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Mankiw's "True but Misleading" Health Facts:

Former Bush economic adviser Gregory Mankiw discusses three "true but misleading statements about health care that politicians and pundits love to use to frighten the public."

1. The United States has lower life expectancy and higher infant mortality than Canada, which has national health insurance.

2. Some 47 million Americans do not have health insurance.

3. Health costs are eating up an ever increasing share of American incomes.

According to Mankiw, these statements are "dangerous" because they are true, yet "don't mean what people think they mean." He concludes: "we should be careful not to be fooled by statistics into thinking that the problems we face are worse than they really are."

Bored Lawyer:
Hard to believe that some modicum of sense was allowed to be published in the NYTimes.
11.4.2007 1:12pm
Ari (www):
"Hard to believe that some modicum of sense was allowed to be published in the NYTimes."

That's exactly what I thought. It's sort of odd, though; the New York Times actually publishes more conservative editorials than the Wall Street Journal and other conservative papers publish liberal ones. I don't know why this is, but I suspect it's true.
11.4.2007 1:49pm
Sasha Volokh (mail) (www):
Note that this was in the Business section. I don't know what difference this makes, just saying.
11.4.2007 2:13pm
Kovarsky (mail):
kudos to current and former bush administration officials for eschewing the recitation of facts that are technically true but create completely misleading inferences.
11.4.2007 2:23pm
A. Zarkov (mail):
"The United States has lower life expectancy and higher infant mortality than Canada, which has national health insurance."

You cannot draw valid inferences using highly aggregated statistics comparing a relatively homogeneous population with a heterogeneous one. It would be much better to compare the two force-of-mortality curves instead of the life expectancy at birth. You should also enumerate the statistics according to race and ethnicity. For example, what are the infant mortality rates of whites in the US as compared to whites in Canada? I would also like to know the vital statistics for observant Christian Scientists, as this would provide a baseline to evaluate the effectiveness of modern medicine. It might also tell us something about iatrogenic illnesses.

"Some 47 million Americans do not have health insurance."


How many of these 47 million are young people who might not need expensive medical insurance? I'd also like to know the average length of time people without insurance are in that status.

"Health costs are eating up an ever increasing share of American incomes."


We spend a lot of money doing expensive screening. For example, we do a lot of PSA tests on men over 50. This test might have good sensitivity (low false negative rate), but it has a lousy specificity rate (high false positive rate). This low specificity leads to a lot of negative biopsies. For example 75% of the prostate biopsies done at the Mayo Clinic come out negative. Stanford doctor Thomas Stamey, who pioneered the test, repudiated his own test in a 2004 publication, End of an Era for PSA. Interestingly a Canadian Task Force on preventive medicine recommends against PSA screening.

Obviously the whole matter of national health insurance is a lot more complicated than citing a few misleading statistics. Are you listening Hillary?
11.4.2007 2:33pm
Bleepless (mail):
One question never, ever addressed is the accuracy of the Canadian statistics. They are collected, analyzed and released by the very people whose money and power are dependant upon their statistical-political success.
Remember the Canadian quads born a couple of months ago in Montana? The births did not occur because Great Falls is an obstetricl haven but because it was the American city closest to the mother's home. There no longer is a single hospital in Canada which can handle quads -- or much of anything else, for that matter, which has been a financial godsend to hospitals in the Northern tier of states, as refugees from the Canadian "health" racket come here to save their lives.
11.4.2007 2:45pm
A. Zarkov (mail):
"That's exactly what I thought. It's sort of odd, though; the New York Times actually publishes more conservative editorials than the Wall Street Journal"

I find Op Ed page on the WSJ somewhat more liberal than the Times. On the whole, it's even sillier, and that's saying a lot. WSJ is also a big supporter of illegal immigration and the H1-B visa program. Both their coverage and editorials reflect this bias. In case you thought the Dow Jones Corporation and the WSJ are conservative, guess again. They run journalism workshops for high school students that explicitly bar white people. One white girl slipped through by accident only to receive a phone call not to come because of her race. I don't know if they have continued this practice beyond 2006. Now Murdock has bought them. I think it's time to drop my subscription. I can get that junk from the Times for free.
11.4.2007 2:46pm
nelziq (mail):
If anyone tried to justify their job performance the way defenders of the US healthcare system defend it, they wouldn't last a week. Sure my team spent twice as much on this project but... oh are results are worse.. yeah well we had bad luck.. it was hard.. what are we going to differently next time? Well nothing! We are doing a great job. Quit complaining! Americans should be outraged at that sort of incompetence.
11.4.2007 2:48pm
Cornellian (mail):
"The United States has lower life expectancy and higher infant mortality than Canada, which has national health insurance."

