March 23, 2007
Arguing Health Care
Is Megan's problem with health care writing really that the literature is too narrative-driven? Yikes. She should read some issues of Health Affairs, or the Annals of Internal Medicine, or the New England Journal of Medicine. This is not a debate that lacks for data.
Meanwhile, Megan actually gets a few things wrong in her argument with Chait. She suggests that waiting lines are longer in Europe. That's, uh, untrue. France and Germany don't have waiting lists. Americans do, by the way, with around 40% of patients waiting one month or more for elective surgery. She then suggests that moving to a French or Canadian system would require walking back the medicine we actually provide, telling people they can't have MRIs anymore. That's similarly incorrect. Care utilization in France and Germany is as high -- and in France, higher -- than it is in America. But they pay less per unit of care. And the technology isn't radically different. Germany actually has more CT scanners per million than we do, while the French have three less. The French and the Germans both have more physicians per capita and more acute care beds. Oh, and the French and Germans pay less, and don't have 47 million uninsured.
All this information -- and more! -- can be found in various data-heavy books on the subject, like Thomas Bodenheimer and Kevin Grumbach's wonderful Understanding Health Policy. The thing is, they tend to point towards the same conclusions Jon Cohn's book does, albeit with fewer anecdotes. One reason I spend less time arguing health care with libertarians these days is that it doesn't seem productive. If you really don't want to believe that other system's in the world are better, you won't. If the costs, outcomes, access, and equity advantages offered by the French, German, Japanese, Scandinavian, or Veteran's Affairs systems don't convince you, you simply don't want to be convinced. There are issues, like card check, where I see how the counterargument could be convincing, the data isn't overwhelming, and understand it is, to some degree, a values judgment. Health care isn't one of those issues. If the evidence already on offer doesn't convince you, there is nothing more I can say, no cleverer argument I can muster, that will.
March 23, 2007 in Health Care | Permalink
Comments
I haven't read as closely as you have, but you seem to have some specific facts you can marshal.
I might prod you to write something informal (a few pages) but with copious footnotes to inarguably factual sources. throw down the gauntlet, as it were. Even better if it is directed at someone specific (just to make it all more of a big deal).
Posted by: mk | Mar 23, 2007 5:28:41 PM
"If ... don't convince you, you simply don't want to be convinced. There are issues ... where I see how the counterargument could be convincing and understand it is, to some degree, a values judgment. Health care isn't one of those issues."
Now there's an argument: if I don't agree with you, I'm wrong, end of story. You are young, aren't you?
Posted by: ostap | Mar 23, 2007 5:31:17 PM
It is easy enough to believe that other systems are better. It is harder to see how they can be implemented here. For example other systems let extremely premature babies die which I think is sensible. But I don't see how that is politically possible here. I expect any attempt to drastically change our system will just make it worse.
Posted by: James B. Shearer | Mar 23, 2007 5:53:21 PM
I like how on feminist blogs trolls accuse you of being a man-hater (or irrational, or unladylike, or ugly); over here, they accuse Ezra of being "young." Anything to avoid actually arguing about the merits of an issue, I guess.
Hey Ezra, did you know anyone born before 1950 can't have an informed opinion? It's true! Some dude on the internets told me so.
Reflexive disbelief in the efficacy and morality of any sort of publicly funded healthcare seems to be so deeply rooted in some people's minds that no amount of research or data is capable of digging it up. It's some sort of weird, twisted macho-thing, I think, or else a belief that deep down, we just don't *deserve* equal access to health in this country.
Posted by: emjaybee | Mar 23, 2007 5:54:02 PM
Ah yes, because to profess certainty in the weight of factual evidence is a sign of youth.
In any case, you misunderstand me. You can disagree with me all you want. But I'm not going to convince you. There is nothing more I could say, no clearer data I could marshal, no cleverer argument I could offer. And so it is not productive to argue. I guess age doesn't guarantee reading comprehension.
Mk: Go through my archives or pick up the book I recommended. It's all there.
