior measures on these statistics?

Seriously, the numbers are all there to see, and they're scandalous. Are you a rational person? How can you possibly defend our health care system, given how it falls short in all ways that matter? Or do you believe that high cost, high infant mortality, reduced lifespan, and reduced health are good things? Do you know of any metric that could possibly be more important for a health care system?

I can only imagine that your paycheck depends on the current busted system. Long term, for either political party, hitching their wagon to the current system is suicide, and I think they have figured this out (maybe you missed the memo). Sure, a party can get insurance money in the short term, but the costs are throttling business, starving municipal budgets, and the insurance companies are already giving us the paperwork, delays, and lack of choice that you claim (probably incorrectly) are the hallmarks of universal healthcare.

Posted by: dr2chase on January 12, 2007 at 1:30 PM | PERMALINK

A couple of points to spur creative thinking among people interested in this topic:

In 1960, when the U.S. spent less than 6 percent of GDP on health care, it ranked 16th out of the 30 countries that now belong to the OECD in terms of life expectancy. Today, we spend 16 percent of GDP and we're ranked 22nd.

Since Medicare was enacted in 1965, it has, in most years, done better at controlling costs than the private health insurance system. However, in the most recent year data is available (2005, the study just came out last week from CMS and was published in Health Affairs), government-run programs saw their costs inflate by over 9 percent while private insurers saw their costs go up less than 7 percent.

For an example of how the private sector is forcing hospitals to deliver better outcomes at lower cost, see the front page of today's Wall Street Journal. To see why Medicare is having such a hard time controlling costs these days, listen to this afternoon's debate on changing the Medicare drug benefit, which was written by the insurance and drug industry lobbyists.

When a regulatory body is taken over by the firms it is supposed to regulate, economists call it "agency capture." I believe "Medicare for all" is a necessary condition for holding down the ruinous increases in health care costs, which is squeezing out other, more socially useful activities. But until that agency relearns how to control the overweaning economic power of the providers in the system -- the drug, device, and durable equipment manufacturers; the physicians and their specialty guilds; and the specialty clinics and hospitals -- it will not be sufficient.

Posted by: GoozNews on January 12, 2007 at 1:59 PM | PERMALINK

dr2chase, the life expectancy for fat 75 year old arthritic diabetics in the U.S. is pretty darn good, compared with most other countries. Of course, the U.S. has higher percentage of 75 year olds who are fat, diabetic, and arthritic, and their votes are competed for with great intensity.

By the way, I was not defending the current system. I was merely observing that 75 year old people with lifestyle-induced health problems
in the U.S. endure less rationing of services than elsewhere, thus making a move to systems employed elsewhere problematic, given how the votes of such people are so highly sought.

Finally, anybody who mentions infant moratlity rates, while remarking how life expectancy rates prove one system in superior to another in regards to services to the elderly, while doubting the rationality of others, is being ironic, perhaps unintentionally so.

Posted by: Will Allen on January 12, 2007 at 2:19 PM | PERMALINK

GoozNews, regulatory capture is a nearly inevitable element of any regulatory structure, which is something that those who favor a high degree of regulation never seem to factor in.

Posted by: Will Allen on January 12, 2007 at 2:23 PM | PERMALINK

dr2chase, the life expectancy for fat 75 year old arthritic diabetics in the U.S. is pretty darn good, compared with most other countries.

"pretty darn good" can be expressed by comparing numbers. Do you have them, or did you imagine them? I got all my numbers from nationmaster.com, who gets them from various reputable sources (CIA Factbook, OECD, etc). You can actually follow a chain of links back to (for example) the Excel spreadsheet where the self-report vs doctor-report obesity data is discussed.

And I'm not being ironic, I was merely pointing out that our system sucks in every way that anyone has cared to actually measure, including infant mortality.

Your claims about the influence of the elderly are also undercut by other data available at nationmaster; currently, only 12.5% of our population is over 65 (we're #48). Other industrialized countries are Japan(#2, 20%), Italy(#3, 19.7%), Germany (#4, 19.4%), Greece(#5, 19%), Spain(#7, 17.7%), Sweden(#8, 17.6%), Belgium(#9, 17.4%), and so on. France is #20, 16.4%, UK is #24, 15.8%. Canada's #43, Australia is #45. It seems to me that among those countries that are democracies, our old people have relatively less influence, not more. And, notice that all these countries with their greater proportion of expensive-to-care-for old people, somehow do it for less money, and have enough money left over to ensure that people are healthier throughout their lives, and also more likely to survive infancy.