You cannot draw valid inferences using highly aggregated statistics comparing a relatively homogeneous population with a heterogeneous one.


Similarly, one should not simply assume the population of Canada is as white as, say, the population of Idaho. Canada has a very diverse population, not quite as diverse as the U.S. but fairly close. It isn't Iceland. There is probably no country is the world that, demographically, more closely resembles the U.S. than Canada does.

Of course, correlation isn't causation and even if the two countries were demographically identical, it doesn't follow that life expectancy and infant mortality are consequences of the health care systems in those two countries.

And not to get all nuanced here, but isn't it possible that it's an oversimplification to say one system is better than the other. Isn't it possible the Canadian system is better at some things and worse at others?
11.4.2007 2:53pm
frankcross (mail):
The NYT business section is generally very good and contains no great liberal bias (though I wouldn't call it especially conservative either).

The WSJ editorial page is enormously conservative. Immigration is the exception, as it is a business benefit that the WSJ won't ignore. Pro-immigration is conservative from a libertarian, free market perspective.
11.4.2007 2:55pm
Le Messurier (mail):
A.Zarkov

We spend a lot of money doing expensive screening. For example, we do a lot of PSA tests on men over 50. This test might have good sensitivity (low false negative rate), but it has a lousy specificity rate (high false positive rate). This low specificity leads to a lot of negative biopsies.

A question. What do you substitute for the PSA test? It admittedly has high false positive rates, but I would rather have had the biopsy as a result of the high PSA reading than allowed the cancer to have grown and metastasized unnoticed inside me. It would eventually have killed me. As a result of the PSA test I have had radiation therapy plus I am presently undergoing brachytherapy. There's about a 90-95% chance of a complete cure.

The PSA test is not expensive and if you are 50 or over you should have one every year. My family physician told me that every man will get prostate cancer if he lives long enough. And he gave me the PSA test and he is a Mayo Clinic "graduate". I think your using the PSA test as an example of expensive, and by inference unnecessary, testing is very misleading and dangerous. If you are over 50 get it done!
11.4.2007 2:56pm
John (mail):
Articles like these always remind me of Section 17(a) of the Securities Act, which makes it illegal "to obtain money or property by means of any untrue statement of a material fact or any omission to state a material fact necessary in order to make the statements made, in light of the circumstances under which they were made, not misleading."

Just think how many people would be in jail now if a provision like this were applicable to people trying to sell healthcare ideas to the voters!

If only.
11.4.2007 3:15pm
MDJD2B (mail):
question. What do you substitute for the PSA test? It admittedly has high false positive rates, but I would rather have had the biopsy as a result of the high PSA reading than allowed the cancer to have grown and metastasized unnoticed inside me. It would eventually have killed me. As a result of the PSA test I have had radiation therapy plus I am presently undergoing brachytherapy. There's about a 90-95% chance of a complete cure.

The asertion is based on cost benefit considerations plus a finding that the life expectancy is not significantly prolonged by PSA in this usually slow-growing cancer, vis-a-vis annual prostate exams. There may be some high risk groups that would clearly benefit. That being said, I get my own PSA each year.
11.4.2007 3:18pm
Smokey:
2. Some 47 million Americans do not have health insurance.
Don't you just love how they conveniently frame the argument?

More honest to ask: How many Americans are denied access to a doctor?

The answer is, of course: zero. It is against federal law to turn anyone away because of inability to pay.

What they want is to raise your taxes substantially so that someone who won't buy insurance - but who has enough money to buy expensive tennis shoes, a big screen TV, video games, and who can afford to eat out at a fast food restaurant twice a day - will now have the added perk of 'free' medical insurance paid for at taxpayers' expense.

See? I can frame an argument just as well as the tax-suckers. And my argument is much more honest.
11.4.2007 3:19pm
Andy Freeman (mail):
> Canada has a very diverse population, not quite as diverse as the U.S. but fairly close. It isn't Iceland. There is probably no country is the world that, demographically, more closely resembles the U.S. than Canada does.

Really? Since when is Canada ~10% black? What fraction of Canada's minorities are Hispanic/Mexican?

Canada has a significantly larger Asian and Indian population (by percentage) than the US.

