Who Should Ration Health Care?

In preparation for what should be a fun health policy forum on Thursday – hey, where are you going? – I’m reading Ezra Klein’s article “The Health of Nations” from the May issue of The American Prospect.  The article includes an interesting omission that might explain Klein’s preference for letting experts – rather than consumers – ration health care:

[T]he right…has argued for a move toward high-deductible care, in which individuals bear more financial risk and vulnerability. As the thinking goes, this increased exposure to the economic consequences of purchasing care will create savvier health-care consumers and individuals will use less unnecessary care…

Problem is, studies show that individuals are pretty bad at distinguishing necessary care from unnecessary care, and so they tend to cut down on mundane-but-important things like hypertension medicine, which leads to far costlier complications.

(Actually, cost-conscious patients also tend to cut down on health care that harms them.  That’s why the best evidence available indicates – contrary to what Klein suggests – that when patients control more of the money and do more of the rationing themselves, overall, it doesn’t harm their health.)

Later, Klein offers this explanation for his claim that Great Britain’s health care system is just as productive as the U.S. system, despite spending less than half as much on medical care:

Much of the health care we receive appears to do very little good, but we don’t yet know how to separate the wheat from the chaff. Purchasing less of it, however, doesn’t appear to do much damage.

So Klein acknowledges that neither individuals nor experts appear to do a good job of separating the wheat from the chaff.  Agreed.

But he appears to prefer rationing by experts, because he believes that when consumers make the necessary tradeoffs, they hurt themselves.  Except that this is not true overall – and it’s very hard to find evidence that supports an argument to the contrary.

So if Klein will acknowledge that letting consumers do the rationing does not lead to worse health outcomes – and I don’t see how he cannot – then why the preference for rationing by experts?

Nanny State Crackdown

Steve Kelly pokes fun at nanny state legislation.

Unfortunately, too many people have a “there ought to be a law” mentality.  Sometimes it is silly, but more often it is dangerous.  The Duke University case is a reminder that innocent lives can be adversely affected even if the criminal law were limited to violent offenses.   Expanding the criminal law is dangerous business.  Better to keep it limited–and keep a good eye on it. 

School Choice Movement Needs to Broaden the Coalition

A must-read article by Howard Rich*, chairman of the Parents in Charge Foundation, ran this weekend in the Wall Street Journal.  It explains why pursuing targeted voucher plans is a bad long-term strategy:

Broader choice plans equal broader support. You don’t have to take
Grassroots 101 to know that successful coalitions are based on
addition, not subtraction. Yet in many instances school choice
supporters have been conditioned to believe that confining the
parameters of parental choice will lead to a broader base of public
support. The opposite is true. As employee stock options and personal
savings accounts have shown, nothing motivates individuals quite like
becoming personally invested in an issue.

Supporters of school choice cannot afford to leave a single ally on
the sidelines – for Christian school parents, home school parents,
parents with special-needs children or parents who for whatever reason
aren’t satisfied with the public school they are zoned for, universal
choice plans offer a much broader base of grassroots support than more
narrowly-drawn proposals.

Rich should be commended for spearheading a new strategy in South Carolina that expands the school choice coalition and makes long-term success more likely.

Educational freedom for all is good policy and good politics.

* Howard Rich is also a Cato Institute Board member.

The “Public Health” Myth

A headline in the Washington Post blares:

Japan’s New Public Health Problem Is Getting Big

Obesity Has Grown, Along With Appetite For Western Foods

But no. Obesity is not a public health problem. It is apparently becoming more widespread in Japan, though still much less so than in the United States, but it remains an individual and non-contagious problem.

The meaning of “public health” has sprawled out lazily over the decades. Once, it referred to the project of securing health benefits that were public: clean water, improved sanitation, and the control of epidemics through treatment, quarantine, and immunization. Public health officials worked to drain swamps that might breed mosquitoes and thus spread malaria. They strove to ensure that water supplies were not contaminated with cholera, typhoid, or other diseases. The U.S. Public Health Service began as the Marine Hospital Service, and one of its primary functions was ensuring that sailors didn’t expose domestic populations to new and virulent illnesses from overseas.

Those were legitimate public health issues because they involved consumption of a collective good (air or water) and/or the communication of disease to parties who had not consented to put themselves at risk. It is difficult for individuals to protect themselves against illnesses found in air, water, or food. A breeding ground for disease-carrying insects poses a risk to entire communities.

The recent concern over a tuberculosis patient on an airplane raises public-health issues. You might unknowingly find yourself in an enclosed space with a TB carrier. But nobody accidentally ingests a Big Mac. And your Big Mac doesn’t make me fat. That’s why obesity is not a public health issue, even if it’s a widespread health problem. As I wrote before,

Language matters. Calling something a “public health problem” suggests that it is different from a personal health problem in ways that demand collective action. And while it doesn’t strictly follow, either in principle or historically, that “collective action” must be state action, that distinction is easily elided in the face of a “public health crisis.” If smoking and obesity are called public health problems, then it seems that we need a public health bureaucracy to solve them – and the Public Health Service and all its sister agencies don’t get to close up shop with the satisfaction of a job well done. So let’s start using honest language: Smoking and obesity are health problems. In fact, they are widespread health problems. But they are not public health problems.

Farm Subsidies: All You Need to Know

As Congress considers a new farm bill in coming weeks, Cato has launched a web resource, Downsizing the U.S. Department of Agriculture, which offers a menu of cuts to shrink the department’s $89 billion budget by 90 percent.

A nice complement to the Cato pages is an updated farm subsidy database from the Environmental Working Group.

Go to Cato to understand why farm subsidies are bad economics. Go to EWG to find out exactly how much millionaire “farmers” such as Edgar Bronfman and David Rockefeller are receiving.

In winning the House last year, the Democrats portrayed themselves as reformers willing to take on wealthy special interests for the benefit of average families. With the farm bill, they have a chance to prove it by making cuts to subsidies that are strongly supported by both liberal and conservative policy experts. 

It Starts with a Hug and Ends with Chaos

Just when you thought solutions to what should be minor problems couldn’t get any more absurd, Kilmer Middle School in Vienna, Virginia, has decided to institute an absolute ban on physical contact.

Why, one might ask? Well, because of overcrowding and behavior problems, of course!

Deborah Hernandez, Kilmer’s principal, said the rule makes sense in a school that was built for 850 students but houses 1,100. She said that students should have their personal space protected and that many lack the maturity to understand what is acceptable or welcome.

“You get into shades of gray,” Hernandez said. “The kids say, ‘If he can high-five, then I can do this.’ “

Right. And it’s the job of adults to use discretion and good sense to stop the “this” that’s disruptive and allow the “high-five” that’s not instead of instituting absurd absolutes to make it easier on incompetent teachers and administrators who want to cover their derrieres.

A hug may be a handshake from the heart, but neither form of platonic affection is allowed at Kilmer. Seventh-grader Hal Beaulieu found that out after getting busted for briefly hugging his girlfriend during lunch. Big no-no.

A review of the policy might be on the way, but here’s an idea: how about parents get to choose the school that works for their child? That way we could have schools without physical contact for the Puritanical or law-and-order types, and hug-fest schools for the “visualize world peace” folks.

Education tax credits are a great way to expand that choice for parents in Virginia. And they would also solve the overcrowding problem that Principal Hernandez mentions … I’m sure at least 250 students would happily transfer to a hugging-allowed school if they had a tax credit program to help them make that choice.