Posted by: Ezra | Mar 23, 2007 5:54:35 PM
Who cares what the French and German systems do for mere humans, or at what cost? The real question is, do those French and German systems provide as much profit to private interests? If not, it would be positively immoral to bring them here!
Posted by: RLaing | Mar 23, 2007 5:58:10 PM
They want facts (sometimes), but they don't want facts (quite often). You are correct, Ezra, they start with their beliefs and they look ONLY for the reinforcing facts - like the drunk looking for his keys on the street that only will look under the streetlight because that is where the light is.
While most the libertarians are electorally harmless (who knows what CATO is?), their myths and non-facts are widely spread by the interested anti-change forces in the health care industry and in Congress.
When you get to the bottom line, you can't win them over to rationality. The only way to better policy being enacted into practice is supportive Congressional majorities and a supportive (Democratic) President, or veto-proof legislative majorities writing laws that allow essentially no executive discretion in execution of the laws.
(My pet grievance rant coming): Congress has been writing laws for too long that allow the Executive branch (and regulatory agencies) to write 'rules'. I suppose they think that legislation shouldn't be burdened with details or that it would be too time consuming to put the details in the laws. In fact, the Executive and Agencies take forever to put the laws in action (far longer than it would take Congress to listen to the parties and write the rules), and they twist and bend the rules to essentially reverse the intent of the laws.
We can no longer assume that the President and his appointees will take care that the laws are faithfully executed, so a different style of legislating is required to actually reform things.
Here's an example of twisting the law and confusing the public:
Under the Medicare law, private insurnce companies can offer health plans of various types that fully replace the Medicare offerings under Part A and B Medicare. However, now the Medicare Benefits annual publication makes these plans seem to be part of Medicare as perceived by the recipients. All this through the magic of writing a publication. Private insurance is not Medicare, but because the Congress failed to specify how these alternate plans were to be characterized, they are all in the same category now.
The camel's nose of Conservatives and Libertarians doesn't just want to come into the tent, they want to take it over or destroy it - and they can because they influence how the laws are carried out (quite often contrary to legislative intent).
Posted by: JimPortlandOR | Mar 23, 2007 6:09:43 PM
Now there's an argument: if I don't agree with you, I'm wrong, end of story.
Actually, what Ezra is telling you is that you are entitled to your own opinions, but not your own facts.
The conservative argument goes like this:
We can't have national health care because in countries that do, they have to wait 40 years for a hip transplant!
Liberal: No, as you can see, from the statistics here, not only are there not significant wait times, but wait times for those surgeries in America are larger.
Conservative: But what about the fact that in socialist countries there is only 1 MRI in the entire country, located in the basement belonging to the Prime Minister's mistress, requiring a 500 mile commute that grandmothers with cancer have died waiting to get access to? That's why we should never have national health care in America!
Liberal: No, actually, in many countries with national health care systems, the number of available MRIs per capita is equal or close to the number available in the United states.
Conservative: Oh yeah? Well look, Stalin was a socialist, and that resulted in the gulags and the deaths of millions? Is that what you want?
At the point, the average liberal will realize that no amount of facts marshaled in the defense of national health insurance is going to convince the conservative/anarcho-capitalist of the wisdom of the program and that the entire discussion is going to revolve around the conservative throwing out fallacious claims and the liberal correcting them with actual facts.
This is similar to the Social Security privatization debacle of 2005. When it was pointed out that Bush's ideas wouldn't save money, wouldn't result in greater benefits, and wouldn't produce better results than the current system, it was clear that the reason he wanted to privatize the system was "just because." Ezra is pointing out that, at the end of the day, much of the opposition to national health care is rooted in these sorts of "just because" arguments.
Posted by: Constantine | Mar 23, 2007 7:28:33 PM
What I found funny about ostap's misreading of Ezra is that it reminded me of why I stopped reading Jane Galt, when she wrote something very like what ostap accuses Ezra of in the penultimate paragraph of this post:
"I will not contradict anyone who avers that their reaction after 9/11 was not tinged with some amount of excitement at the sheer fact of having a just cause to pursue, an enemy to triumph over. But I will not believe them, either."
