Tag: medical care

Medicare for Everyone?

According to The Hill, House Democrats are considering re-branding their new government-run health insurance program.  A “public option” evidently isn’t catchy enough.  Now they’re thinking, “Medicare Part E” as in, Medicare for Everyone.

By all means, model a new government program after Medicare, which:

Pleeeeease don’t throw me into that briar patch.

Hurting the Sick Is Not Good Politics

I was glad to see James Pinkerton engage my criticism of Louisiana Gov. Bobby Jindal’s (R) endorsement of federal price controls for health insurance.  I was even more pleased to see that Pinkerton has his own blog devoted to developing a Serious Medicine Strategy.

If I understand Pinkerton, his argument is essentially: it’s all well and good for some unelectable wonk in the “citadel of libertarian thinking” to “uphold ivory-tower free-market purity” by opposing price controls.  But Republicans need “art-of-the-possible solutions” to win elections, and 90 percent of the public support those price controls.  “Everyone has a right to his or her principled position,” Pinkerton writes, “but the majority has rights, too.”

Two problems.

First, Pinkerton suggests that libertarians oppose price controls for reasons that only matter to libertarians, and therefore may be safely ignored.  Problem is, price controls hurt people.  Were Pinkerton to explore the merits of Jindal’s proposal, he would soon conclude that imposing price controls on health insurance taxes the healthy, reduces everyone’s health insurance choices, and creates even greater incentives for insurers to shortchange the sick.  (Turns out that what Larry Summers said about price controls applies to health insurance, too.)  As John Cochrane explains, those price controls also block innovative products that would provide more financial security and better medical care to the sick.

But Pinkerton’s advice for Republicans is, essentially: “Do what’s popular now, even if it hurts people and voters end up blaming Republicans for it later.”  How is that a good strategy?

Second is this idea that “the majority has rights.”  Majorities don’t have rights.  Individuals have rights.  For example, you have the right to negotiate the terms of your health insurance contract with the individuals at this or that insurance company.  Majorities may attain power, but that’s the opposite of rights.  (See the Bill of Rights.)

Finally, a couple of important odds and ends.  Pinkerton suggests it is “un-libertarian” to be “pro-life,” or to “support the police, the military, and other upholders of public order,” or to “support government restrictions on…euthanasia.”  Writing from the “citadel of libertarian thinking,” I can assure him he is wrong.  Might I suggest Pinkerton read the relevant chapters from The Encyclopedia of Libertarianism?  (The health care chapter is a page-turner!)  Also, I did not “denounce Jindal” any more than Pinkerton denounced me.  I criticized his ideas, and I respect the man.

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

The Wonders of Socialized Dentistry

As we all know, the American health care system is less than perfect.  An inefficient amalgam of government spending, federal tax incentives, employer-based insurance, and private providers, the U.S. system costs us more than it should for the services provided.  Nevertheless, medicine in America remains far more directed by and for patients, in contrast to nationalized systems, which are usually organized by and for bureaucrats.

The results sometimes are horrific.  Indeed, the best way to understand the consequences of Britain’s National Health Service is simply to read stories in British newspapers.  Consider this one in the Daily Mail about  the lack of adequate dental care:

Like so many young women, Amy King always took great pride in her appearance.

Standing in front of the mirror to check her make-up before a night out, the 21-year-old would always try a smile - friends told her they loved the way it lit up her face.

Eight weeks ago, all that changed. The student from Plymouth was admitted to hospital where, in a single operation, she had every tooth in her mouth removed.

Obviously, not all foreign systems do so little for their patients.  France, Germany, and Switzerland all provide care differently, and in all of these nations people receive better treatment than in Britain.  But no where is turning health care over to government the best way to ensure quality yet affordable medical care.  Instead, control over health care should be placed back in the hands of those who have the most at stake:  patients.

Health Policy Death Match: Klein vs. Ponnuru

I count both Ramesh Ponnuru and Ezra Klein as friends.  (I’m so post-partisan.)  Why, oh why must they force me to choose between them??

