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March 18, 2007
In Which I Compare America's Health System To A Delicious Cupcake
By Ezra
I don't have a whole ton to say about the voucher schools argument going on between Matt, Kevin, and the newly-renamed McMegan. I'm pretty sure, though, that arguing this out through the frame of single-payer health care is almost certainly unwise, and you should probably, when talking about major changes in education policy, focus the discussion on education policy.
Moreover, Megan's claim that every liberal is for single-payer, but not Britain's NHS, is a bit misleading. Most people use single-payer incorrectly, so it's largely a misunderstanding, and they are in fact for nationalized health care, but not what's considered a bad example of it. A lot of us who aren't for the NHS are for the VA -- and both are single-payer systems, one's just better than the other. It's sort of like how I can be for Cakelove*, against those gross Safeway cupcakes, and broadly in favor of delicious baked goods all at the same time!
But look: This NHS bashing misses the point. In 2003, the British spent $2,231 per person. America spent $5,635. In other words, they spent 39% what we did. So whether they're "better" or "worse" is a bit hard to argue. Better or worse for what? They're certainly cheaper. And I've never, ever heard anyone argue that their health outcomes are 60% worse than ours. I would certainly prefer to get in a car accident in America, particularly if I had awesome insurance. But I'd certainly prefer to pay my health bills in Britain. And I'd really prefer if people stopped pretending you could make an apples-to-apples comparison between the two.
*This is actually a surprisingly robust analogy, because while Cakelove is delicious, it is way, way, way overpriced.
March 18, 2007 in Health Care, Health of Nations | Permalink
Comments
Of *course* Cakelove is overpriced; they throw in too much butter and sugar, and that ain't free.
Posted by: Chris | Mar 18, 2007 1:43:41 PM
It may not be free, but it's not $3.30 per cupcake expensive.
Posted by: Ezra | Mar 18, 2007 1:47:16 PM
It's funny, but the people who are most against single payer are also the most against people being able to sue those who injure them. Single payer would most likely have the result of cutting the number of lawsuits, simply because people won't be forced into bankruptcy by medical bills.
To argue from anecdote, a friend of mine in London was hit by a car while riding his bike. The motorist stopped, apologized, picked him up and drove him to hospital. My friend never thought of suing, mainly because he never had to pay for emergency room treatment, casts, follow on care from orthopedists, etc.
Of course I suppose you could argue that lack of lawsuits will make drivers more careless, but I find it hard to believe they've got much room to decline.
Posted by: MikeJ | Mar 18, 2007 1:57:36 PM
It's a bad analogy if only because you don't need cupcakes. As long as we don't admit that healthcare is indepensable- like education- then we are in the same place as before. That may not be your point- but emotionally I think we need to start making the point that some goods and services are indepensable, and some are not. Healthcare is one of them.
If we are able to categorize which are and are not dispensable we are able to then deal with them better. The problem with the right is that they MUST pretend they are all not necessary, and are all a matter of choice. Why must they believe this?
On another thread- the one on global warming, someone made an excellent point: The problem is that all collective action is per se bad to the right. I would say for liberals now for about 20 years, the argument has been that "it depends." So, if our position is that 'it depends' as to what actions are subject to the individual and what actions are subject to collective decision, why then do we have such resistance?
What we need to understand is that "sometimes" is not a response that "never" will accept. It's basic logic really. But, our side refuses to understand that logic. So we argue thinking this is about convince them that here, in this case, 'sometimes' or case by case liberal pragmatism, if you prefer, is applicable. In other words, we argue based on our own assumptions that it's sometimes, not never.
They argue always on the assumption that it's never. "Sometimes" is the equivalent in their minds of saying "always." It's a falsehood, but makes sense from their skewed position. That's why the chief principle of the right in terms of argument is denial on those issues of which we are talking "sometimes" the market fails for the goals that we have. Whether its education, healthcare or the environment (all three have the link of being collective inputs that unlike say buying a cupcake or a car or even a house, are indespensable to the long term health of a functioning economy) , we are arguing that liberal pragamtism for collection action applies. The problem can not be solved by resorting to arguments because they will by the definition of their idealogy have to find a way around what you are arguing. "Never" as an idealogy depends on denial. "Sometimes" does not. You will "never" convince them.
Posted by: akaison | Mar 18, 2007 2:11:25 PM
Watch your mouth. I love Safeway cupcakes.
