Topic: Health Care & Welfare

Costs vs. Spending

In yesterday’s New York Times, David Leonhardt writes:

Mr. Wagoner’s argument has become the accepted wisdom about the [health care] crisis: the solution lies in restraining costs. Yet it’s wrong.

In fact, the solution does lie in restraining costs.  Leonhardt is wrong because he conflates costs and spending

Spending is the amount of money we devote to medical care.  Costs are different.  The money devoted to medical care represents a cost, because we give up the next-highest value use of that money (e.g., a skiing trip).  But we also bear costs due to illness, including pain, limited mobility, and shortened lifespans.  We spend money on medical care to reduce the total costs that we bear.  Spending a lot of money on medical care is therefore desirable – so long as the benefits (reduced pain, enhanced mobility, longer lifespan) exceed the costs for each increment of spending.  The solution to every economic problem undeniably lies in restraining costs. 

Leonhardt probably meant to shoot down the idea that the solution to America’s health care crisis is in restraining spending.  Indeed the thesis of his article seems to be that even though there are many wasteful medical expenditures, a lot of what America spends on health care is very worthwhile.  But he repeatedly confuses the two concepts:

But the No. 1 cause of the cost increases is still the one you can see at the hospital and in your medicine cabinet — defibrillators, chemotherapy, cholesterol drugs, neonatal care and other treatments that are both expensive and effective.  

But if those treatments are expensive and cost-effective, then they would reduce costs. 

The confusion keeps Leonhardt from reaching the $64,000 question: How can we eliminate waste while preserving what works?  Or to put it another way, How can we reduce spending without increasing costs?

It’s Getting Better All the Time (contd.)

The Washington Post has a 12-inch story on Tuesday with this headline:

Freshman from Arlington

Comes Down With Mumps 

Is that news? When I was a kid back in the benighted 60s, everyone got mumps. Why is it news today? Because now we have vaccines, and kids don’t get mumps any more. So it’s actually news when somebody gets “the mumps, a highly contagious viral disease.” Sounds bad when you put it that like that, but it seemed a standard part of growing up a generation ago.

According to this timeline, a vaccine was licensed in 1967, and an improved one in 1971. And since then, I guess, nobody gets mumps. Another reminder of why paying a high percentage of our income for medical care is not exactly a bad thing.

Doctors without Borders

I have to join Ezra Klein in copying in its entirety this Dean Baker post to The American Prospect’s blog Tapped:

NPR had a piece this morning on the possibiity that Medicare reimbursements for doctors will be cut. It told listeners that if this cut went into effect, then there may be a shortage of doctors who are willing to serve Medicare beneficiaries.

In other contexts, such as supplies of farm workers, custodians, and restaurant workers, NPR has told listeners that shortages meant that the country needed immigrant workers. No one interviewed for this segment mentioned the possibility of more immigrant doctors, even though doctors receive much higher pay in the United States than they do in the developing world, or even Europe. Surely, if the United States worked to eliminate the barriers that make it difficult for foreigners to train to U.S. standards and practice in the United States, there would be large numbers of foreign physicians who would be willing to do the work that NPR tells us American workers do not want to do.

The great thing about economic models is that you can use the same models for almost anything, you just have to change the words that appear on the axis. If getting immigrants, who will accept low pay, to work in our farms and factories makes economic sense, then getting foreign doctors, who are willing to accept low pay, also makes sense. Maybe NPR will one day get reporters who know economics, if we elimiante [sic] barriers to trade among journalists.

Perhaps a cut in Medicare reimbursements could spark a conversation about liberalizing immigration and licensure restrictions on physicians and allied health professionals.

Tell Me That’s Not Your Final Answer

The congressionally chartered “Citizens’ Health Care Working Group” today released its final recommendations on how to reform America’s health care sector. (I commented on their interim recommendations here and here.)

As with many GOP-led health care reform efforts, this one began with leftist premises about the role of government. Recommendation #1 is that the federal government should “Establish Public Policy that All Americans Have Affordable Health Care.” Recommendation #2 is that the feds should “Guarantee Financial Protection Against Very High Health Care Costs.” (The group inadvertently neglected to cite any passage from the U.S. Constitution that actually grants Congress the power to do such things.)

Given those premises, there was little doubt that the group would recommend left-wing reforms. For example, the group claims to have developed both a “market–based model” and a “social insurance model” for achieving universal coverage. Yet the former is a mirror image of the statist Massachusetts health plan. What kind of “market-based model” increases taxes and government spending while forcing individuals to purchase government-defined insurance policies? Good grief.

I would give my right eye for a health care reform panel that would make this its charter:

To make health care of ever-increasing quality available to an ever-increasing number of people.

To me, that doesn’t just seem simple and non-controversial, it seems to be what everyone involved in health policy wants.

Moreover, a mission like that would force the panel to consider not just the goodness of its intentions, its knowledge of today’s health care sector, or its ability to do math, but also the incentives that its recommendations would create, and their long-term impact.

Let’s hope some enterprising panel-creator is reading this.

Aside from That, Mrs. Lincoln, How Did You Enjoy the Show?

A website called TheBudgetGraph.com offers a visual representation of federal spending based on President Bush’s proposed budget for fiscal year 2007. (Click here, then click on “View the Graph.”) It is truly a monstrosity.

But look more closely and you’ll notice that it only counts budget items to which Congress must fix a dollar amount every year. It completely ignores those parts of the federal budget where the dollar amount is set automatically by formula. (Those two categories are usually called “discretionary” versus “mandatory” expenditures, but that bifurcation is misleading. Nearly all expenditures are discretionary, with the possible exception of interest payments on the national debt.)

That latter category — which includes Social Security, Medicare, Medicaid, interest payments on the debt, etc. — comprises 63 percent of the federal budget. That makes “The Budget Graph” more like “a visual guide to where one-third of your federal tax dollars go.”

Were the graph to count the entire budget, heck, I’d probably buy the poster.

(HT: Frederic Sautet.)

Medicare Politics Will Sink Quality Efforts

As David Hyman explains in Medicare Meets Mephistopheles (book forum today), Medicare’s already-high tax burden is set to explode when the baby boomers begin to retire in 2011. Yet for all that money, the quality of care that Medicare delivers is downright mediocre.

Some members of Congress, led by Senate Finance Committee chairman Chuck Grassley (R-IA), are using the threat of a cut in Medicare payments to force physicians to accept tying those payments to government-defined quality measures.

Physicians, led by the American Medical Association, are essentially responding, Ditch the planned pay cut – then we’ll talk.”

Who’s right? Whose approach will get seniors and taxpayers the most value for their Medicare dollars? No one really knows, and thus all the political wrangling.

But one thing can be known: the approach that Congress chooses will be determined by raw political power – not by what provides the greatest value. For example, if the physicians get their way, every bit of quality improvement will cost taxpayers more money, because the AMA won’t even support pay cuts for lousy doctors.

As I explain in a recent paper, that is exactly why we don’t want Congress itself in the business of measuring and rewarding health care quality. That task is better left to a competitive market process. Congress should confine “pay-for-performance” to private Medicare plans, and encourage greater enrollment in private plans by giving seniors risk-adjusted vouchers rather than a defined benefit.