While the two country's minority percentages are similar, the minorities are quite different.
11.4.2007 3:35pm
Le Messurier (mail):
MDJD2B

life expectancy is not significantly prolonged by PSA in this usually slow-growing cancer, vis-a-vis annual prostate exams. There may be some high risk groups that would clearly benefit. That being said, I get my own PSA each year.

Since you do get a PSA exam each year you don't need convincing (and good for you!). However, as to the "annual prostate exam" (digital exam) in my case the tumor was missed twice by this method! Once by my family physician mentioned above, and later by a Urologist (who did the biopsy). The PSA test by my family MD was key. For you other guys 50 or over out there - Get A PSA test every year!
11.4.2007 3:39pm
Dan Weber (www):
Added screening sounds like an efficient way to doe medical care, since prevention is cheaper than cure.

But screening has costs itself, especially when it gives false positives.

Americans also fight against long odds a lot harder. When told that they have an incurable disease, something like 90+% of Americans go to another doctor. Most nations get in the 30%-70% ranges, IIRC.
11.4.2007 3:42pm
J. F. Thomas (mail):
The answer is, of course: zero. It is against federal law to turn anyone away because of inability to pay.

Talk about distorting facts. It is against the law to turn anyone away from an emergency room that accepts federal funds (not that ERs don't regularly figure out ways to do it).

And did you notice how he just concentrated on the amount of money we spend on healthcare in this country without comparing it to other countries. That would be a really "dangerous" but true fact.
11.4.2007 3:42pm
AF:
I'll sort of buy Mankiw's point number 1, but numbers 2 and 3 are highly unpersuasive. Rephrase them as positive assertions.

2. Mankiw: It's "misleading" to cite the high numbers of uninsured in America, primarily because 18 million of them have "have annual household income of more than $50,000" and therefore "could buy insurance but haven't."
Assertion: "The fact that 18 million people with household incomes over $50,000 are uninsured is not a public policy issue. If those people want insurance, they should buy it."

3. Mankiw: It's "misleading" to state that health care costs are eating up an ever increasing share of American incomes, because the rising cost of health care "is not a problem: It is the modern form of progress."
Assertion: "The fact that America are spending more and more on health care is not a public policy concern because it is a reflection of economic progress."

Neither of those propositions are anything like uncontroversial. If Mankiw wants to take a controversial view on the proper role of government in health care, fine. He should not call the facts "misleading" just because some people draw different conclusions from them than he does.
11.4.2007 3:48pm
Dan Weber (www):
As we get richer and richer, we'll probably spend even higher portions of our GDP on health care. It's a rather bottomless well that you can keep on pouring dollars into to get marginally better (if shrinking) returns.
11.4.2007 4:03pm
Ben P (mail):
I was going to say something about the turning away statistic but it appears to have been handled. That particular federal law only applies to emergencies. Not to say that hospitals don't play with that definition as well.

On the other hand, it also contributes considerably to rising costs in the health care industry. Two reasons in particular.

1. By forcing hospitals to take emergency cases, especially where federal funds often cover a fraction of the costs, we force them to eat the expense and redistribute those costs to the paying patents. If you have insurance You're already paying for those uninsured, you're just doing it via the high price of hospital visits.

2. By limiting this rule to emergency cases only, we've set up a situation where some percentage of those who are unable to get health insurance wait until their problem actually becomes an emergency (in some cases catastrophic). Which they then get treatment for at hospital expense. This increases the overall expense where preventative care could have minimized it.



I'm not saying either that the Government should be paying for it all or that hospitals ought to be able to turn away individuals.

But I think that if you look at the developed world, everyone, the US included, has accepted that health care policy is a legitiamate place for government regulation. In that context, the absence of a policy is a policy in and of itself. That does not mean the absence is a bad thing, but the costs and benefits are worth looking at.
11.4.2007 4:03pm
Michael Poole (mail):
AF- I think you are making a strawman version of Mankiw's arguments.

You ignore the other factors that he gives for thinking the 47 million number is overstated. His assertion on the second item is more that out of the 47 million uninsured, many could get insurance but choose not to.

Likewise, his assertion about the fraction of income going to health care is more that when that fraction increases, it does not automatically imply a failure of the US health care system to contain costs (or imply a concerted effort to Americans by charging more for the same goods and services). As a side note, the kind of progress that most shifts the demand curve for health care is not economic progress but scientific or technical progress.
11.4.2007 4:10pm
rlb:
It's just plain untrue to say that Canada has as many minorities as America does-- a cursory search shows that, as of 2000/2001, Canada was 87% white (that is, 13% "visible minorities") compared with the US at only 69% non-Hispanic white.

