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July 16, 2007
Ah, Krugman
It's really quite pleasant to wake up and read this:
it’s true that Americans get hip replacements faster than Canadians. But there’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.
That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that’s what they call their system) because it has more lavish funding — end of story. The alleged virtues of private insurance have nothing to do with it.
The bottom line is that the opponents of universal health care appear to have run out of honest arguments. All they have left are fantasies: horror fiction about health care in other countries, and fairy tales about health care here in America.
I've grown convinced that many conservatives actually don't understand what rationing is. They appear to consider it some sort of intrinsic quality of state-run health systems -- national health care has rationing in much the way a car has doors. It's just there.
Of course, that's not the case. A state-run system could decide, as Medicare does, that they'll pay for any and all necessary procedures, and do so quickly. Then there would be no rationing. There would be, as there is in Medicare, enormous spending and astonishingly fast cost growth. Instead, other systems, and their attendant societies, makes a judgment to devote relatively fewer resources to health care and relatively more to other things (like leisure!). That's a fair allocation of resources.
What we do in this society is devote relatively unlimited resources to health care for wealthy and insured people and relatively fewer to health care for poor people. It isn't clear whether we think that's a useful way to spend trillions of dollars, or whether we'd prefer some alternate ordering of expenditures, with more going to preventive medicine and paid maternal leave. This is largely because the political party that has tasked itself with protecting the unlimited privileges of the rich has skillfully made it taboo to discuss such things as limiting or redirecting health care expenditures through collective action, but it is, theoretically, something we could explore.
July 16, 2007 | Permalink
Comments
"What we do in this society is devote relatively unlimited resources to health care for wealthy and insured people and relatively fewer to health care for poor people." Excellent summary, it's just hard to understand why this isn't obvious to everyone.
Posted by: SteveH | Jul 16, 2007 10:50:38 AM
Is it a dishonest argument to state the UHC plans do a poor job of managing cost growth and that, if growth continues on its current track, the programs will be unsustainable in their current form?
Note: this is not an argument FOR our current system.
Posted by: DM | Jul 16, 2007 10:59:17 AM
I don't think a lot of people understand what rationing means - on the one hand as you point out, it suggests to conservatives a Soviet style, cold, "wait here" approach to medicine that easily scares people; on the other hand, I think a lot of liberals operate on what you describe - it's not rationing if everyone gets care.
Well yes and no; it's not rationing of, say, hip replacements. It could very well be rationing of other, less common procedures. There will, under almost any universal care system imagined, be a process for determining medical necessity and best practices. In many cases, that will be a simple process of agreeing to common knowledge and long time principles. But where medicine is still making advances, where experimental treatments show great promise for a few, these are where we will have to make choices, and they will need to involve cost, and things like survivability and quality of life that sound okay in the abstract but can be hard to deal with in practical terms. The reality is that if we're all covered, at some point, somebody will be denied something. And probably an important, at least to them, something. That's rationing. And if we're not honest with people and lead them to believe that there won't be compromises and some things that will be unavailable (at least under some form of basic care, if we plan to allow add on policies and things), then we're setting up a recipe for big problems. Yes, we have a system now in which a few people get amazing stuff and a lot of people get nothing. Changing that does not mean everybody gets amazing stuff. And I think there's a real dilemma for proponents of Universal Care in selling that and not making it sound negative. I'm not saying it's impossible. Just very very challenging.
Posted by: weboy | Jul 16, 2007 11:06:04 AM
>> I've grown convinced that many conservatives actually don't understand what rationing is.
I find this laughable. Check out this story of explicit government rationing before you swallow Krugman's propaganda:
http://www.freemarketcure.com/twowomen.php
Posted by: Stuart Browning | Jul 16, 2007 11:12:26 AM
As I said, I'm convinced conservatives actually don't understand what rationing is.
Posted by: Ezra | Jul 16, 2007 11:17:59 AM
I'd say this form of intellectual dishonesty is endemic to our policy debates in general. Our debates have all taken on an apriori character. They proceed from unquestioned premises of the ideological kind.
Years ago someone taught me that the way to win a debate was simple. You only had to be sure that you controlled the premises under which the argument operated and you would automatically determine the outcome of the argument.
If you start the debate from the premise that activist Government is an evil by definition, you will naturally arrive at conclusions biased toward private sector "solutions." This regardless of the actual merits or demerits of such "solutions" in the case being considered. Of course the reverse holds true as well.
This at bottom is what the whole struggle to "frame the debate" is about. As for whether "Conservatives" are aware of the difference between a discourse based on the concrete meaning of terms such as "rationing" and one based on the assumption of ideological absolutes, I imagine that there is roughly as much self serving as self delusion involved.
However, when you have a generation that has no experience of policy debate not defined by one-sided, ideologically driven premises, it would be surprising if they didn't succumb to this sort of conceptual illiteracy. It's certainly possible that a large percentage of today's younger conservatives do think in such manichean categorical terms.
