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August 28, 2007
The Straw Reformers
"I would like to hear from a large number of single-payer advocates," writes McMegan, "who will say that if the American system could be proven to provide higher quality care per dollar on average than other industrialised system, then they would be content to leave 40 million people uninsured." And I would like to hear from a large number of auto enthusiasts who will say that if the car I'm selling them can be proven to go really fast, then they won't care that it's missing two seats, a mufflers, half a door, and three cylinders.
The 45 million are not some puppies-and-rainbows issue we're talking about because they make us feel sad and draw frownie faces in the margins of our notebooks. It's not efficient to have 45 million people going without preventive care. I could name about 45 million reasons why this is so -- ranging from enhanced productivity to the cost-effectiveness of statin drugs to the young uninsured who should be in the risk pool -- but that's the fact of it. The reason policy reformers are so intent on pulling them into the system isn't because policy reformers are Really Great People, it's because their absence is mucking everything up, and causing gross inefficiencies for hospitals, clinics, Medicare, Medicaid, taxpayers, and themselves.
On the other hand, if Megan could decisively prove that a non-single payer system would be more effective than a single payer system -- which would mean it offered full coverage, not sacrificed it to prove its own seriousness -- then most reformers would happily support it. Indeed, most reformers already believe that, which is why so few of us support single-payer systems in the first place, and tend to instead promote hybrid systems like France. But at least this straw reform movement which believes dogmatically in single payer for incomprehensible reasons and laughs at efficiency claims isn't around to menace us any longer. We can thank Megan for that.
August 28, 2007 in Health Care | Permalink
Comments
"It's not efficient to have 45 million people going without preventive care ... their absence is mucking everything up, and causing gross inefficiencies for hospitals, clinics, Medicare, Medicaid, taxpayers, and themselves."
Quite true.
It's not efficient to have 45 million people without access to health care.
But it's also not moral to have 45 million people without access to health care.
Both arguments must be made, and both arguments reinforce one another.
Posted by: Petey | Aug 28, 2007 8:27:03 AM
who will say that if the American system could be proven to provide higher quality care per dollar on average than other industrialised system, then they would be content to leave 40 million people uninsured.
Actually, this is more like saying, "I would like to hear from a bunch of auto enthusiasts that if it could be proven a 1979 Cadillac El Dorado had great gas mileage then they'd be content to accept the unwieldy size and weight."
Look, the American system, whatever else you might wish to say about it, just doesn't provide good care per health care dollar. The proponents of the current system simply say that the system just provides "the best health care in the world." Plus, as Ezra points out, the lack of insured is part of the very nature of the inefficiency. Finally, the argument against single payer is that it is not acceptable to sacrifice innovation/freedom/doctors' salaries on the altar of efficiency. She's made up an argument that simply doesn't exist and, by its nature, can't exist.
Ah, and this from Megan is hilarious:
that the old and/or sick are not entitled to get money from other people simply by virtue of being old and or sick
I look forward to my insurance company attempting to argue that I am not entitled to reimbursement simply by virtue of being sick and having received health care.
I feel like I have become dumber for having read Megan's post.
Posted by: Tyro | Aug 28, 2007 8:33:01 AM
Ezra. What do you call someone who continually debates an idiot?[/Jeopardy format]
Posted by: calling all toasters | Aug 28, 2007 8:35:49 AM
It seems Megan, like so many on the right, assume that we support government intervention into the health care and insurance markets because we simply love that sort of thing. As Ezra says, that could hardly be the case. If the market were so much better, we'd support that, but as other counties, like France, show, it's possible to have some form of government intervention and have a better system.
Posted by: Brian | Aug 28, 2007 9:03:01 AM
Thankfully, Ezra didn't feel the need to preface this post with a few sentences telling us how McMegan's a great writer and nice person and bakes really good cookies.
Posted by: Brock | Aug 28, 2007 9:13:39 AM
It's not efficient to have 45 million people going without preventive care.
Ah, but if Megan McAntoinette bothered her little head over those people, she'd get frown lines, and that would be so unfair to her. How about this? I'll take a system that insures everyone except her, since she's apparently convinced of her own imperviousness.
The American system is expensive and immoral. If making it less immoral were inherently and vastly more expensive, there'd be room for a debate.
Posted by: pseudonymous in nc | Aug 28, 2007 9:32:52 AM
Why would I wish for the US to have some 'efficient' health care system?
Currently, I am healthy, and I expect this to continue. Sure, I don't know this.
But since everyone else is my competitor, I want there to be maximum opportunity for them to fall prey to illness or death. Only the strongest should survive.
Yes, the market is a vicious place for competition, but not as vicious as viruses and death. Clearly what America needs are higher rates of competition brought about by the deaths of weaker competitors.