If you don't agree with me (with my universalizing of my own experience) then I won't believe you. Of course, if I don't believe you, then I think you're lying, which is to say telling an untruth, which is to say you're wrong: so, if you don't agree with me *about a personal reaction* you're wrong. This compounds the "if you disagree you're wrong" issue by tying it with my personal pet peeve, the "in this respect all people are like me!" argument. Were I ostap I'd condescendingly point out that Jane Galt herself is fairly young - but she's older than I am, and I'm too old to put up with that shit.
Posted by: Quarterican | Mar 23, 2007 7:46:53 PM
The thing that bothers me about liberals is that when you want to compare the US to Europe, the continent, they break out Germany and France.
Posted by: DM | Mar 23, 2007 8:03:18 PM
Okay, fair enough -- "Europe" isn't Germany and France. So what? If the data showed that Estonia had a health care system that was significantly better than France's, we should be talking about how we could steal ideas from Estonia instead.
Posted by: Evan Goer | Mar 23, 2007 8:31:03 PM
Of course, if I don't believe you, then I think you're lying
No, people are wrong about their own feelings often enough, especially where there's some reason to suppress them, as there might be in this case. I don't know why Megan was skeptical about people in this connection, but it isn't unreasonable in principle as you make it out to be.
Posted by: Sanpete | Mar 23, 2007 8:51:01 PM
"I will not contradict anyone who avers that their reaction after 9/11 was not tinged with some amount of excitement at the sheer fact of having a just cause to pursue, an enemy to triumph over. But I will not believe them, either."
What a silly thing to say. I remember my reaction was "dammit, now we have to take stuff seriously. Taking stuff seriously is totally lame." Not that that doesn't make me an asshole, but it's still what I was feeling. A giant disappointment that the end of the world would be driven by dudes in turbans with kalishnikovs rather than post-singularity robot automatons.
Posted by: Consumatopia | Mar 23, 2007 8:57:48 PM
Sanpete -
I wanted to make my post succint, so yes, I compressed a few logical steps. But for my purposes, the difference between "you're lying about your true feelings" and "you're mistaken about your true feelings" is irrelevant; both get back to "any person who does not assert that he feels X is wrong about the content of his feelings," which is a ridiculous thing to write. Given the arrray of strange and unusual psychological conditions out there, that statement *might* never be true, for any value of X, although I wouldn't know; it's certainly not true for anything remotely as complex and developed as the idea in question. I'm glad she wrote it, though, because I'd been increasingly frustrated with her writing for some time, and that throwaway so perfectly pushed my personal collection of buttons that I was able to stop reading her without any anxiety that I was missing anything valuable. Of course, she's much more knowledgeable than I am on many topics, but to me it's just not worth the bullshit.
Posted by: Quarterican | Mar 23, 2007 9:20:34 PM
"any person who does not assert that he feels X is wrong about the content of his feelings,"
The words you quoted, taken by themselves, don't imply this, only that such people may be wrong, which isn't as ridiculous. I'll grant you that in the context of her post it appears to mean something stronger, though.
I agree with you and Consumatopia that this seems a peculiar view on its face, but I don't think it's as silly as it might first appear to be. In the context of her post, it seems she means we all have an animal urge to war and its glorification, one that must have stirred, even if unrecognized, in response the events of September 11th. It may not be put as clearly as it could be, but I think it's a reasonable possibility. Don't you? (Sorry--don't mean to undo your reason for not reading something you don't like anyway.)
Posted by: Sanpete | Mar 23, 2007 10:05:20 PM
Constantine's comment cuts to the heart of this debate: whether libertarians and their ilk are entitled to their own set of facts. It's not just libertarians, obviously — perhaps it's anyone outside the reality-based community.
Here in Colorado there's a "blue ribbon" commission charged to find the best proposal for comprehensively reforming health care in the state.
