Topic: General

Depends on What the Meaning of “Universal” Is

Ezra Klein thinks some countries have achieved universal health coverage. Ramesh Ponnuru demurs: “If you can’t get an operation because your country’s national health insurance system has you on a long waiting list, in what sense have you enjoyed ‘universal coverage’?” Klein replies by defining away the problem: “waiting for an elective procedure – no country I know of has waiting lists for emergency procedures – that you then receive doesn’t contravene the terms of health coverage at all.” Jonathan Cohn adds: “some countries with universal coverage don’t seem to have waiting lists at all,” notably France and Germany. Who’s right?

The evidence seems to lean toward Ponnuru’s position. A few items:

  1. Canada’s Supreme Court wrote in a case last year: “The evidence shows that, in the case of certain surgical procedures, the delays that are the necessary result of waiting lists increase the patient’s risk of mortality or the risk that his or her injuries will become irreparable. The evidence also shows that many patients on non-urgent waiting lists are in pain and cannot fully enjoy any real quality of life.” So the issue isn’t just about elective or unnecessary medical care, or just about mortality risk. (Next Monday, the Cato Institute will release a study by the doctor who litigated that case.)
  2. In a 2004 poll conducted by the Stockholm Network, residents of France and Germany expressed the least dissatisfaction with treatment delays (out of eight European nations surveyed). Nonetheless, the French and Germans who were dissatisfied with their health care system’s waiting times outnumbered those who were satisfied (50 percent and 55 percent dissatisfied, respectively). So there may be a problem in those countries, even if the authorities do not measure it. (Perhaps we could approach the uninsured the way that France and Germany approach waiting times, and just stop counting them.)
  3. There are indications that people who actually get sick in the U.S. fare better than in nations with “universal” coverage. Women who get breast cancer in Germany are slightly more likely to die of it than breast cancer victims in the U.S. (31 percent vs. 25 percent). For prostate cancer, you are twice as likely to die of it in Germany as in the U.S. (44 percent vs. 19 percent). More such data can be found here and here. If that’s the case, the appeal of “universal” coverage fades.

Can we achieve “universal” coverage? If we could, would it be better than what we have? If it would, would it be worth the cost of a tax burden like that of France? These are open questions, and they are for proponents of universal coverage to answer.

As they try to answer that question, I recommend Crisis of Abundance, a short Cato Institute book by econo-blogger Arnold Kling.

Sometimes, Governments Lie

Year after year, federal officials speak of the Social Security and Medicare trust funds as if they were real.  Yesterday, the government announced that the Social Security trust fund will be exhausted in 2040 and that the Medicare hospital insurance trust fund will be exhausted in 2018 – projections that the media dutifully reported

But those dates are meaningless, because there are no assets for these “trust funds” to exhaust.  The Bush administration wrote in its FY2007 budget proposal:

These balances are available to finance future benefit payments and other trust fund expenditures—but only in a bookkeeping sense. These funds…are not assets…that can be drawn down in the future to fund benefits…When trust fund holdings are redeemed to pay benefits, Treasury will have to finance the expenditure in the same way as any other Federal expenditure: out of current receipts, by borrowing from the public, or by reducing benefits or other expenditures. The existence of large trust fund balances, therefore, does not, by itself, increase the Government’s ability to pay benefits.

This is similar to language in the Clinton administration’s FY2000 budget, which noted that the size of the trust fund “does not…have any impact on the Government’s ability to pay benefits” (emphasis added).

I offer the following proposition:

  • If the government knows that there are no assets in the Social Security and Medicare “trust funds,” and yet projects the interest earned on those non-assets and the date on which those non-assets will be exhausted, then the government is lying. 

If that’s the case, then these annual trustees reports constitute an institutionalized, ritualistic lie.  Also ritualistic is the media’s uncritical repetition of the lie.

Florida Senate Ties its Own Straightjacket

The Florida Senate yesterday killed, by one vote, a proposed state constitutional amendment that would have allowed it to pass school choice legislation. Back in January, the state supreme court fitted the legislature with an education policy straightjacket. It claimed, simply because the state constitution requires the existence of a uniform public school system, that legislators are forbidden to create alternative systems – including, but not necessarily limited to, school choice programs. 

Rather than undoing this bit of judicial overreach, the Senate decided to tie the straightjacket snugly on itself – killing constitutional amendment language that would have allowed it to once again do its job on education policy. 

This leaves Florida’s lawmakers – and more importantly its students – stuck with the “uniform” public school system that has been failing them for decades. The state has one of the lowest graduation rates in the country, according to two independent assessments, and both its mathematics and verbal SAT scores are below the national average. In fact, even Floridian students whose first language is English score 15 points below the national average for such students on the verbal portion of the SAT. 

That’s the system to which the Senate and the judiciary have consigned Sunshine State schoolchildren. 

It’s a sad day for Florida. 

Fourteen other states have public school “uniformity clauses” much like Florida’s so stay tuned to this issue. 

For more on the run-up to this vote, see The American Spectator.

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May Day: Two Directions for Latin America

Bolivian president Evo Morales has nationalized his country’s natural gas industry. He sent soldiers to occupy the gas fields on May 1, celebrated by socialists worldwide as May Day. This May Day was also the 25th anniversary of  Chile’s Social Security privatization. As Jose Pinera wrote in the New York Times:

Since the system started on May 1, 1981, the average real return on the personal accounts has been 10 percent a year. The pension funds have now accumulated resources equivalent to 70 percent of gross domestic product, a pool of savings that has helped finance economic growth and spurred the development of liquid long-term domestic capital market. By increasing savings and improving the functioning of both the capital and labor markets, the reform contributed to the doubling of the growth rate of the economy from 1985 to 1997 (from the historic 3 percent to 7.2 percent a year) until the slowdown caused by the government’s erroneous response to the Asian crisis.

Perhaps 50 years from now, we will know whether Chile’s privatization or Bolivia’s nationalization brought a higher standard of living to citizens.

It might also be noted that Pinera is sometimes criticized for having engineered the privatization as part of a military government (although such critics rarely acknowledge that successive Social Democratic governments have not abolished the pension reform). But  how free is a country in which a president, just back from a summit with Fidel Castro and Hugo Chavez, can unilaterally send soldiers to seize an industry from its legal owners? Morales is taking very little time to earn the attribution “increasingly authoritarian.”

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