Notable statistics especially relevant to health include blacks, who are 13% of the US and only 3% of Canadians.
11.4.2007 4:11pm
John Neff (mail):
According the the CIA World Fact Book that was updated in Nov 2007 the infant mortality rates ranged from 2.3 per 1000 live births in Singapore to 184.4 in Angola. The rates for Canada and the US are 4.6 and 6.4 respectively so it is true that Canada has a lower rate but is the difference significant when the range is from 2 to 184? Not all infant mortality rates are listed because some counties do not report them. I suppose Darfur has the highest unreported infant mortality rate.
11.4.2007 4:18pm
Cornellian (mail):
It's just plain untrue to say that Canada has as many minorities as America does-- a cursory search shows that, as of 2000/2001, Canada was 87% white (that is, 13% "visible minorities") compared with the US at only 69% non-Hispanic white.

I said Canada more closely resembles the US demographically than any other country does, I didn't say they were demographically identical. In fact I even went on to say "even if they were demographically identical . . . ." so it was clear from my post that I was saying they are not demographically identical.

As for percentage of "white" versus "hispanic" I've never understood why "hispanic" counts as a race or why some of them count as white and others don't or what the proportion is, so I don't think a percentage of "non-hispanic whites" really means much.
11.4.2007 4:30pm
Smokey:
J.F. Thomas:
Talk about distorting facts.
Pointing out the distorting of facts is what my post was all about.

If someone had said that 47 million Americans do not have a car, the answer would be obvious: buy a car! If it makes for a tight budget, then cut back on restaurants, TV sets, and other less necessary expenditures. But don't come sniveling to the taxpayers for your free car, no matter how essential a car is to your livelihood - or even to your life. If you need a car, get one yourself. But don't tell the taxpayers to open their wallets ever wider for you.

Someone recently noted here that catastrophic health insurance [over $10,000, IIRC] can be purchased for under $15 a month. It's also clear from the link above that just about anyone can afford health insurance without big government getting involved. They just need to control their spending. All of these things that "poor" people buy costs plenty of money. As pointed out, health insurance is something ignored mostly by young, healthy people.

Why should working families have to do without in order to pay for 'free' health insurance for young people, when almost anyone - including "poor" people - can afford to buy health insurance at their own expense?
11.4.2007 4:31pm
Bottomfish (mail):
From Mankiw article:

Fortunately, our incomes are growing, and it makes sense to spend this growing prosperity on better health. The rationality of this phenomenon is stressed in a recent article by the economists Charles I. Jones of the University of California, Berkeley, and Robert E. Hall of Stanford. They ask, "As we grow older and richer, which is more valuable: a third car, yet another television,
more clothing - or an extra year of life?"


All the advice givers on health tell us (and it does seem to be true) that the way to add extra years of life is through moderate eating, exercise, keeping your brain active, and so on -- much less expensive than health insurance. It's the people who don't do these things who make health insurance expensive. What will happen to me if I say I don't want to pay for their self-created problems?
11.4.2007 4:35pm
AF:
Michael Poole:

I am having trouble understanding what "strawman" argument you think I am making.

Mankiw is arguing that certain facts are "misleading" because, if they were properly understood, most people would not think they raise serious public policy concerns. He then proceeds to explain why. I accurately characterized his explanations -- in fact, I quoted him -- and then argued that even taking account of these explanations, most people still believe these are serious public policy concerns. You and Mankiw might disagree on grounds of political philosophy, but Mankiw has failed to demonstrate that the facts "don't mean what people think they mean."
11.4.2007 4:36pm
A. Zarkov (mail):
Le Messurier"

"A question. What do you substitute for the PSA test?"


We don't have a substitute yet, but that's a different question.

" … but I would rather have had the biopsy as a result of the high PSA reading than allowed the cancer to have grown and metastasized unnoticed inside me. It would eventually have killed me."

