« Do Immigrants Depress Wages? | Main | Open Link Thread »
November 06, 2007
Vouchers and Health Care
Julian complains that I had the temerity to post data from the DC voucher study even though it's only one-year-old! Shocking stuff, I know. Though since these private schools have been in operation for years, reacting to all sorts of pure price signals in the market, it wouldn't be crazy to think there would be effects, and you can damn well bet that if year one showed a 10 percent improvement, it would be shouted from the rooftops.
But whatever: DC stat just caught my eye. I've also posted about the nonexistent improvements from the multiyear Milwaukee study, the Dayton program, from the New York program, and so on. I've posted the conclusions of books, studies, and RAND monographs. Voucher programs simply haven't worked. They've not failed, either. They've just not done much of anything.
It's actually an odd thing. When talking health care, I can point to literally dozens of nationalized systems that perform better, cost less, and cover more individuals. And this doesn't convince anyone on the Right. I can point to the VA, which is a fully-functioning, fully-socialized domestic health system with far better results than the private market, and that convinces no one. But when the talk turns to education, the Right can point to dozens of voucher programs that cost about the same, return no better results, and don't give even one more kid an education. And yet they love vouchers and loathe universal health care.
November 6, 2007 | Permalink
Comments
"A man hears what he wants to hear, and disregards the rest."
-Paul Simon
Posted by: low-tech cyclist | Nov 6, 2007 2:46:36 PM
On what basis is the VA providing better results? I hear tons of complaints about lack of access. Las Vegas has been crying for years that we don't have a VA hospital that ws just finally approved but is 4-5 years out.
http://www.nvdems.com/news.php?newsid=875
Most peoples complaints about moving to "a fully-functioning, fully-socialized domestic health system" are exemplified by the VA, i.e. the 1999 GAO report. "It found that the VA wastes as much as $1 million a day maintaining vacant, underused and obsolete properties." Thats the exact sort of waste we see from governemnt programs.
http://www.military.com/opinion/0,15202,87287,00.html
The above link is from military.com, in 2006 they claim 100,000s of vetrans where routinely denied access to the system or made to wait months. Sounds like the same complaints we hear about Europena systems.
Your claim about the great results of the VA ignoring the ample evidence of actual veteran discontent reminds me of the liberals supporting our troops by bringing them home even though the majority of soldiers support the war and choose to be their.
Posted by: Nate O | Nov 6, 2007 3:11:04 PM
When talking health care, I can point to literally dozens of nationalized systems that perform better, cost less, and cover more individuals.
Just remember that we have a more relevant data point on a nationalized system in the US. Medicare. And we spend as much per capita just on Medicare as other countries do to cover all of their citizens. Its not wholly unreasonable to think that the differences on the cost/outcomes may have to do with other things than nationalized system versus not.
I can point to the VA, which is a fully-functioning, fully-socialized domestic health system with far better results than the private market, and that convinces no one.
At some point, perhaps you'll taken on the substantive criticisms here, because this simply isn't true. At a macro-level, the data you cite are based on methodology developed by VA staff or funded by the VA, with a number of detailed problems that I'd be happy to address. There is not a lot of literature on the VA that doesn't fall into one of those two camps. On a micro-level, as I've said continually, health professionals who have worked in both VA and non-VA settings, including myself, would overwhelmingly disagree with you.
Together, these points bring together something I'd been meaning to say for a while, which relates to both health care and education. You put too much stock in the macro-level studies that are rife with confounding factors. They are a helpful and valuable data point. But its a messy one. From a policy and politics perspective, it just isn't sufficient to look at this type of data and make broad sweeping claims as if they are an open-and-shut case.
For education, people may hear your data points, but intuitively believe that parents should have the choice/know what's best for their kids. Unless you have randomized, placebo-controlled data suggesting otherwise, its not wholly unreasonable for people to believe that. Same holds true for health care reform. People don't believe that government bureaucrats in a single-payer system will do what's best for them. And macro-level data from other countries with different cultures, problems, etc. aren't going to change that.
Posted by: wisewon | Nov 6, 2007 3:20:34 PM
"I can point to literally dozens of nationalized systems that perform better"
Name one -- much less dozens -- that performs better for middle-class people with health insurance. I receive fabulous health care. Great doctors, little to no waiting time, excellent technology.