Posted by: Greg | Mar 18, 2007 2:16:41 PM
PS: You can see this in full force on the global warming discussion. You can see the "reasonable" types. Not real reasonable. They are reasonable in the sense that a car headed toward a cliff. You response practically- "hey, the car is running off the cliff." The right response, "I don't see it." "And because it's you saying it is running off a clift, it must be lie." "Look here at this 1 person or 10 out of thousands who says that a car can't run off a cliff" The reasonable types will say, "well let's come to accomadations. I can see both sides positions. I certainly agree we may or may not be riding off a cliff. I don't understand the left's beligerance to the right about the car headed toward the cliff. And really, I can see the point that the left has also ran cars toward cliffs." In other words, they are reasonable in a sense that works for the right, and it's goal of admitting what's happening. It's a truly bizzare conversation such as the other day when one points out that our educational system is increasing in cost at a rate that is twice that of inflation to hear that a sound economic concern is met with "you are whining." How can you debate this? The answer you can't. You shouldn't. You should scold them, and treat them like they are. I look forward to a post scolding the right rather than treating them as equals. They aren't. To be equals they would have to enter reality. I have conservative friends who are equals because they disagree about policy outcomes, not that there is a problem.
Posted by: akaison | Mar 18, 2007 2:21:36 PM
It's a bad analogy if only because you don't need cupcakes.
I pity you, akaison. It must be terrible to go through life thinking like this.
Don't need cupcakes. What do you need, then?
Posted by: Stephen | Mar 18, 2007 2:44:28 PM
I suppose it falls to me to attempt the impossible.
Here goes. Even if you have *great* insurance, the odds are that 50% of the time the surgical specialist you see in the US will not have had enough practice at various procedures (because he only operates when people with *great* insurance show up) to be better than his British NHS counterpart.
Of course 50% of US surgeons do plenty of low-paid work to keep their hand in, but it's worth keeping in mind that the incentives within the system aren't all that well aligned to getting good surgeons to anyone who doesn't happen to have their accident near one of the world famous institutions (Johns Hopkins etc.)
Posted by: Meh | Mar 18, 2007 2:49:33 PM
Can we argue about muffins instead of cupcakes? Muffins good, cupcakes bad. It's the sugar, stupid!
Meanwhile, some folks (at least 30% of them, maybe 40%) will NOT ever believe in any collective social actions by government, but they truly believe in collective military actions by government. Interesting?
Here we are, at least 70 years after Social Security was enacted, and I'm confident 30% of the people think it is socialism or worse - maybe even worse than terrorism. Well, fuck them.
This is a democracy, and when we get to 50%+, we should do what we believe needs to be done. There is no 'bi-partisan' compromise possible or desirable when 3/5ths or more of the conservative folks will oppose any action. I'm sure 30% or more would vote against free speech, or trial by jury, or innocent until proven guilty.
Posted by: JimPortlandOR | Mar 18, 2007 2:55:54 PM
stephen- my addictions are comic books, good looking guys and filmmaking. cupcakes- I just don't get it. I mean- why eat a cupcake when you can have hot sweet potato pie with vanilla ice cream? but then maybe I'm showing my Southern roots.
Posted by: akaison | Mar 18, 2007 3:12:00 PM
I mean- why eat a cupcake when you can have hot sweet potato pie with vanilla ice cream?
Ok, I feel a lot better for you now.
Posted by: Stephen | Mar 18, 2007 3:25:37 PM
I'm hungry.
Posted by: Sam L. | Mar 18, 2007 3:58:05 PM
I'll take you one further - getting injured seriously in the sticks in the US is BAD. You get poor treatment, even if you have good insurance. Then, you might return to the City, and you suddenly get GOOD treatment. And you are astounded, and even more happy to have good insurance.
Which actually might play in Britain's favor - our extreme breadth and dispersed population may make provision of medical services more expensive.
Posted by: MDtoMN | Mar 18, 2007 5:08:09 PM
I'm not sure you understood the distinction I'm drawing. This genuinely was not supposed to be an argument over single-payer; it was just a question about funding structures of services. While there are some people in the single payer movement who favour single-provider health care, like the NHS, where the physicians are salaried government employees in government-owned hospitals, most people advocating a national healthcare system say that they genuinely do not want that, and I believe them. They say they want a system like continental European systems where the government pays the bills, but doesn't directly employ providers.
That set of people is not the same as the set of people who argue vociferously for single-provider education, but there is substantial overlap. So my question is, what is the distinction between the two, such that health care is well provided by single-payer, but education can only be provided under a single-provider model?
Posted by: Jane Galt | Mar 18, 2007 5:22:26 PM
See Drum: http://www.washingtonmonthly.com/archives/individual/2007_03/010942.php
But also Yglesias: http://www.matthewyglesias.com/archives/2007/03/consistency/#more
Posted by: Karl Radek | Mar 18, 2007 8:22:55 PM
I have little in the way of opinions on the education debate (which is why I'm talking about the NHS issues), but this seems like a much less interesting distinction than you appear to think. Indeed, it would seem to me that the burden is on you to prove that the health and education sectors are similar and should receive similar policy solutions, not on others to suggest that social science education and heart surgery are different.
Meanwhile, I think a lot of the folks you're talking to have no particularly well thought out views on whether they want providers to be employed. Since you're not allowed to say socialized health care in this country, or be for it, most people don't, and they protest when it's accused of them. Would most folks care if a sufficient number of GPs were emplyoed by the government to provide basic care at low prices? I doubt it.