A libertarian commissioner from Colorado's Independence Institute (which, ironically enough, hasn't been at all independent from Exxon's happy climate money), has her own set of facts about U.S. healthcare — beginning with the "fact" that actually, there is universal healthcare in the U.S. — because emergency rooms can't turn people down. (Other times she's railed about how unfair is that!)
Outside the ideological libertarian nonsense, the difficulty in reforming our mess comes down to the healthcare insurance industry being 5 percent of the U.S. economy. strategy+business magazine, in an article in their spring 2007 issue on "Does Health Care Have a Future?" posited that healthcare's reform in the U.S. has to be practical. "We cannot take seriously any proposal that wipes out the existing health plans, for example, for the simple reason that health plans alone represent 5 percent of the U.S. economy."
So no matter how inefficient, we're supposed to hold onto them? By that reasoning we'd still be using horses and buggies.
That article, by the way, was at least intellectually honest enough to say that a lot of their reform ideas would be easier to achieve under a single-payer system.
Posted by: Kristen Hannum | Mar 23, 2007 10:32:30 PM
Kristen nails it. Not only on the issue of healthcare but for a lot of other issues as well. There are entrenched economic interests whose continued well being is dependent on thwarting any substantive structural adjustments to the US economy other than those required by deregulation. This regardless of the cost to the US as whole. For them, public policy's sole legitimacy lies in its ability to divert ever larger quantities of capital into their coffers.
Posted by: WB Reeves | Mar 24, 2007 1:19:07 AM
Care utilization in France and Germany is as high -- and in France, higher -- than it is in America. But they pay less per unit of care.
Without controlling utilization, I have a hard time understanding how a single payer system could drive down costs and the incomes of providers, especially doctors. Government price controls on prescription drugs could bring about some savings, though at significant risk to innovation over the long term. Prescription drugs account for about 10% of healthcare costs these days, up from 5% 20 years ago. Ultra expensive biologics for cancer, etc. are priced essentially at the same rate worldwide, and these now account for over 20% of drug spending. Generics, which are actually cheaper here, for the most part, according to McKinsey are probably another 15%-20% of drug spending (and more than 50% of prescriptions).
Holding doctors aside for a moment, all of the other providers that interact with patients – nurses, pharmacists, therapists, orderlies, nursing home attendants, home health aides, etc. are paid reasonably (some would say low) market rates that are not likely to shrink under single payer. Indeed, the shortage of many of these workers would likely be exacerbated which would probably force wages up.
Doctor compensation is driven, at least in part, by the opportunity cost that the bright, ambitious people attracted to the field could have earned in law or business which is probably higher, on average, that people in such fields command in Europe and Canada. Moreover, the U.S. economy and society is probably more entrepreneurial, materialistic and achievement oriented. In short, there is more interest in accumulating wealth here and the lifestyle that wealth makes possible than there is elsewhere.
Finally, the administrative cost savings that single payer advocates think can be reaped by getting rid of private insurers are wildly overstated. According to the latest edition of its Healthcare 101 Report, the California Healthcare Foundation pegs administrative costs at only 7% of healthcare costs. Private insurers pay for only 35% of healthcare costs, and a significant percentage of those are on behalf of self-insured employer plans for which administrative costs are only 5%-7% at most. By way of example, UnitedHealth Group pays out $30-$35 billion per year of healthcare claims on behalf of self-funded plans that do no appear on its income statement. The fee that it is paid for this service is included in its Uniprise Division.
The California Healthcare Foundation report is available here.
Posted by: BC | Mar 24, 2007 6:49:21 AM
What I think you see here is not the simple disregard for evidence but the common practice of cherry picking the information most favourable to your position. Whereas upon a broad reference to european healthcare the countries that come to a liberals mind may be Germany and France, the countries that come to a libertarians will likely be Britain and Spain. It's in most cases an unconscious bias and, apart from what some of the posters here may flatter themselves in believing, isnt restricted to any group in particular.
Posted by: the invisible pimp hand | Mar 24, 2007 7:27:33 AM
The reliance on anecdotes by various partisans in the debate is, sad to say, due to intellectual laziness. It’s much easier to discuss the problems that Aunt Mabel had with some hospital in Dubuque than to pore over dry statistics relating to such things as per capita health care expenditures and their relationship to outcomes.