In fact, we may want to pass laws such that investors on the floor of the New York Stock Exchange cannot access ANY health care whatsoever.
Posted by: El Cid | Aug 28, 2007 9:38:34 AM
El Cid, that's some grade A snark ya got there. Keep up the good work.
Posted by: Bill from OH | Aug 28, 2007 10:05:31 AM
I'm telling you, Megan's entire shtick is taking every argument into some sophistic blind alley, and then later declaring that she really was not arguing whatever it was it seemed like she was arguing, but instead was just arguing that you were wrong about some hypothetical with an attenuated connection to the topic at hand. If she can get you to admit that you would accept 45 million uninsured Americans IF the other 255 million Americans were all given pet unicorns, then she has won the argument-- not that she is saying it's okay to have 45 million people without access to healthcare, OBVIOUSLY. Any more than she is arguing that torture is okay or that Rudy is an anti-terror genius or that she was right about Iraq. I mean, obviously, right?
I have no idea how she got hired by the Atlantic.
Posted by: Jeff in Texas | Aug 28, 2007 10:35:15 AM
Look, this is ridiculous. I'm simply trying to establish a very small point: that distributive justice matters more to most advocates of single payer than cost-effectiveness. I'm not asking you say that the American system is cost effective; I'm just trying to establish a relative weighting of values. Which is to say, that I think you care *more* about covering the uninsured, than about per capita or gross health care expenditures, even if those things can be gotten down too. This hardly seems controversial.
As for whether it is efficient to have 45 million people going without care, that assumes facts not in evidence. First of all, obviously, there aren't 45 million; the number has been slightly revised downward. But that is a quibble. Second of all, there's no evidence that all 42 million are going without preventative care; many of them are young people for whom preventative care would do little good, and many others (the significant fraction with incomes about $75K) are affluent people who are probably getting preventative care if they need it. Third of all, about a quarter of those 42 million are immigrants who are not likely to be covered under a single payer system. But the largest problem is that there's no evidence that preventative care is cost-effective, as you yourself have blogged. The case for covering the uninsured is a moral question; it is not going to save us money or substantially increase the efficiency of our healthcare system. (I understand that there are other arguments in favour of greater single-payer efficiency. But the act of covering the uninsured is not what creates those efficiencies.)
This back and forth between morality and efficiency arguments, both of them muddily defined, is exactly why I'm trying to scope out the boundaries of the argument by nailing down small points one by one, rather than just trading random claims about how awesome our respective systems will be.
Posted by: Megan McArdle | Aug 28, 2007 10:40:43 AM
I agree! Ridiculous! You're "trying to establish a very small point: that distributive justice matters more to most advocates of single payer than cost-effectiveness." This point is wrong. And to make it, you're dividing other people's arguments in ways that they can't be divided. That's my point.
And if you believe that I think preventive care isn't cost effective, you're wildly misinterpreting just about everything I've ever written. Not necessarily bringing costs down isn't anything near the same as not being cost-effective. It's cost effective -- if you're end is better health care per dollar -- to give people better health care per dollar. Nothing you said about the uninsured, or preventive care, suggests a universal or single-payer system wouldn't do that. You're conflating cost-effective with cheaper, and they're not the same.
Posted by: Ezra | Aug 28, 2007 10:47:54 AM
This back and forth between morality and efficiency arguments, both of them muddily defined, is exactly why I'm trying to scope out the boundaries of the argument by nailing down small points one by one, rather than just trading random claims about how awesome our respective systems will be.
Or, alternatively, you're trying to force advocates of reform to caricature their arguments to fit your own caricature. Sorry, not playing, and not eating brioche either.
Here's the deal-i-o: there are systems in other countries that are more equitable, satisfy the basic moral principle of not denying people coverage because they're poor... oh, and they also happen to deliver more bang for the buck. If they were vastly more expensive, then there'd be room to agonise. Sorry about that.
Posted by: pseudonymous in nc | Aug 28, 2007 11:00:51 AM
"The case for covering the uninsured is a moral question"
Yup. Where is your morality, Megan?
"(universal healthcare) is not going to ... substantially increase the efficiency of our healthcare system."
Wrong. You really might be able to add more to the debate if you had the slightest idea what you were talking about.
"I understand that there are other arguments in favour of greater single-payer efficiency. But the act of covering the uninsured is not what creates those efficiencies."
And finally, are you really incapable of distinguishing between "single-payer" and "universal healthcare" that would cover the uninsured?
If you don't care to understand the basics of the debate, and you don't give a shit about the morality of policy, why are you even bothering to talk about this? Oh, that's right. It's because you're Megan McArdle and your entire schtick is spouting amoral ignorance.