To repeat myself, do you have any statistics, actual measured numbers, that support ANY claim to the superiority of our system, or inferiority of universal health care? Every number I can find says that our system sucks, substantially (and I certainly hope that you can come up with a number that matters -- "survival rate for ingrown toenail repair" is not a significant number by itself).

Posted by: dr2chase on January 12, 2007 at 3:16 PM | PERMALINK

"I make the following point repeatedly, but it seems to never sink in with this crowd: it does not follow that universal healthcare in the United States, based on the model of any of the countries frequently cited, will produce the same outcomes and levels of expenditures those countries have." - Yancey Ward

Boy, you guys apply American Exceptionalism to just about everything. I guess that's part and parcel of your worldview. So exactly how much pity do you have for people who are so unfortunate to be stuck without an American identity? Sure sucks to be them, I guess (though they live longer and work less).

Posted by: cthulhu on January 12, 2007 at 4:13 PM | PERMALINK

From the New England Journal of Medicine:

http://content.nejm.org/cgi/content/abstract/333/18/1232

"Results: In the United States, life expectancy at the age of 80 and survival from the ages of 80 to 100 significantly exceeded life expectancy in Sweden, France, England, and Japan (P

Conclusions: For people 80 years old or older, life expectancy is greater in the United States than it is in Sweden, France, England, or Japan."


The elderly, particualrly the non-poor elderly, do extremely well in the U.S.. compared to other nations. Now, one has to be very careful about life expectancy numbers as a proxy for quality of health care. It could be that those that survive to 80 in the U.S. are especially pre-disposed to a further long lfe. However, those that use life expectancy ar birth numbers are really, really disingenuous, ignoring factors like different nations categorizing infant deaths in different ways, or homicide rates, or auto accident rates, which don't really reflect differences in health care quality, to say nothing of factors like obesity or sedentary lifestyle.

In any case, if one looks at average waiting times for heart procedures and joint replacement surgeries, one really must conclude that the non-poor elderly in the U.S. endure less rationing than elderly elsewhere. Furthermore, this cohort in the U.S. is now used to not enduiring such rationing, and are very politically motivated to maintain that state of affairs. They vote. Young people in the U.S. vote at a much lower rate. Who do you suppose have their desires more closely paid attention to by elected representatives?

Posted by: Will Allen on January 12, 2007 at 4:28 PM | PERMALINK

I would dispute the statement that doctors are paid well under Medicare. On my Medicare claims I see how heavily discounted the Medicare reimbursements are to doctors vs. the charge. My son-in-law, who is a doctor, says he often loses money on Medicare patients - flu shots etc.. Not only do the eldery tend to have more than one diagnosis, requiring more time and care, they see the doctor more frequently. Because of this more and more family practice doctors (not specialists) are NOT accepting any new Medicare patients, so it becomes challenging to switch doctors.

Posted by: PSato on January 12, 2007 at 4:34 PM | PERMALINK

I might rate the Social Security Administration an 8 or 9. If we do national health insurance in that mold I think we will be just fine.

Posted by: dale on January 12, 2007 at 5:36 PM | PERMALINK

Yes, dale, mailing out checks, or electronically depositing funds, is very similar to delivering high technology goods and services to 300 million people.

Posted by: Will Allen on January 12, 2007 at 6:24 PM | PERMALINK

However, those that use life expectancy ar birth numbers are really, really disingenuous, ignoring factors like different nations categorizing infant deaths in different ways, or homicide rates, or auto accident rates, which don't really reflect differences in health care quality, to say nothing of factors like obesity or sedentary lifestyle.

I am not being "really really disingenuous", and you can even see nods to lifestyle in the paperclip analogy that I posted. I would regard the statistics differently if there were a couple of outliers that exceeded our performance -- if it was just Japan, I would be much more concerned about lifestyle choices as an explanation. Instead, we are embedded well down at the bottom of the industrial pack, no matter how we choose to measure (except, as you note, the longevity of those people lucky enough to make it 80 -- perhaps we kill the weaker ones before they reach 80). Canada's quite a lot like us -- but they beat us handily. Countries that are much poorer in terms of GDP per capita, beat us handily.