Posted by: ostap | Nov 6, 2007 3:26:01 PM
Name one -- much less dozens -- that performs better for middle-class people with health insurance. I receive fabulous health care. Great doctors, little to no waiting time, excellent technology.
Yep, as long as you ignore the uninsured, under-insured and those outside the middle class, things look just peachy.
Posted by: WB Reeves | Nov 6, 2007 3:35:41 PM
ostap: that you think a health care system can be assessed by pretending that there are no poor people says a lot about your priorities.
It seems to me that quibbling over how many countries bolster Matt's point or how close the VA comes to qualifying as the kind of system liberals would want to see is beside the point. Republicans have had a great deal of difficulty dealing with reality-based arguments for several years now (it was a Republican who boasted about this in 2004), and if a Republican points to dubious successes in vouchers at home and dubious failures in health care abroad, well, all things being equal I'd believe just about anyone else before believing that person.
Posted by: Martin | Nov 6, 2007 3:36:33 PM
the VA is not a fully functioning system. Look at any of the large VAMC's homepages and you will see that they are not that similar to other hospitals/HMO's. The VA does not have obstetrics; barely has GYN; does not have labor and delivery, pediatrics, neonatal icu, sports medicine, or even an emergency department.
If they had to provide those services and had to worry about patient satisfaction, they would not been seen as that good.
Posted by: superdestroyer | Nov 6, 2007 3:49:41 PM
> Name one -- much less dozens -- that performs
> better for middle-class people with health
> insurance. I receive fabulous health care.
> Great doctors, little to no waiting time,
> excellent technology.
Germany.
Cranky Observer
Posted by: Cranky Observer | Nov 6, 2007 3:59:55 PM
ostap, the system performs reasonably well for middle-class people with health care who aren't very sick. For a view of what can happen if you're middle class, with insurance, and you have a really serious problem, see this:
http://www.feministe.us/blog/archives/2007/10/23/what-color-are-the-holes-in-your-parachute/#more-5995
You have to well above middle class to avoid this sort of thing.
Posted by: Bloix | Nov 6, 2007 4:13:32 PM
" And yet they love vouchers and loathe universal health care."
Is having choices a positive thing even if the choices don't allow better results?
Posted by: Dave Justus | Nov 6, 2007 4:16:14 PM
Ezra: any chance you could take a stab at a quick response to Mankiw's post the other day in the NY Times? I'm sure I'm not the only one who would be interested in your take:
http://www.nytimes.com/2007/11/04/business/04view.html?ex=1351828800&en=7ebf86b6773f35bd&ei=5090&partner=rssuserland&emc=rss
Posted by: Jasper | Nov 6, 2007 4:29:12 PM
Ezra -- it's almost as though there is an ideological commitment toward dogmatic rejection of empiricism. If only we had some anecdote about contempt for being based in reality to point to...
Posted by: Punditus Maximus | Nov 6, 2007 4:52:12 PM
"I've posted the conclusions of books, studies, and RAND monographs. Voucher programs simply haven't worked."
Then Stuart Buck's comment on your previous voucher post is wrong? The very RAND study you cite seems to have positive findings for vouchers. How does this reconcile?
Posted by: DM | Nov 6, 2007 5:02:51 PM
I have to echo some of the commenters: Ezra, you simply don't take the libertarian's concerns about coercion seriously. If a capitalist policy and a socialist policy function equally well, isn't there overwhelming reason to favor the capitalist policy simply on the grounds that it involves less coercion?
That is, of course, unless you think equality trumps non-coercion as a value or you think equality can justify coercion.
Although, maybe you don't think that the social democratic options ARE more coercive. I'd be interested in seeing your case for this.
Posted by: Selfreferencing | Nov 6, 2007 5:15:58 PM
Of course, if vouchers don't hurt then the fact you are against them should also qualify as "odd". Clearly it is something else you don't like about them and something else the pro-voucher crowd does like.
There are a lot of good reasons to be against vouchers but also some reasons to be for vouchers. There is a lot to be said for choice, flexibility and supporting a system that does not assume everyone is the same or should be molded with the same cookie cutter.
Posted by: Mark | Nov 6, 2007 5:16:47 PM
"Isn't there overwhelming reason to favor the capitalist policy simply on the grounds that it involves less coercion?"