Posted by: Petey | Aug 28, 2007 11:07:30 AM
Megan said:
"The case for covering the uninsured is a moral question; it is not going to save us money or substantially increase the efficiency of our healthcare system. (I understand that there are other arguments in favour of greater single-payer efficiency. But the act of covering the uninsured is not what creates those efficiencies.)"
But isn't this precisely where you and Ezra disagree? Wouldn't he argue that 'covering the uninsured' includes both the moral benefit of them having health care and the efficiency gains of including them in the risk pool?
While on the other hand, you seem to think that 'covering the uninsured' would provide little to no efficiency gains, but would have moral benefits?
I would be very curious (I'm serious, I'm not being sarcastic!), Megan, if you could elaborate on why you believe that including the 40 million or so w/out insurance in the pool would provide no efficiency gains. Ezra raised a few points that I'd love to see debated:
1.) Having the healthy members of the 40 mill contribute would help distribute costs.
2.) Reduces productivity losses from sick days/illnesses from members of those 40 mill.
I'm sure Ezra could list some more...
On a side note, Megan, I think that perhaps part of the reason that (in this case at least) people have been flying off the handle a bit towards you is that you've _appeared_ to be taking the position that
(One of) single payer's advocate's argument is X
and Ezra and others have replied,
No, that's not our argument, our argument is Y
And instead of appearing to address the argument Y, you seem to keep insisting that they are actually arguing X and that they should simply admit they're wrong because you've demolished argument X.
At least, that's the way it has seemed to me...
Posted by: jme | Aug 28, 2007 11:15:29 AM
Is this a dangerous argument or merely an annoying one?
Posted by: Steve Balboni | Aug 28, 2007 11:23:24 AM
The question of whether preventive care is cost-effective can only be answered at the margin. There is undoubtedly an optimal level of prevention. The challenge for any socialized system is finding that optimum without knowledge of individual preferences.
Posted by: henry evans | Aug 28, 2007 11:31:48 AM
This back and forth between morality and efficiency arguments, both of them muddily defined, is exactly why I'm trying to scope out the boundaries of the argument by nailing down small points one by one, rather than just trading random claims about how awesome our respective systems will be.
Megan,
Let's start with not equating univeral health coverage with single-payer. They are two separate (but related) topics, which is clearly evidenced by the fact that Obama and Edwards have put forth proposals for the former, Massachusetts has implemented UHC not single-payer and California is pursuing something similar.
Based on the excerpts and posts above, you've clearly mistaken the two, using the terms interchangeably or inappropriately. Whether preventive care is cost-effective has little to do with single-payer and much to do with universal health care. So wondering what single-payer advocates think about cost-effectiveness is less the issue than whether UHC advocates think about cost-effectiveness.
Posted by: wisewon | Aug 28, 2007 11:54:00 AM
"I agree! Ridiculous! You're "trying to establish a very small point: that distributive justice matters more to most advocates of single payer than cost-effectiveness." This point is wrong."
Seriously, have you taken a poll? Having read this blog for some time, I would say that, for a significant number of those who comment, this is true.
Posted by: DM | Aug 28, 2007 12:13:12 PM
this = "that distributive justice matters more to most advocates of single payer"
Posted by: DM | Aug 28, 2007 12:15:41 PM
for a significant number of those who comment, this is true
Actually, I don't think it is, but that's because Megan conflates "single payer" with "Universal Health Coverage." The argument for single payer, as opposed to other UHC plans, is that it is the best precisely because it would be the most efficient means of delivering UHC.
Posted by: Tyro | Aug 28, 2007 12:25:29 PM
I have health insurance but it does not 'cover' preventive care per se. Since I am 56, own a small business and my spouse is a cancer survivor, I can only afford coverage with huge individual deductibles. All my family's health care short of a multi-day stay in a hospital is out of my pocket. I figure my coverage will be available for only a few more years and then I will on my own until 65 and Medicare kicks in.
Given the trends in health care costs those of you aged less than 50 are screwed worse that I am. Health insurance is not available under any circumstances for many people today and that trend will grow. I have no doubt that a significant number of participants in this thread will not have health insurance past the age of 50 should the current system remain in place.
The point of single payer of some permutation is a more efficient and cost effective system. Period. Poor people without insurance already are given free catastrophic care. The life long smoker with lung cancer or the 20-something drunk who wrecks his car get free treatment. If they qualify for an entitlement or not the treatment is not denied.
Preventive care is no longer encouraged by our system. 15 years ago I had coverage that included free yearly physicals. Now the highly encouraged post 50 colonoscopy is completely out of my pocket.