Unfortunately, the tedious work of objective analysis has to be done if American health care is to be “reformed” in some way that doesn’t make it worse.
Posted by: Catron | Mar 24, 2007 8:47:44 AM
Whereas upon a broad reference to european healthcare the countries that come to a liberals mind may be Germany and France, the countries that come to a libertarians will likely be Britain and Spain.
Yes, but liberals and conservatives/anarchists/libertarians are coming at it from two directions. Liberals are saying, "we can do better, so lets look at examples where the system worked." The conservatives/libertarians are saying, "we cannot possibly ever to better, and any solution will end up being, worse, like in my cherry-picked example. And please ignore the cases where it did work."
It is the nature of any new initiative (private or government) to say, "let's see what other people did that worked and do what they do." Thus, it makes sense for liberals to look at the working health care systems to do what they do, but it makes no sense for conservatives to restrict their perspective only to health care systems that aren't as good.
Posted by: Constantine | Mar 24, 2007 10:42:07 AM
Whereas upon a broad reference to european healthcare the countries that come to a liberals mind may be Germany and France, the countries that come to a libertarians will likely be Britain and Spain.
Yeah, liberals totally don't pay any attention to healthcare in Mozambique or Darfur! It obviously makes sense to cite the worst healthcare systems in the world when one's goal is to improve the US system.
I'll go further than Constantine. When a liberal who wants to improve our healthcare system "cherry picks" those countries that provide good examples for us to follow or learn from, that's being rational and objective.
When a conservatarian who claims to address the issue of improving the US healthcare system "cherry picks" systems that are not only poor examples but often don't have any relationship to what the conversation is about, that's bias.
Let me know when any of us liberals either claim that Britain's healthcare system is the perfect example or that we can replicate it here and make it magically work better.
Posted by: Stephen | Mar 24, 2007 11:20:07 AM
" A giant disappointment that the end of the world would be driven by dudes in turbans with kalishnikovs rather than post-singularity robot automatons."
Don't feel bad, Consumatopia - I have it on good authority that the end of the world will be driven by post-singularity robot automatons in turbans with kalishnikovs.
Catron: "The reliance on anecdotes by various partisans in the debate is, sad to say, due to intellectual laziness. It’s much easier to discuss the problems that Aunt Mabel had with some hospital in Dubuque than to pore over dry statistics relating to such things as per capita health care expenditures and their relationship to outcomes."
That's certainly a big part of it, but I think there's also another aspect. While we without question need those dry statistics to see the big picture, anecdotes can provide a face, a story. Whether these stories are representative, or being used at all responsibly, is a question that stats have to help us with. While anecdotes can certainly be part of a misleading appeal to emotion, taking those dry statistics alone can render things soothingly abstract, in some ways obscuring the human reality of the matter.
""I will not contradict anyone who avers that their reaction after 9/11 was not tinged with some amount of excitement at the sheer fact of having a just cause to pursue, an enemy to triumph over. But I will not believe them, either."
Fuckin' crusade junkies. They're gonna get us all killed one of these days . . .
Posted by: Dan S. | Mar 24, 2007 2:41:58 PM
Stephen -- When a conservative cherry picks a bad example, why can't the liberal say ok we won't do it like them, we'll do it like this good example here? The two are not on equal footing as far as arguments for and against doing it in the US. If there IS a good system, we can just ignore the others and do it that way. (Obviously the real world gets a bit more complicated than that, but that's the essence)
Posted by: Chris O. | Mar 24, 2007 3:32:00 PM
The problem with Megan's argument is more than that she cherry-picks examples. The problem is that she cherry-picks examples and attributes them not to a particular country but to national health insurance generally.
According to Megan, national health insurance means no hip-replacement surgery to people older than 75. I wonder what country she's talking about? Or if there really is such a country?
Posted by: Ragout | Mar 24, 2007 4:25:51 PM
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