Of course-- but you use ex post reasoning. Why not give every man over 50 a prostate biopsy? If you get a biopsy then should have a six-needle or a twelve-needle biopsy? Or how about a saturation biopsy, which uses upwards of 30 needles and requires and at least a sedation anesthetic if not a general. More needles means a smaller rate of false negatives, which introduces another question. What is the false negative rate for a prostate biopsy, and how much does it drop with more needles? A frequently quoted figure is 20%, but at least one Mayo physician says that we don't know the false negative rate. At what point to you get into excessive precaution? You could go all the way and remove every man's prostate after a certain age and that would really drop the prostate cancer death rate.

"I think your using the PSA test as an example of expensive, and by inference unnecessary, testing is very misleading and dangerous."

The expense lies not in the PSA test, but the large number of negative biopsies that result from using this test. If not getting a PSA test is "dangerous," then why is not getting a preventative biopsy not also "dangerous?" We currently have a big controversy over this issue, and the answer is not so clear cut as "get a PSA test," period.
11.4.2007 5:13pm
Ben P (mail):

Why should working families have to do without in order to pay for 'free' health insurance for young people, when almost anyone - including "poor" people - can afford to buy health insurance at their own expense?


Because we're paying for it anyway?

You talk about catastrophic insurance. That's perhaps most relevant to your initial point. Although they're not exclusively overlapping, generally if only "catastrophic" insurance qualifies, they also qualify as those in need of "emergency care" and can't be turned away until they're stabilized.

If that's the case, why would they bother paying for insurance if they can get a free ride?

Then hospitals bear the cost, and redistribute it in the form of higher rates to everyone else. So you are paying for their healthcare regardless.

Now, the obvious counter argument would be to repeal federal laws that require hospitals to at least stabilize emergency cases before transferring or "releasing" them.

I can see that argument, but I, personally, cannot reason my way past the moral barrier of denying life saving care for lack of ability to pay for it, it's maybe a little easier if they could have paid for insurance and chose not too, but no one can has time to make those distinctions when someone is bleeding out on an operating table.
11.4.2007 6:10pm
Ben P (mail):
Before someone points it out. My point on moral barriers on the previous post is a very limited one. I'm in no way intending to make the point that all levels of healthcare should be justified on some sort of moral imparative, I don't believe they are.

To the extent I think government provided healthcare can be justified, it can only be justified on a utility basis, much like education is in my eyes.

It might be true that private entities can run education more efficiently than the government can. However, I think few would dispute that if there were a solely private system of education, a substantial portion of the populace would not seek education at all. (as was the case in much of human history)

I also think that few would dispute that the national benefit from having a populace that can make use of public education far exceeds the cost.

In my opinion limited government healthcare can be justified on grounds similar to this, but any potential plan should be carefully examined to determine where the cost of taking free market incentive out of the equation exceeds the potential benefit. Including, potentially not covering a portion of the populace if necessary.
11.4.2007 6:16pm
Le Messurier (mail):
A. Zarkov

We currently have a big controversy over this issue, and the answer is not so clear cut as "get a PSA test," period.

If you want to save a few bucks I suppose there can be a controversy. If you want early detection of prostate cancer then narrow your odds with a PSA test. It isn't a perfect solution, but it beats the alternative of no detection. Until there is a better way to detect prostate cancer I'd go for the PSA and have a biopsy if indicated. As for "preventive biopsys" that's not a good idea for any number of reasons: first it is invasive; second, side effects are not comfortable or nice (though the procedure is not painful); third it is not a very appealing prospect for most mean and there fore mot likely to be a successful method of prevention. I do have a friend who is on a "watchful waiting" regimen who has a biopsy once a year as minimal cancer has been detected. It was discovered by a PSA test. If needed in the future he will have additional treatment. All of his treatment is being done at Mayo in Rochester, MN.

A.Z. are you over 50 and if so do you have an annual PSA test? If not why not and if yes why yes given your comments?

By the way, as far as I know a local anesthetic is always used except where, as you indicate, a general is called for.

The PSA test is all about early detection as is a digital exam. An ultrasound can also be used for detection as can some types of scans. So in addition to biopsies there are any number of possibilities. I guess the PSA/biopsy is the least expensive route despite the false results.
11.4.2007 6:35pm
A. Zarkov (mail):
The proponents for a US national medical insurance system generally favor it covering non-citizens, including illegal aliens. Even if somehow we didn't include illegal aliens, that wouldn't last long. Lawsuits backed up by enough sob stories in the media would eventually force universal coverage regardless of cost. Thus the US would get stuck with paying for treatment of chronic diseases for anyone who manages to jump the border. The open borders crowd simply refuses to come to grips with this potentially huge expense for the American taxpayer. People earning less than the median income pay about 3% of all federal income tax so most of those getting the benefit would not have to pay for it. It's very easy to be compassionate with other people's money.
11.4.2007 6:36pm
Le Messurier (mail):

third it is not a very appealing prospect for most mean and there fore mot likely to be a successful method of prevention.