And furthermore, the numbers are so terribly much worse for us, that simply pointing to a few other potential causes (numbers, please? Correlations, please?) is not sufficient to make the problem into a non-problem. Something's causing this across-the-board shortfall in our health, and if by some miracle it isn't our healthcare system, it is something else, and it should be fixed.

I also tested the obesity claim over at nationmaster (you did go look, right?) and it turns out that national obesity stats (besides being variably reported -- it's discussed in the original source) are not especially well correlated with any general national health measures (teen pregnancy was correlated, I recall).

You are welcome to also go to nationmaster, to look up whether the other statistics that you are think not consistently reported, are in fact, not consistently reported. You can get stats on homicides and auto accidents, too -- you could get the numbers to make your case. How about you do that for your next set of factoids? You seem to have the strategy of assuming that eventually I will tire of shooting town your lazily surmised assertions with actual statistics, and then "you win" by default. My assumption is that unsourced numbers are crap.

It also seems a little farfetched to me that inconsistently reported statistics would so consistently put us at the bottom of the heap. We do worse than 20-plus countries on 4 different general metrics (spending, infant mortality, life expectancy, percentage of life in ill health), especially given our demographic advantage (such a small percentage of our population over 65). That's some coincidence you've got going there.

Posted by: dr2chase on January 12, 2007 at 6:52 PM | PERMALINK

dr2chase, I'll repeat myself, given you either cannot or choose not to read what I wrote. I make no defense of the health care delivery system in this country. I'll amend that with one exception. The profits that can be made in the U.S. delivering innovative health care technology quite likely attracts a lot of private capital that would be employed elsewhere, absent such profit potential. Now, Kevin Drum and others here have made the extraordinary claim that private capital formation is not a factor in health care technology innovation. Talk about an extraordinary claim requiring extraordinary evidence!

In any case, that really is the only positive remark I have to make about health care delivery in this country. My point in my initial post was that the non-poor elderly really do endure less rationing of health care services in this country compared to others. There is no better place on earth to be an elderly middle class fat diabetic in need of a bypass or a new knee. The difference in waiting times, with, say, Canada, is significant. Given that the elderly middle class is the most sought after electoral demographic in this society, any change which will make your granny wait another month for her knee replacement, to say nothing of her heart procedure, is not likely to fare well in Congress.

As to other issues, a study at Stanford (yes it can be found via Google) indicated that the single strongest correlation with mortality was the ability, or inability, to achieve and maintain a high metabolic rate, which, of course, is highly correlated with obesity and a sedentary lifestyle. If you wish to think that Americans are not more obese or more sedentary that their counterparts in the industrialized world, fine.

Posted by: Will Allen on January 12, 2007 at 7:22 PM | PERMALINK

From the New England Journal of Medicine:

Will Allen cited the following:

"http://content.nejm.org/cgi/content/abstract/333/18/1232

"Results: In the United States, life expectancy at the age of 80 and survival from the ages of 80 to 100 significantly exceeded life expectancy in Sweden, France, England, and Japan (P

Conclusions: For people 80 years old or older, life expectancy is greater in the United States than it is in Sweden, France, England, or Japan."

So I must then point out this quote from the article:

"Greater heterogeneity in social and economic status and health insurance coverage in the United States may account for much of the disadvantage at younger ages in this country. Medicare, Medicaid, and Social Security reduce this heterogeneity at older ages. Whereas 84.3 percent of Americans under 65 had health insurance in 1991, 98.4 percent of the elderly had Medicare coverage. Reduced survival of disadvantaged groups also decreases heterogeneity at older ages."

This would seem to support the notion of expanding Medicare to all people in the US.

Posted by: cthulhu on January 12, 2007 at 8:21 PM | PERMALINK

What utter BS. The "paperclip industry"? What a moron. As the basis for analogy it's pathetic. Paperclips are mass produced almost exlusively by machines. There might be a human driving a forklift, but who knows. Healthcare, of course cannot be mass produced.

If it was as easy to select between health care options (hard to produce) as it is to select between paper clips (easy/cheap to produce), then I guess the "free market" would lead to extremely high quality health care (or at least as good as the paper clip options we enjoy!).

Hmm...Does the free market work best for inexpensive to produce goods which allows for many options/choices? If the goods are expensive to produce resulting in fewer choices, is the free market as efficient? At what point do we not rely on free markets to provide what we want? I hadn't thought about that before.