Ponnuru had an op-ed in yesterday’s New York Times where he reaffirmed his membership in the Anti-Universal Coverage Club.  Klein responded in a way that’s sure to satisfy his base, but I think he left the reality-based community wanting.  Are you ready for the fisk?

Klein suggests that if “80+ percent of Americans … think the system needs fundamental changes or a complete rebuild,” then 80+ percent of Americans must support universal coverage.  Hmmm, bit of a stretch.  In fact, I can recall one poll where nearly one-third of likely Democratic primary voters rejected universal coverage.

Klein suggests that giving consumers the freedom to avoid unwanted state health insurance regulations would mean that Arizonans wouldn’t get coverage for colorectal cancer screening, and that there would be no mammogram coverage in Idaho.  Mmm, that’s good crazy.  I refer my right honorable friend to the episode where The New Republic’s Jonathan Cohn made a similar claim about mandates for prostate and cervical cancer screening.  I looked up the services covered by the plans made available to the Cohn family by the University of Michigan.  It turned out that six out of the seven available plans cover both prostate and cervical cancer screening — even though Michigan requires insurers to cover neither.  (I offered to wager Cohn a fancy dinner that his family has coverage for both, but I never heard back from him.  Foolish, really, to let me know where he gets his insurance. Klein would never give me such an opening … or would he?) What Ponnuru proposes is to let Arizonans and Idahoans and everyone else choose what their health plan covers.   Imagine that: people rationing medical care according to their preferences, rather than the preferences of employers, interest groups, bureaucrats, health policy wonks…  Why Klein clings to such regulations despite zero evidence that they actually increase access to the targeted services is beyond me.

Klein criticizes Ponnuru for proposing to replace the current tax preference for job-based coverage with a tax credit available to everyone, much like John McCain proposed during his (latest) presidential campaign.  Ponnuru cites a study estimating that tax credits would reduce the number of uninsured by 20 million.  Klein counter-cites one study estimating that tax credits would have zero net effect on the number of uninsured, and a second study estimating that those who transition from job-based coverage to the “individual” or “non-group” market would pay an additional $2,000 per year for an identical policy.   Klein’s criticisms sound persuasive – provided you know precious little about the topic.  For one thing, the two studies Klein cites are actually the same study.  Pity, really.  Had Klein found a second study to support his position, perhaps it would not have been quite so flawed as the one he did find.  Here’s what I wrote back in September about that study’s flaws:

Thomas Buchmueller et al. estimate that replacing the tax exclusion for employer-sponsored insurance (ESI) with Sen. John McCain’s proposed health insurance tax credit would have zero effect on the uninsured. Yet their estimates neither incorporate nor even acknowledge factors that would tend to increase coverage. First, workers who lose ESI would see their wages rise significantly as labor markets force employers to “cash out” those workers.

That effect would help all workers afford health insurance — but particularly older and sicker workers, because they would get cashed-out more.

Second, the authors estimate that non-group enrollment would double, yet they ignore that administrative costs would fall in a thicker non-group market.

So that $2,000 mark-up really wouldn’t be $2,000.  Even if some mark-up remained, workers could reduce their premiums by purchasing less coverage.  Not all that crazy a concept, considering that the tax treatment of job-based insurance encourages people to buy too much coverage.

Then there’s this effect, which would further reduce premiums for healthy workers:

Third, the authors acknowledge that employment-based insurance forces the healthy to subsidize the sick, yet they ignore that the non-group market would reduce premiums for a majority of workers by allowing them to avoid that hidden tax.

The study’s authors also ignored the premium-lowering effects of McCain’s proposal to allow people to avoid unwanted regulatory costs (e.g., mandated benefits):

Fourth, though the Congressional Budget Office estimates that state health insurance regulations increase premiums an average of 13 percent, the authors ignore that McCain’s proposal to let consumers shop nationwide for insurance would further reduce premiums by allowing consumers to avoid that hidden tax as well.