Sorry! Should be: third it is not a very appealing prospect for most men and therefore not likely to be a successful method of prevention.

(My proof reader was out to lunch)
11.4.2007 6:40pm
calmom:
The best way to compare health care systems is to compare outcomes once a person becomes sick. That tests the adequacy of healthcare rather than lifestyle choices. This would be difficult to do since Canadians who can afford it come to the U. S. for treatment (most notably a Canadian MP came to California for her breast cancer treatment). Or Canada has its citizens brought to the U. S. as many mothers (not just the Great Falls quads) have to travel from British Columbia and Alberta to the United States to deliver their high risk babies. In other words, Canada is improving its statistics through access to American health care.
11.4.2007 6:42pm
Gonerill (mail) (www):
The best way to compare health care systems is to compare outcomes once a person becomes sick. That tests the adequacy of healthcare rather than lifestyle choices.

A shiny quarter to the first commenter to spot the subtle flaw in this proposal.
11.4.2007 7:17pm
Frater Plotter:
The proponents for a US national medical insurance system generally favor it covering non-citizens, including illegal aliens.
Really? Can you name one mainstream advocate of nationalized medical insurance who proposes to extend it to illegal immigrants while they are illegal?

In other words, it doesn't count if the same person supports legalizing those immigrants (e.g. amnesty or a guest-worker program) and extending nationalized insurance to the newly legal immigrants.
11.4.2007 7:22pm
A. Zarkov (mail):
"Really? Can you name one mainstream advocate of nationalized medical insurance who proposes to extend it to illegal immigrants while they are illegal?"

Arnold Schwarzenegger. He did say he wanted his proposed California health plan to cover illegal aliens. In 2006 when the California citrus crop was damaged, Arnold did favor giving illegal unemployed agricultural workers emergency aid. Talk to Senator Feinstein's staff about her position on covering illegal aliens and you can't get an answer. I take this as a "yes." Look Hilary couldn't even give a straight answer to the question of giving driver's licenses to illegal aliens at a debate. Later she said "yes." Let me turn the question around. Name me one Democrat in party leadership who has explicitly stated that illegal aliens would be excluded from any national medical insurance plan.
11.4.2007 7:45pm
Bottomfish (mail):
The best way to compare health care systems is to compare outcomes once a person becomes sick. That tests the adequacy of healthcare rather than lifestyle choices.

The most conscientious healthcare system in the world may not be able to do much for certain kinds of sick people. If such a healthcare system gets a higher than average percentage of people whose illnesses are difficult to treat, then according to the comparison test it will appear as less competent than another system which gets smaller percentages of difficult cases, even if the second system is no more conscientious than the first. Two patients with the same illness (in general terms) may differ greatly in terms of the prognosis. How bad one's prognosis is will likely depend on one's lifestyle before becoming sick.
11.4.2007 7:50pm
A. Zarkov (mail):
"A.Z. are you over 50 and if so do you have an annual PSA test? If not why not and if yes why yes given your comments?"

Actually I do speak from experience. After years of PSA tests, negative biopsies, and a lot of reading, I've become skeptical of the utility of the PSA test. I've seen no compelling evidence that we wouldn't get the same results if we simply randomly did a biopsy on any man over 50 with PSA <10. But it's one thing to spend your own money to be extra cautious, and other to have an expensive program of massive screening at public expense.

"By the way, as far as I know a local anesthetic is always used except where, as you indicate, a general is called for."

A topical anesthetic followed by an injected anesthetic is used for a regular biopsy. For a saturation biopsy, they use IV Valium (actually Versed). Since Valium usually erases their memory of the procedure, men will be more willing to undergo additional saturation biopsies.
11.4.2007 7:50pm
Not a lawyer but ... (mail):
How to mislead with statistics:

First, Mankiw says that the 10 million illegal immigrants in this country wouldn't qualify for health insurance anyway, so (implicitly) he says to subtract that number from the 47 million without insurance. BUT lots of illegal immigrants are employed by businesses that offer health insurance; they just use a fake social security number.