Isn't there overwhelming reason to recognize that any functional system has some balance between coercion and choice, and that we're arguing about where the trade-offs should be? Even a pure capitalist system has enforcement of property and contracts, defense, etc. Whether any libertarian wants to admit it or not, those amount to coercion that ensures reasonable functioning of markets. And market failures mean that many insurance markets work fairly poorly, so there is a reasonable argument to be made for coercing people to participate in them.
Libertarian concerns about coercion are realistic and serious, but most libertarians only see the coercion that they don't like and conveniently ignore the coercion from which they benefit.
Posted by: DCBob | Nov 6, 2007 5:34:07 PM
Ezra wrote:
"When talking health care, I can point to literally dozens of nationalized systems that perform better"
http://www.achse.org.au/publications/martins/indigenous.html
Australia's Indigenous People Greater Disadvantage
The draft discussion paper on the National Aboriginal and Torres Strait Islander Health Strategy (OATSIH 2001) documents graphically that standardised all-cause mortality rates for Indigenous people in Australia are considerably higher than those in United States, and New Zealand and that these differences have been consistent over time.
Other Sources confirm that the life expectancy of Australian Aboriginals is at least 10 years behind that of the Indigenous people in New Zealand, Canada and the United States. The estimates also indicate that the gap between the life expectancy of Australian Aboriginals and the whole population is considerably higher than the gaps in these three other countries.
Table 3. Life Expectancy of Indigenous People
Australia, New Zealand, Canada and United States
People (circa) Life Expectancy at Birth in Years
Males Females
Australian Aboriginals (1997-99)
Maoris (1997-99)
Canada Aboriginals (1990)
US American Indian (1999?)
56
68
67
69
63
73
74
78
Sources: ABS 2001b, IHS 2002, INAC 2000.
It is hardly a source of consolation that the life expectancy of the Australian Aboriginal people is higher than that of the Brazilian Indian population in the Amazon basin that was 46 years circa 1996 compared with 67 years for the whole population of Brazil (CIMI 1996). "
Our USA healthcare seems to be as good as any, but we spend way too much. Our effort should be on reducing cost.
Our very corrupt Gov. spends more per capita than the French gov. spends but the French cover every one. I say we should keep Gov. spending the same but cover everyone.
Posted by: Floccina | Nov 6, 2007 5:36:34 PM
Actually, no, Ezra doesn't take libertarian arguments very seriously.
This is, ultimately, not a blog where the fundamentals of our outlook of government's role are debated. Thus, you're not going to see fundamentalists have their arguments closely engaged with, any more than you would expect an Anglican-Catholic dialogue to engage the Baptists' argument that churches should not have any sort of written "Creed".
Posted by: Tyro | Nov 6, 2007 5:39:57 PM
And they can point to the Indian Health Service which is a fully functioning, fully-socialized domestic health system with far worse results than the private sector in nearly every major category, Diabetes, Stroke, Hypertension, Heart Disease. They can expect to live to the ripe age of 71. Their stats would be great in Africa.
Posted by: jenga | Nov 6, 2007 5:48:35 PM
Also things like a nicer looking hospital or doctors office count for something. Just like in education a nicer looking building counts for something.
Posted by: Floccina | Nov 6, 2007 5:49:13 PM
So, the takeaway here would be that if you make so much money that you don't care about your health insurance premiums, and you're not really sick, you'll be happier if the doctor's office has new furniture.
And really, who can quarrel with that?
Posted by: serial catowner | Nov 6, 2007 6:04:51 PM
I actually explained yesterday why I don't trust vouchers -- I don't think the profit motive is something I want governing the provision of education. I think you'd end up with something a lot like you have in, well, health insurance, where competition takes place not on quality and cost, but on selection and superficialities. I'm perfectly willing to endorse charters, with all their experimentation and freedoms, but I'm not willing to divorce public funds from public accountability.
Posted by: Ezra | Nov 6, 2007 7:48:18 PM
I actually explained yesterday why I don't trust vouchers -- I don't think the profit motive is something I want governing the provision of education.
Private schools are non-profit.
Posted by: wisewon | Nov 6, 2007 7:54:23 PM
>Private schools are non-profit.
So is Blue Cross/Blue Shield. They still rip you off.
Posted by: Spike | Nov 6, 2007 8:24:21 PM
Easy - Vouchers benefit racists, while universal health care would help poor brown people. I'd like not to think that all conservatism is really racism in disguise, but the eveidence keeps proving that it is.
Posted by: fasteddie | Nov 6, 2007 8:24:42 PM
The comments to this entry are closed.
