Tag: Ezra Klein

Average vs. Marginal Effects of Health Insurance

I have to thank Ezra Klein.  I have for some time been trying, without success, to spark a debate about whether expanding health insurance coverage would actually save any lives.  Even my bet with Karen Davenport seemed to go nowhere.  But when Klein accused Sen. Joe Lieberman (I-CT) of being “willing to cause the deaths of hundreds of thousands of people” because Lieberman was jeopardizing passage of legislation that would expand health insurance to 30 million people, Klein made a debate possible.

Following on my first response to Klein that the evidence supporting his claim is remarkably thin, others have joined the discussion.  Matt Yglesias of the Center for American Progress rose to Klein’s defense.  Megan McArdle (in The Atlantic magazine and her blog) and Tyler Cowen (at Marginal Revolution) both argue that we don’t really know if Klein’s claim is true.

Today, Yglesias poses the following question on his Twitter page:

Do rightwingers really believe that US health insurance has no mortality-curbing impact?

I see two problems.  First, there are no right-wingers in this debate.  McArdle, Cowen, and I all support gay marriage, for example.

Second, Yglesias sets up a straw man.  He asks whether health insurance on average has a positive impact on mortality, when the debate is actually over the effect of health insurance at the margin.  In other words, would covering the uninsured save lives?

I don’t know anyone who thinks health insurance has zero effect on mortality overall.  Yet it is entirely possible for the average effect to be positive and the marginal effect to be zero. One reason may be that the uninsured do benefit from the human and physical capital that health insurance makes possible.  It may also be the case that when the uninsured do obtain health insurance, the additional medical care they receive is more likely to harm them than to help them.  The researchers behind the RAND Health Insurance Experiment make essentially the same point.

If the marginal effect of health insurance on health is zero, it raises other interesting questions.  Would it also have zero effect on health outcomes if we were to reduce the number of people with health insurance?  What is the size of the margin over which health insurance has zero impact?  (Robin Hanson suggests it may be very, very large.)

Klein recently declined an invitation to debate these issues at Cato.  Too bad.  This is worth pursuing.

Yglesias, Defending Klein’s Slander of Lieberman

Blogger Matthew Yglesias has a response to my post on Ezra Klein’s slander that Sen. Joe Lieberman (I-CT) is okay with the mass murder (or the mass negligent homicide) of hundreds of thousands of uninsured Americans.

Yglesias claims that only one of the three studies I cited speaks to what he claims is the central point: the Institute of Medicine’s estimate of how many Americans die each year because they lack health insurance.  Yglesias is incorrect.  The central point/threshold question is whether giving the uninsured health insurance will save lives.  All three studies speak to that point, and all three all cast doubt on the intuitively appealing idea that giving uninsured people health insurance ipso facto saves lives.

To rebut the one study that Yglesias believes to be on point (Kronick), he offers two others.  Yet all studies are not created equal.  Kronick, Finkelstein/McKnight, and Levy/Meltzer represent the most reliable work that has been done on the relationship between health insurance and health.  If I am wrong about that, I hope that one of those authors or another expert in the field will correct me.

But if I am right, it means that Yglesias and Klein are slandering Joe Lieberman and millions of others based on their (Yglesias’ and Klein’s) limited and distorted understanding of the world.  (And even if I’m wrong, the Washington Post’s Charles Lane explains why Klein’s slander is still wrong.)

Then again, considering that Yglesias also has another post suggesting that Lieberman and House Minority Whip Eric Cantor (R-Va.) are “dumb” Jews free-riding on the intelligence of other Jews, I’m not sure that the Church of Universal Coverage is open to persuasion right now.

Joe Lieberman, Mass Murderer?

So insinuates the Washington Post’s Ezra Klein, who writes that, because Sen. Joe Lieberman (I-CT) does not support the health care legislation forwarded by Senate Democrats, Lieberman “seems willing to cause the deaths of hundreds of thousands of people in order to settle an old electoral score.”

In a subsequent post, Klein relies on the Institute of Medicine’s methodology – which has been used to estimate that 22,000 Americans die each year from lack of insurance – to conclude that the Senate bill would save 150,000 lives over 10 years.  He further claims that “Medicare saved lives.”  (In fairness, Klein writes that he’s not accusing opponents of murder.  When he writes of Lieberman’s willingness to cause hundreds of thousands of deaths, maybe he’s thinking of mass negligent homicide. Or something.)

On Twitter, Klein writes, “People are oddly resistant to talking about the impact of [health care reform] on lives. Do they think insurance has no connection to mortality?”