Do such people exist on the Left? Of course but they have been thoroughly marginalized from the mainstreams of national debate over the last 27 years. So much so that is was the last President from the party of FDR who announced, prematurely as it turned out, that the "era of big government" was over.
What has been allowed to develope is a discourse in which the ideological extreme's of one side of the political spectrum have been privileged, while the extremes of the other have been delegitimized. This has resulted not only in a skewed discourse but in skewing the entire conceptual framework in which that discourse takes place. It is both a symptom and a contributing factor in the collapse of the consensus model of US politics.
Posted by: W.B. Reeves | Jul 16, 2007 11:23:51 AM
It's so weird, in this country we do have rationing, our rationing is that rich people get lavish care while poor people get nothing. Non-rich and non-poor get a patchy combination of both, leaning if anything slightly on the side of lavish care. Other countries say that poor people get a baseline standard of care, and everyone else can pay a little for a private plan (just as rich old folks can in this country) that offers them coverage above and beyond the baseline.
Posted by: Joshua | Jul 16, 2007 11:41:33 AM
>> the political party that has tasked itself with protecting the unlimited >>privileges of the rich has skillfully made it taboo to discuss such things as >>limiting or redirecting health care expenditures through collective action, but >>it is, theoretically, something we could explore.
Amazing - "conservatives don't know what rationing is". ... and here he is advocating just that - via physical force.
Posted by: Stuart Browning | Jul 16, 2007 11:41:57 AM
So we're back to "Medicare For All!" are we? Politically, it's a fantasy. Fiscally, it would be a catastrophe. And as a universal health care system, it would be hugely wasteful and inefficient.
Posted by: JasonR | Jul 16, 2007 12:00:51 PM
It is a fantasy... a catastrophe... hugely wasteful and inefficient...
Because Jason R says so. And he says so based on what?
Because he says so.
Posted by: JimPortlandOR | Jul 16, 2007 12:18:09 PM
Im in ur bathtubz, stranglin ur gubermint!
Posted by: TJ | Jul 16, 2007 12:24:12 PM
JasonR would also like to add that we should drink Diet Coke just for the taste of it, pork is the other white meat, you are in good hands with All State, and that the king of beers is Budweiser.
Posted by: ChowChowChow | Jul 16, 2007 12:37:30 PM
Because Jason R says so. And he says so based on what?
The Medicare Trustee's report. Medicare is already headed for bankruptcy in little more than a decade. And "Medicare For All!" would add at least a trillion dollars a year in additional spending to the federal budget. That's over a third of the entire existing budget. It's a fantasy. Even Ezra recognizes that.
Posted by: JasonR | Jul 16, 2007 12:39:15 PM
Amazing - "conservatives don't know what rationing is". ... and here he is advocating just that - via physical force.
A good illustration of what I was talking about above. By "force", of course, Stuart is refering to Law. The same force that imposes speed limits, zoning and building codes, standards of sanitation, etc. Clearly, he is drawing distinctions based on ideology rather than outcomes. For him, "rationing" is a matter of the instrumentality used rather than the actual result produced.
Posted by: W.B. Reeves | Jul 16, 2007 12:40:08 PM
Ditto what WB Reeves wrote. I would add that you can't have "discourse" with someone who has already made anything you say impossible. The difference between the left and right in the US at this point is that the left has admitted its flaws and strengths, and the right still proceeds as if it has no flaws and that the left has no strengths. So long as commentators like JasonR remain the norm, I think conversation is a waste of time. The real battle is to build consensus among the middle and the left.
Posted by: akaison | Jul 16, 2007 12:41:37 PM
WB on your last post I would add- Stuart would never admit what effects the private sector has and deny what benefits the public sector has. It's why conversations with Stuart are pointless.
Posted by: akaison | Jul 16, 2007 12:43:15 PM
The Medicare Trustee's report. Medicare is already headed for bankruptcy in little more than a decade. And "Medicare For All!" would add at least a trillion dollars a year in additional spending to the federal budget. That's over a third of the entire existing budget. It's a fantasy. Even Ezra recognizes that.
All of which assumes that "medicare for all" would entail no revamping of the current system to answer these problems. An assumption that is certainly not a given.
Wonderful how JasonR appeals to Ezra's "authority" whenever it suits his purpose.
Posted by: W.B. Reeves | Jul 16, 2007 12:45:22 PM
I don't get the rationing argument at all. When my dad was a kid in the 1930s and during WWII, beef was rationed - meaning that you only got a certain amount of beef no matter what. That's why people ate horsemeat. That's rationing.