Posted by: Ezra | Mar 18, 2007 9:48:23 PM
So if I read you correctly, what you're saying is that the people who tell me that they don't want a single provider system are lying. Which makes their beliefs about healthcare consistent with their beliefs about education, except they aren't telling me the truth about their beliefs about healthcare, which makes it seem inconsistent, when in fact it isn't. Not hypocrites or muddled thinkers, or subtle thinkers drawing some as-yet-unclear distinction between education and healthcare; liars. Did I get that right?
Posted by: Jane Galt | Mar 19, 2007 12:29:30 AM
Meanwhile, I don't see why the burden of proof is on me; do I have the burden of proof to say why toothpaste and grapefruit are, despite their superficial differences, products whic, we should purchase with similar financing structures? I'm a libertarian; I think we should pay for all goods, except a tiny class of things like the military (a class I will be happy, upon request, to define with mind-numbing specifity) the same way. When people want to institute special funding mechanisms, I want to know what makes that particular good special.
Posted by: Jane Galt | Mar 19, 2007 12:33:59 AM
a class I will be happy, upon request, to define with mind-numbing specifity
I request.
Posted by: Sanpete | Mar 19, 2007 12:56:45 AM
Worth noting that the NHS employs 1.3 million people, the VA 250,000. If you really think that you can scale up a management system (single payer, single provider) by half an order of magnitude then I suggest you talk to some business majors. If you think you can scale it up again by another order of magnitude, to the 13.5 million in the US health care sector then I would respectfully say you have to be nuts.
It might also be worth pointing out that the Continental health care systems, like, for example, the French, generally agreed to be the best bang per buck, is neither a single payer (the social funds cover 75% or the cost of treatment, the rest usually by private insurance or perhaps out of pocket) nor a single provider (many competing providers, for profit, not for profit and State).
In fact, one could in fact make the argument that the French system is less state funded than Medicare is. Which might also be why people sometimes regard it as better.
Finally, those 2003 numbers. Way out of date for the NHS, sopending has soared since then: to no discernible benefit in treatment either.
Posted by: Tim Worstall | Mar 19, 2007 7:54:08 AM
If you really think that you can scale up a management system (single payer, single provider) by half an order of magnitude then I suggest you talk to some business majors.
With one mighty blow, Tim proves that the US Army, which is almost an order of magnitude larger than the British Army, cannot possibly function. Come back tomorrow, as he demonstrates that Canada cannot exist: it's an order of magnitude bigger than Ireland, people! For heaven's sake!
For an encore, he will prove that Microsoft is too big (compared to other publicly-listed software companies) to make any money.
So if I read you correctly, what you're saying is that the people who tell me that they don't want a single provider system are lying.
You didn't read him correctly. That's not even close to what he said.
Posted by: ajay | Mar 19, 2007 8:36:02 AM
Sanpete, it will have to come later, as I am rather under the gun right now, but I will be happy to do so. Or you could just read any minarchist tome on the provision of public order.
Posted by: Jane Galt | Mar 19, 2007 9:35:21 AM
"With one mighty blow, Tim proves that the US Army, which is almost an order of magnitude larger than the British Army, cannot possibly function."
It doesn't function in the same way, no. Regiments have an entirely different function, just as an example. Try looking up trickle posting.
Canada is Federal, Ireland is not.
Very few think of Microsoft as an efficient company you knpow. Possessor of a fabulous monopoly, yes, but not efficient in anything else.
Posted by: Tim Worstall | Mar 19, 2007 9:48:40 AM
Bearing in mind the deadweight loss of taxation, British healthcare costs twice as much as you suggest.
Posted by: Chris | Mar 19, 2007 10:56:20 AM
McMegan -
I don't think Ezra, Matt, or Kevin have really answered your question. While I don't hold the positions you describe I do see how they can be seen as consistent.
There is a great amount of risk involved in health. The current system of pooling risk through employer based insurance is inefficient and becoming more so as employees become less attached to a single employer. This is why, at least for some level of catastrophic coverage, we should pool our risk at the national level.
Education - like national defense is a public good. We all benefit if all young people are trained to read, write, do a little math, etc... Left to a private market people may under-invest in education because they do not consider the benefit their basic level of education provides to society: a more informed public, higher productivity, less crime, and so on. The fear is that a voucher system would undermine the level of education received by the poorest students. Drum is not for a single-provider in the sense that it is illegal to go outside of the public education system to get higher quality education if you want to. Rather, he wants to ensure the minimum standards of education are in place and even rise.
So the difference in the markets is the risk insurance nature of health care and the public good nature of education.
If you want to see more support for vouchers I would say you need to show some concern for the poorest students and show how vouchers or a general move toward market-based education provides a better education for even those students who are planning to drop out as soon as it is legally possible for them to do so.
Posted by: Publius | Mar 19, 2007 7:07:01 PM
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