Indeed, health insurance does have a connection to mortality.  But I’m pretty sure Klein doesn’t know what it is, mostly because people with more expertise and fewer axes to grind don’t know what it is.

For example, a careful study by health economists Amy Finkelstein and Robin McKnight found that in its first 10 years, Medicare had no discernible impact on elderly mortality rates.  The authors hypothesize that prior to Medicare, seniors who lacked coverage largely got the care that they needed either by paying out of pocket or relying on public or private charity.  Whether Medicare had any impact on elderly mortality after its first 10 years remains an open question.

Or consider a study by Richard Kronick, a professor of family and preventive medicine at U.C.-San Diego and a former health policy adviser to the Clinton administration.  Kronick performed the largest-ever study on the health effects of being uninsured and concludes that the IOM estimate “is almost certainly incorrect.”  Kronick concludes that “the best available evidence” suggests “there would not be much change in the number of deaths in the United States as a result of universal coverage.”

How can that be, when Ezra Klein finds his own argument so “intuitive”?  Kronick admits “it is not clear” why the data produce such a counterintuitive result, but posits that existing channels “may provide ‘good enough’ access to care for the uninsured to keep their mortality rate similar to that of the insured.”

Economists Helen Levy of the University of Michigan and David Meltzer of the University of Chicago surveyed the entire economics literature on the connection between health insurance and health.  They conclude, “The central question of how health insurance affects health, for whom it matters, and how much, remains largely unanswered at the level of detail needed to inform policy decisions.”

Sarah Palin’s “death panels” claim had far more credibility than Klein’s slander of Joe Lieberman, which, incidentally, also slanders anyone else who opposes the Senate bill.  If there be justice in the world, that slander will backfire.

(Cross-posted at Politico’s Health Care Arena.)

The Constitutionality of the Individual Mandate

Ezra Klein defends an individual healthcare mandate against charges that it’s unconstitutional, and what’s striking to me is that the argument seems awfully wobbly even if you’re on board with a lot of the post–New Deal jurisprudence about the scope of federal power.  Sez Ez:

The summary is that you can look at the individual mandate as a tax, which is constitutional, or as a regulation forcing private actors to engage in a certain transaction, much like the minimum wage, which is also constitutional. I’ve also heard scholars mention auto insurance, which is an obvious analogue, and the Americans With Disabilities Act, which proved that the government can order businesses to install ramps, despite the fact that the constitution doesn’t explicitly give the federal government jurisdiction over entryways.

This doesn’t seem like the right level of analysis. Some taxes and regulations are within the ambit of federal powers; that doesn’t mean anything capable of being so described is. Some things not explicitly and specifically mentioned in Article I are nevertheless necessarily implicit in the enumerated powers; that doesn’t mean anything is. Auto insurance seems like a poor analogue because it’s a condition of access to government-maintained roadways. Ezra also mentions Massachusetts’ individual mandate, which seems rather beside the point in a discussion of the scope of Congress’ Article I powers. But bracket that. Even if you think the federal commerce power legitimately extends to legislation like the ADA, there’s intuitively a world of difference between saying that a commercial enterprise providing services to the public must provide them in such-and-such a fashion and insisting that private persons have to engage in a specified type of transaction just by dint of being alive. I don’t think the best reading of the Commerce Clause encompasses either, but it’s not that hard to conceive a reading that extends to the former but not the latter. I stress this just because I don’t think you have to be a libertarian or have a very restrictive view of the legitimate scope of federal power to believe there’s a genuine question here. The real form of the argument here looks an awful lot like: “Look, we’ve stretched commerce…between the several states so absurdly already, why are we even pretending it might be found to exclude anything?”

Cutting Health Care Costs

Ezra Klein, the young Washington Post blogger who writes a lot about health care, contributed an article to the paper’s Sunday Business section in which he made this compelling point along the way:

The surest way to cut health-care spending would be to make people shoulder more of the burden directly, as opposed to hiding it in taxes and lost wages.

Bingo! Exactly! So why does Klein want government to get more involved, to wrap our health care in a web of mandates and subsidies and regulations and gatekeepers and monitors? When, as he says, making the cost of health care clear and direct would be “the surest way to cut health-care spending”?

Michael Cannon’s proposal for “Large HSAs” would move us in the right direction. It would allow workers to receive the full amount that they and their employer spend on their health benefits as a tax-free cash contribution to the worker’s health savings account. That would give consumers control over their health care dollars, giving them an incentive to shop around, ask questions, and generally hold down costs as consumers do in normal competitive businesses.