Waiting an extra month, or week, or 6 months to undergo a procedure isn't rationing, it's an issue of scheduling, of the number of doctors/facilities available for the procedure vs. the number of people who need it. Or has Canadian Medicare put a cap on the number of hip replacements for each year, or the number of doctors who can perform them?
Whether you have no insurance, good insurance or billions of dollars, people you don't know, who haven't seen your particular case are going to have set up standards regarding your care. It's not like I could admit myself into the hospital for open heart surgery just because I have the money to pay for it.
This is why insurance is fundamentally different than other industries. Adding more people to a particular insurance pool doesn't just increase demand for services, it also increases the funding source for those services. If we were to create an insurance pool, so to speak, of 300 million people, that doesn't mean there would be 300 million hip replacements every year, or 300 million prescriptions to fill every month. Even the very poor and the elderly do not all need to go to the doctor all the time.
Further, we could stabilize costs by not using our nation's emergency rooms as quasi-family doctors, an inefficient practice that causes the cost of all hospital care to rise. This cost stabilization would also not be the result of "rationing" care.
Finally, I don't want Canada's system, or Britian's or even Germany's or Norway's. I want an American system that capitalizes on our strengths and addresses our weaknesses. Other countries' systems are useful as guides or examples, but we don't have to just replicate them here.
Posted by: Stephen | Jul 16, 2007 12:50:15 PM
And here's a Washington Post story on the enormous waste and inefficiency in Medicare. That's how it gets away with those low "administrative" costs. Instead of closely monitoring the cost-effectiveness of its spending like private insurers do, Medicare simply rubber-stamps claims, and the result is huge waste. Quote:
For a year, The Washington Post crisscrossed the country to examine the economics of Medicare and how it monitors the quality of its services -- reviewing thousands of documents and interviewing hundreds of researchers, regulators and patients. Medicare is highly valued by 42 million elderly and disabled members, but it wastes an enormous amount of money on inefficient medicine, the examination found.
Researchers at Dartmouth Medical School, who have been studying Medicare's performance for three decades, estimate that as much as $1 of every $3 is wasted on unnecessary or inappropriate care. Other analysts put the figure as high as 40 percent.
Posted by: JasonR | Jul 16, 2007 12:52:06 PM
Everyone I know who has had a hip replacement has put it off for at least 2-3 years (in the case of my grandfather 25 years) after the doctor told him/her it was absolutely medically recommended. Is this just an odd coincidence or is there any statistic to back this up?
After enduring the pain for (40 + 25) years (between the accident and the development of hip replacement technology and then until he was willing to do it) I don't think Grandpa was too worried about a 9-month delay.
Cranky
Posted by: Cranky Observer | Jul 16, 2007 12:52:53 PM
From JasonR's link, here's the moneyshot;
Medicare has outsourced many enforcement activities to private groups that have overlooked or missed cases in which patients were injured or killed, according to hundreds of inspection reports and interviews with state regulators...
To obtain more ambitious savings, some analysts say, Medicare will have to take a more aggressive stance. But that requires confronting the powerful lobby of hospitals, doctors and nursing homes.
"The more successful [Medicare officials] are, the more likely provider interest will rise up to prevent the program from ever implementing these changes on other than a demonstration basis," said Robert A. Berenson, a physician and former top Medicare official now based at the Urban Institute.
So, if the damned greedy private medicine industry would stop screwing up everything, it could start to get better.
Posted by: ChowChowChow | Jul 16, 2007 1:33:19 PM
It's often worthwhile to follow one JasonR's links, if for no other reason than for the insight it gives into the mindset of an ideologue.
For example, on reading JasonR's above post with it's exerpt, one would never know that the thrust of the article was that Medicare's woes arise from the inadequacies and negligence of private health care providers. Nor would you know that the article lays the onus for Medicare's inability to control cost through improved oversight directly at the feet of such private providers as well as the mania for privatization which led to outsourcing oversight functions to private firms.
Of course, recognizing these aspects would have spoiled his simplistic narrative of Government incompetence vs. the efficiency and benignity of private health care providers.
Posted by: W.B. Reeves | Jul 16, 2007 1:39:47 PM
Reeves,
Do please quote the parts of the article that you think blame private health care providers for Medicare's waste and inefficiency. You're not making things up again, are you?
Posted by: JasonR | Jul 16, 2007 1:47:34 PM
Kenneth Kizer tells Canadian politicians and business leaders how they can learn from the VA:
http://thetyee.ca/News/2007/02/08/HealthCare/
Posted by: mijnheer | Jul 16, 2007 2:03:15 PM
So, if the damned greedy private medicine industry would stop screwing up everything, it could start to get better.
Damn that greedy private medicine industry! How do you propose to fix it? Through a government takeover of health care delivery as well as health care funding? That's the British single-payer, single-provider model--the National Health Service. Is that now the proposal? It seems to keep changing.
Posted by: JasonR | Jul 16, 2007 2:04:11 PM
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