Posted by: mezon on January 12, 2007 at 8:27 PM | PERMALINK

The difference in waiting times, with, say, Canada, is significant.

Someone, somewhere, measured this, did they not? What are the numbers? How do they compare with the other nineteen countries? And why does this difference in wait times not give us a superior metric for "percentage of life in ill health"? That is, perhaps for some peculiar reason perhaps we are very good getting this one operation done, and nothing else comes close.

I am perfectly willing to believe that Americans are more obese and more sedentary; that is what the statistics (reported at the usual place) say. However, that same repository of statistics reported no particular correlation between national reported obesity rates and any of the general national health statistics. Perhaps the obesity data is dirty, but variations between other countries did not lead to significant differences in their mortality rates. Perhaps the Stanford study (you can use cut and paste to put URLs in your post, works for me) was not able to measure differences in national health care delivery, and had to concentrate on those things that could easily be measured in this country.

I also had a look at the differences in homicide and motor vehicle death rates, and the US indeed does poorly there, but the differences did not seem large when compared to the differences in total mortality rates. To further complicate things, the US was in the middle (muddle) of the overall mortality rates, so there is some demographic age-distribution nonsense at work as well. I also tried to find miscarriage statistics, to see if perhaps what we call "infant mortality" might be counted as "miscarriage" (and here, you want 2-3 trimester miscarriage, because I am sure that the 1 trimester rate will be variously reported) -- but I did not find it, yet.

Posted by: dr2chase on January 12, 2007 at 8:31 PM | PERMALINK

cthulhu, whether that is true or not, the economic reality is that expanding medicare to 300 million people will, in all likelihood, result in rationing that the health care systems elsewhere engage in with regards to the elderly. This will conflict with the political reality of the elderly being the most powerful interest group in this country.

I really am short of time, so I just searched "joint replacement waiting time U.S. Canada" and came up with this from the New England Journal of Medicine...

"Results: About 80 percent of the questionnaires were returned, but not all the respondents answered all the questions. The rate of response to specific questions was about 60 to 65 percent in both countries. The median waiting time for an initial orthopedic consultation was two weeks in the United States and four weeks in Ontario. The median waiting time for knee replacement after the operation had been planned was three weeks in the United States and eight weeks in Canada. In the United States, 95 percent of patients in the national sample considered their waiting time for surgery acceptable, as compared with 85.1 percent in Ontario."

Now, that study is 12 years old, but everything I've read is that the disparity has grown larger in the interim. Also, satisfaction is closely linked to expectation. Middle class elderly Americans have been trained for the past 40 years that health care rationing is for other people, and they are not going to be satisfied to learn that they are going to be waiting another seven weeks for their surgery. That is a political reality.

It isn't just joint replacement surgery, either. Similar disparities have arisen in regards to heart procedures and oncological radiation treatments. Why does this not get reflected in "percentage of life in ill health"? Who knows? That is a very subjective state, and the quality of health care is not the only thing which affects the percentage of life in ill health. These are very complex things that are being attempted to be measured, so people who think they have simple explanations are most likely in error.

Yes, the people who defend out current regime are frustrating when they refuse to acknowledge it's many shortcomings. The people who advocate change are just as frustrating when they refuse to acknowledge that nearly everything on the planet involves trade-offs, and some people aren't going to favor them. In this case, the most powerful political demographic in the country is unlikely to favor them.

Posted by: Will Allen on January 12, 2007 at 9:27 PM | PERMALINK

dr2chase, keep in mind that homicide and fatal car accidents primarily affect the young (I believe homicide was the leading cause of death among young African-American males unitl recently), and thus have a disproportionate impact on life expectancy at birth, than would be the case if these deaths were evenly spread among age cohorts. Naturally, the way in which premature infant deaths are recorded also may have a disproportionate impact. Again, believing there are simple explanations for the differences in a complex phenomena is likely to lead one down an erroneous path.

Posted by: Will Allen on January 12, 2007 at 9:34 PM | PERMALINK

Several things I would have said have been said... but some bear repeating: proponents of "Universal Health Care" and Single Payer never completely explain how we are supposed to transition from what we currently have (a complicated set of not fully integrated systems) to one big (presumably governmental) payer. Transition costs alone would likely be huge.

Again, Medicare expenditures eat up a huge chunk of the federal budget now, and a system expanded to cover more people, or all people at current levels of coverage would be all but impossible (without large tax increases or other revenue generation).