Posted by: Nat | Aug 28, 2007 12:37:15 PM
“The argument for single payer, as opposed to other UHC plans, is that it is the best precisely because it would be the most efficient means of delivering UHC.’
I would agree with this statement. My point (and Megan’s, I think) is that there are a significant number of people that don’t care about the efficiency nuances of Single Payer versus other UHC plans; they’ll support anything that covers all, for reasons other than efficiency. What percentage of those who regularly comment in this blog belong to this group? Not sure, but I think a poll would be interesting. I would venture to guess it’s a fair share though I wouldn’t bet that it’s the majority.
Megan is trying to create some boundaries around the discussion; she’s trying to keep it on a single thread: moral arguments for UHC/single payer/etc. Her argument was a counter to what she would deem to be “typical” moral reasons to advocating UHC or Single Payer -- in fact, she mentioned should discuss the efficiency side later this week, which I look forward to.
Now, when you get to the efficiency argument, then the pros and cons of different flavors of UHC do come into play.
Posted by: DM | Aug 28, 2007 12:41:54 PM
I'm not sure why this discussion proceeds. Megan speaks for who?
Megan: the old and/or sick are not entitled to get money from other people simply by virtue of being old and or sick.
One wonders how this question would poll across the nation. Indications are that very few people are this amoral, and are actually repelled by this position.
I'm sure there are people who advocate that each person pay only for their own care, and pay as much as some hypothetical market charges for that care. In a universal care solution, I'd even consider allowing these people to opt out of the plan, but be flagged in a nationwide database as 'cash pay only' when they arrive at the emergency room or doctors office. No cash, no treatment. Full stop (to mimic Megan). For those without health insurance today this is the system they face with the exception that the ER has to by law provide stabilizing treatment, which in the McMegan Plan should not be provided. I'd make one exception, I'd allow the providers to pay for taxi for the uninsurered so that the bodies didn't pile up too high at the checkpoints around medical facilities.
Megan should deeply consider Petey's point above:
It's not efficient to have 45 million people without access to health care.
But it's also not moral to have 45 million people without access to health care.
Both arguments must be made, and both arguments reinforce one another.
Posted by: JimPortlandOR | Aug 28, 2007 12:43:48 PM
Based on what Meghan says above, it seems that she wants to reduce proponents of NHC to the status of ideologues under the sway of perverse altruistic impulses. Notably absent is any hard data indicating that such a characterization is justified.
It might be worthwhile to consider why she thinks this either important or effective.
The most obvious supposition is that she believes NHC proponents are driven by this sort of logic because it mirrors her own subjective approach. If Meghan argues that the demand for NHC is actually fueled by the desire for "distributive justice", she can then argue that this is the "real" question and all other practical considerations are mooted. If she defines such "distributive justice" as immoral, it follows that all arguments flowing from that position are immoral as well and can be dismissed without reference to their practical merits.
Her syllogism appears to be "NHC advocacy is driven by the desire for distributive justice. The desire for distributive justice is immoral. Therefore, all advocacy of NHC is immoral."
For those not acquainted with the tinker toy intellectual constructs of "Objectivism" this premise can also be expressed as "NHC advocacy is driven by altruism. Altruism is immoral. Therefore all NHC advocacy is immoral."
The trouble with this silogism, as with most faulty silogisms, lies in what it excludes. It doesn't appear to occur to Meghan that individuals may judge that a general benefit to society accrues to indirect, or even direct, benefits to themselves. Hence, since she perceives no direct benefit to herself in insuring the uninsured, she concludes that those differing with her are driven by immoral ideological impulses, whereas she is the soul of objective rationality.
Now Meghan does pad her central philosophical conceit with a great deal of serious sounding rhetoric. However, this doesn't succeed in obscuring the reality that she is attempting to establish a premise that dictates a teleological conclusion favorable to her own ideological preference.
If Meghan is serious about inquiring into the "first principles" and "priors" of those who dispute her, she would do well to query them on those points. As it is, she invents caricatures and mistakes them for reality.
Posted by: WB Reeves | Aug 28, 2007 12:57:35 PM
there are a significant number of people that don't care about the efficiency nuances of Single Payer versus other UHC plans
I just don't see those facts in evidence. You have a bunch of people on this blog in favor of Universal Health Coverage. Some of them support single payer, some of them don't. When Megan figures out that single payer is a mechanism (possibly the most efficient mechanism) for delivering health care in general, and universal health coverage, specifically, then perhaps she can make some kind of argument worth discussing.
The people I've heard arguing for Single Payer for the purpose of single payer are generally those who have some kind of hostility to insurance companies or the health-care-administration-industrial complex, and those tend to be doctors. :)
Posted by: Tyro | Aug 28, 2007 12:59:15 PM