A few random clarifications.  Klein fears living “in a space where insurers could still discriminate based on pre-existing conditions.”  That’s Church-of-Universal-Coverage-speak for, “I want price controls on health insurance.”  Government can outlaw the practice of charging higher premiums to the sick, but it cannot outlaw the reasons behind those higher premiums.  So when government prohibits insurers from competing on price, insurers respond to those underlying reasons by competing to avoid the sick.  Yes, yes, it’s that pious preference for price-controlled premiums that unleashes the beast of adverse selection — and prevents the market from developing innovative insurance products that help sick people pay those higher premiums. Klein fears a world “where millions of Americans will still lack access to health insurance,” because to the devout, access to insurance matters more than access to health care.  Klein fears that when people move from ESI to the individual market, risk pools will get smaller and insurers will get stronger.  Yet risk pools would get bigger, and insurers weaker relative to consumers.  Klein believes we can “ensure that all Americans have health coverage, [and] that their coverage is comprehensive,” and that we can do all that without rationing “access to health services.”  How?  Just “bring down costs in the system.”  Riiiight.

To cap things off, Klein claims that Ponnuru and I think the U.S. health care sector as it exists is “fine.”  I really can’t blame him for arguing with straw men.

In the end, Klein’s case against Ponnuru boils down to the same absurdity I found in Buchmueller and colleagues’ case against McCain:

The McCain plan would eliminate forced subsidies: of the sick by the healthy (via ESI and community rating) and of particular providers by unwilling consumers (mandates for chiropractic coverage, etc.). Buchmueller et al. would have us believe that if we stop robbing Peter to pay Paul, not even Peter would benefit. A more balanced critique might have been more persuasive.

Klein spends a lot more time thinking about health policy than Ponnuru does. But you’d never know it.

Democrats Agree on Health Plan Outline: Be Afraid, Be Very Afraid

The New York Times reports that key congressional Democrats have agreed on the basic provisions for a health care reform bill.  And while many details remain to be negotiated, the broad outline provides a dog’s breakfast of bad ideas that will lead to higher taxes, fewer choices, and poorer quality care.

Among the items that are expected to be included in the final bill:

  • An Individual Mandate. Every American will be required to buy an insurance policy that meets certain government requirements.  Even individuals who are currently insured – and happy with their insurance – will have to switch to insurance that meets the government’s definition of acceptable insurance, even if that insurance is more expensive or contains benefits that they do not want or need.  Get ready for the lobbying frenzy as every special interest group in Washington, both providers and disease constituencies, demand to be included.
  • An Employer Mandate. At a time of rising unemployment, the government will raise the cost of hiring workers by requiring all employers to provide health insurance to their workers or pay a fee (tax) to subsidize government coverage.
  • A Government-Run Plan, competing with private insurance.  Because such a plan is subsidized by taxpayers, it will have an unfair advantage, allowing it to squeeze out private insurance.  In addition, because government insurance plans traditionally under-reimburse providers, such costs are shifted to private insurance plans, driving up their premiums and making them even less competitive. The actuarial firm Lewin Associates estimates that, depending on how premiums, benefits, reimbursement rates, and subsidies were structured, as many as 118.5 million would shift from private to public coverage.   That would mean a nearly 60 percent reduction in the number of Americans with private insurance.  It is unlikely that any significant private insurance market could continue to exist under such circumstances, putting us on the road to a single-payer system.
  • Massive New Subsidies. This includes not just subsidies to help low-income people buy insurance, but expansions of government programs such as Medicaid and Medicare.
  • Government Playing Doctor.   Democrats agree that one goal of their reform plan is to push for “less use of aggressive treatments that raise costs but do not result in better outcomes.”  While no mechanism has yet been spelled out, it seems likely that the plan will use government-sponsored comparative effectiveness research to impose cost-effectiveness guidelines on medical care, initially in government programs, but eventually extending such restrictions to private insurance.