You can’t say it enough:

The surest way to cut health-care spending would be to make people shoulder more of the burden directly, as opposed to hiding it in taxes and lost wages.

Congress should stop moving in the other direction.

Economics Bloggers Weigh in on Income Inequality

The economics blogosphere has been buzzing about Will Wilkinson’s new paper on income inequality.

George Mason University economist Tyler Cowen discusses why social inequality has been falling for some time in the United States:

I agree with Will Wilkinson’s point that real social inequality has (mostly) been falling for some time in the United States.  Today many an upper middle class person is plausibly happier than many a billionaire.  Yet most self-made billionaires work very hard to get to that position, which creates a possible tension between cardinal and “observed choice” or “ordinal” metrics of welfare.  Why work so hard for so little?  Presumably many of these billionaires really want to “be there,” even if they are only marginally better off or in some cases worse off.

The Atlantic’s Megan McArdle offers her initial thoughts, and promises more analysis soon:

I broadly agree with Will that consumption inequality, not income inequality, is what matters.  If the rich have access to broad classes of goods that the poor can’t have, I find this worrying.  On the other hand, if the problem is that Bill Gates has a really awesome 80 inch flat panel television, while the poor have to be content with a 32 inch CRT, well, I can’t say my heartstrings are plucked very tight by this injustice.  So it’s important to know what the real differences are.

Ezra Klein parses some of Wilkinson’s arguments at WashingtonPost.com:

One of Will’s first arguments is that income inequality is not a good way to think about the issue. The real key is consumption inequality. It’s not, in other words, how much money people make, but how much stuff they buy. And “the weight of the evidence shows that the run-up in consumption inequality has been considerably less dramatic than the rise in income inequality.”

The Economist Free Exchange blog has mixed reactions to the study:

Inequality, in and of itself, is no bad thing, and inequality in America has co-existed right alongside significant improvements in welfare across the income spectrum—and contributed directly to them, in many cases. Redistribution for its own sake is bad policy, and as Mr Wilkinson notes, it’s often bad policy pursued to cover up for still more bad policy elsewhere. But America’s society is a very unequal one, by developed nation standards, and it’s not always clear that that inequality is justified or advantageous. And any good student of human behaviour can tell you that wealth will seek to protect wealth, and will often succeed.

Matt Yglesias from Think Progress has posted twice on Wilkinson’s study:

I’m not in agreement with the overall thrust of Will Wilkinson’s paper on inequality for the Cato Institute, but one point that I think is in the spirit of what he’s saying was brought to mind by a question at last night’s event. The way I would put the point is that it’s a mistake to think of the world as composed of, on the one hand, “economic issues” in which we worry about wealth or income inequality and then on the other hand, “social issues” in which we worry about racism or sexism. Progressives ought to be concerned with a general issue of justice and social inequality, of which gaps in money income or wealth may be part.

Ezra Klein: Socialized Medicine = Slavery

The Church of Universal Coverage really, really, really wants you to think that the Democratic health care reforms moving through Congress are not “socialized medicine.”  Last year, I wrote a paper about why they’re wrong. On June 25, I’ll be debating the issue at a Cato policy forum with the Urban Institute’s Stan Dorn.

Today, The Washington Post’s Ezra Klein lends his voice to the chorus of socialized-medicine deniers. Klein doesn’t add much to the discussion, except for this: Klein (correctly) observes, “Socialized medicine is a system in which the government owns the means of providing medicine” (emphasis his).  Single-payer systems, like the U.S. Medicare program or France’s health care system, are not socialized medicine because “the payer does not own the doctors.”

That’s right. Under socialized medicine, the government owns the doctors. When human beings can be owned, we call that slavery. Klein was probably just trying to do what other Church of Universal Coverage faithful have done over the past few years: narrow the definition of socialized medicine to the point where it has no meaning at all. (Duh, Canada doesn’t have socialized medicine – they don’t put Canadian doctors in chains, do they??)

Instead, Klein was inadvertently helpful because he clarified that the reforms he supports, and the reforms before Congress, would give the government ownership over the human capital of doctors and other clinicians. Whether we’re talking about wages, insurers’ assets, medical facilities, medical products, or even clinicians’ labor, ownership is a bundle of rights. If health care reform gives government the right to exclude people from using those resources in forbidden ways (e.g., retainer medicine, balance-billing, pure fee-for-service, whatever), then government gains control over a larger share of each bundle of ownership rights.  That equals more state ownership – of financial, physical, and even human capital – which is the very yardstick Klein uses to define socialized medicine.

If only all the socialists could be so helpful.