Finally, Medicare reimbursement is a complicated system that doctors do not love, that is confusing for patients (especially ones that lack additional coverage), and that bis heavily beaurocratic and mired in undetected fraud in the millions of dollars. Medicare creates incentives for Doctors to do unnecessary procedures and tests to maximize profit, and puts evaluation of medical procedures in the hands of beaurocrats rather than health care providers and patients. I am amazed atg the siren song of "Medicare for all" that comes from progressives.

I have no love for our broken system. But ultimately, we need better health care, not more health insurance, and we need to do with some big probolems that no one mentions because it's not fashionable: things like hospitals as wasteful, poor delivery systems for most primary care; doctor training and the incentives toward specialization rather than general practice medicine, mental health care, disability treatment and rehab services and long term elder care. We don't even touch these, and insurance solutions don't address them either. So yeah, I'd go with Tyler Cowen's 3 rating on the prospects for national health insurance, until shown a lot more concrete thinking around more of the issues in healthcare and how we'll address them.

Posted by: weboy on January 12, 2007 at 11:52 PM | PERMALINK

Will Allen stated:

"cthulhu, whether that is true or not, the economic reality is that expanding medicare to 300 million people will, in all likelihood, result in rationing that the health care systems elsewhere engage in with regards to the elderly. This will conflict with the political reality of the elderly being the most powerful interest group in this country."

First of all, I would suspect expanding coverage to everyone can, in fact, be done without rationing if people are willing to pay for it. That is another way to look at it after all: is it the all powerful senior lobby that can't be beat or the selfish not yet sick younger generation that doesn't want to pay increased taxes today for less expensive care in the future?

We are already covering the most expensive group. Adding everyone under 18 is almost a no-brainer. Phasing in the rest of us can be done at a slower pace (Besides isn't the "common wisdom" now that deficits don't matter so, hell, you don't even need to raise taxes, haha).

And as for lobbying power, I'm not sure the senior lobbying groups have shown that much influence of late. I'm sure you might point to the recent failure of Social Security "reform" but that dog was pretty much a loser in my generation (X) as well and had, at best, tepid support in the Millennials. On the other hand, corporate lobbying seems to be doing quite well (Medicare part D, among other things). Ironically, increasing pressure by business groups in support of government taking over health coverage may very well be the tipping point toward some form of a single payer system.

As an aside, I find it fascinating that critics of single payer regularly note wait times for knee and hip replacements, surgeries for conditions that are generally years in the making and, with regular check-ups can be managed such that the surgery can be planned months in advance with limited disability in the interim. But I guess if you can't point to overall indicators such as life expectancy, infant mortality, immunization rates, etc., you have to focus on the minutiae and point to obvious but meaningless facts like "some people won't be satisfied."

Posted by: cthulhu on January 13, 2007 at 12:53 AM | PERMALINK

comparing paper clips to health care is imbecilic.

Posted by: secularhuman on January 13, 2007 at 2:40 AM | PERMALINK

cthulhu, when it gets to the point that someone asserts, in regards to political or economic behavior, that it is "meaningless" that people won't be satisfied, the discussion is no longer based in rationality. Have a nice day.

Posted by: Will Allen on January 13, 2007 at 11:22 AM | PERMALINK

Middle class elderly Americans have been trained for the past 40 years that health care rationing is for other people, and they are not going to be satisfied to learn that they are going to be waiting another seven weeks for their surgery. That is a political reality.

It may well be political reality. But it's not clear to me that the manifestation of this political realty is avoidance of an eventual move to government-guranteed and mandated universal healthcare along the lines of the various single payer models in existence in the rich world. In other words, it might be that this political reality -- the desire of Americans for lots of healthcare with minimial waits -- will be realized with very very large government budgets and minimal rationing.

I think it's instructive that one of the arguments used by opponents of radical reform is to compare waiting times for the elderly in different countries. If you do this, what you're essentially doing is comparing one government's program with a different government's program. You are, in other words, comparing differing levels of governmental largesse. Canada's problem is not that its government is heavily involved in the provision of healthcare. Candada's problem is that its government doesn't spend enough money on healthcare.

I don't see why the private sector has an edge over the public when it comes to reducing waiting times. What's needed is money, whether that money comes from taxpayers or from premiums payers.

Posted by: Jasper on January 13, 2007 at 2:46 PM | PERMALINK




 

 

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