Given the problems facing our health care system-high costs, uneven quality, millions of Americans without health insurance–it seems that things couldn’t get any worse.   But a bill based on these ideas, will almost certainly make things much, much worse.

Or maybe it’s all just a massive April Fool’s joke.

Deadly Canadian Care

An Illinois physician is arguing that actress Natasha Richardson might have survived her skiing accident if it had occurred in the United States rather than Canada. Explains Dr. Cory Franklin:

Canadian health care de-emphasizes widespread dissemination of technology like CT scanners and quick access to specialists like neurosurgeons. While all the facts of Richardson’s medical care haven’t been released, enough is known to pose questions with profound implications.

In the U.S. Richardson likely could have been both diagnosed locally and flown to emergency care in a nearby city.  Adds Franklin:

What would have happened at a US ski resort? It obviously depends on the location and facts, but according to a colleague who has worked at two major Colorado ski resorts, the same distance from Denver as Mt. Tremblant is from Montreal, things would likely have proceeded differently.

Assuming Richardson initially declined medical care here as well, once she did present to caregivers that she was suffering from a possible head trauma, she would’ve been immediately transported by air, weather permitting, and arrived in Denver in less than an hour.

If this weren’t possible, in both resorts she would’ve been seen within 15 minutes at a local facility with CT scanning and someone who could perform temporary drainage until transfer to a neurosurgeon was possible.

If she were conscious at 4 p.m., she’d most likely have been diagnosed and treated about that time, receiving care unavailable in the local Canadian hospital. She might’ve still died or suffered brain damage but her chances of surviving would have been much greater in the United States.

American medicine is often criticized for being too specialty-oriented, with hospitals “duplicating” too many services like CT scanners. This argument has merit, but those criticisms ignore cases where it is better to have resources and not need them than to need resources and not have them.

Obviously, Americans also die needlessly from substandard care on occasion.  But where government controls the entire health care system, politics is likely to trump consumers from beginning to end.  And that is evidently the case in Canada, where pets typically have speedier access than humans to many of the technological advances that Americans take for granted.  Policymakers must not forget the needs of patients as they rush to “reform” the U.S. health care system.

(H/t to Matthew Vadum.)

Deadly Canadian Health Care

Opponents of nationalize health care rightly warn about the negative impact of politicizing medical care, but it’s never easy to prove that someone who otherwise would have lived died as a result.  Yet Canadians are asking whether that may be the case with actress Natasha Richardson.  Reports the News & Observer (hat tip to Matthew Vadum at the American Spectator blog):

Questions are arising over whether a medical helicopter might have been able to save actress Natasha Richardson.

The province of Quebec lacks a medical helicopter system, common in the United States and other parts of Canada, to airlift stricken patients to major trauma centers. Montreal’s top head trauma doctor said Friday that may have played a role in Richardson’s death.

Richardson, 45, died Wednesday at Lenox Hill Hospital in New York after falling Monday on a ski slope at the Mont Tremblant resort in Quebec.

“It’s impossible for me to comment specifically about her case, but what I could say is … driving to Mont Tremblant from the city [Montreal] is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn’t set up for traumas and doesn’t match what’s available in other Canadian cities, let alone in the States,” said Tarek Razek, director of trauma services for the McGill University Health Centre, which represents six of Montreal’s hospitals.

While Richardson’s initial refusal of medical treatment cost her two hours, she also had to be driven to two hospitals. She didn’t arrive at a specialized hospital in Montreal until about four hours after the second 911 call from her hotel room at the resort, according to a timeline published by Canada’s The Globe and Mail newspaper.

Because of the pervasiveness of both third party payment and government regulation, the American medical system spends more than it should.  But it remains far more oriented towards meeting patient needs than does government-dominated health care.  As policymakers debate various “reform” measures, they should keep Natasha Richardson’s tragic fate in mind.