Second, the rising percentage of GDP used for health care doesn't bother Mankiw, and at first look that makes sense - it's simply consumer choice. BUT the fact that the U.S. spends a much higher percentage of the GDP than other industrial countries - that is NOT mentioned, though that puts us at a competitive disadvantage (and argues strongly that there is a lot of waste in the U.S. health care system). And, of course, we don't have better health outcomes than France, or Switzerland, or Sweden, despite spending much more - but let's not mention that.

Third, Mankiw doesn't think that government has an role to play in problems like obesity and the diabetes, despite the billions of dollars that the food industry spends each year to persuade consumers to eat poorly. (Or does he really think they spend all that money, as cigarette companies argued a while back, simply to get consumers to CHANGE brands?) Instead, it's an individual choice problem, and if somehow the citizens of the U.S. are far less self-disciplined than Europeans, that couldn't have anything to do with government policies, could it?
11.4.2007 8:02pm
Smokey:
Ben P, I essentially agree with your two posts above [and also with Zarkov's 6:36 post]. The central problem with Hillarycare II is the excessive cost, pumped up by the giant [and forever-growing] army of salivating bureaucrats who would take over the system.

If the proposal was for some type of voucher along with a substantial part of the cost being paid by the recipient, I could live with that. But this is heading straight toward a huge government run system - which, despite the thoroughly mendacious claims of its proponents, will cost many, many times what they claim.

Just look at Hillarycare, which would have given the government total control over 14 - 17% of the entire $12.4 trillion U.S. economy. That translates into close to $2 trillion -- and it would add a thick new layer of nameless, faceless and completely unaccountable bureaucrats to shuffle the paperwork - with zero market competition to keep their costs from ballooning out of control. And the very same inexperienced Hillary, who has never met a payroll, is pushing this debacle.

If this isn't a recipe for financial disaster, then what is?
11.4.2007 8:11pm
MarkField (mail):
Mark Thoma criticizes Mankiwhere.
11.4.2007 8:12pm
Thoughtful (mail):
Two points, as a physician:

First, one reason American infant mortality rates are higher than many other countries is that in America we often try to save very early pre-term deliveries. If in the US we fail to keep a 27 week fetus alive despite spending $100K to do so, it counts as a case of infant mortality. In most other countries, it counts as a miscarriage.

Second, it is NOT true, though frequently falsely believed, that screening saves money because it catches disease early. The reason this is not true is that one always dies of something. So if I, for example, pick up a small breast cancer on screening mammography and save the life of a 50 year old woman, she will eventually die of, say, congestive heart failure at age 87, after having much more money spent on her health in the extra 37 years, much of it paid by the federal government as Medicare. The argument for screening is NOT that it's cheaper. It's more expensive. The argument is that it's cost-effective, which is to say that the extra expense is more than compensated by the improved longevity.

This argument would be logically more sound if screening studies were paid for by the individuals choosing to be screened. Sadly, physicians today believe that, prior to what they consider adequate proof, no one should be screened (even should they choose to pay for it out of pocket), because it hasn't been "proven effective", while with adequate proof of effectiveness they believe insurance should be mandated to pay for it, despite the fact that not everyone needs to be screened and despite the fact that screening is a paradigmatic example of an elective, easily planned for event, with known costs, and therefore exactly what we DON'T want to pay for via insurance mechanisms.
11.4.2007 8:36pm
Harry Eagar (mail):
I am having a little trouble squaring the insoucience with which people advocate spending thousands of dollars on possibly meaningless PSA tests while simultaneously getting bent out of shape by the price of sugar, which is the cheapest food with the smallest margin between farm-gate and housewife prices.

Decide whether price is the controlling factor in your decisions and stick with it, please. You are confusing me.
11.4.2007 8:47pm
Michael Poole (mail):
AF- What gives your argument away as a strawman is the fabricated quotes, which you call his assertions and defend as accurate summaries. Your comment seems to make the exact kind of slanted oversimplification that Mankiw argues against; that might be clever satire on your part, but you show all the signs of taking it seriously.

Mankiw does not stop (as your "assertion" quote implies) at noting that because 18 million of 47 million uninsured residents have incomes above $50,000, they can afford insurance. He calls out several other reasons that the 47 million number should not be viewed as the number for whom the health care system has failed -- which is the usual implication of those who trot out talk about 47 million uninsured.

He also does not say (as your paraphrased "assertion" does) that we should dismiss sharply increasing health care expenditures simply as a sign of economic progress. He explains why percentage of income spent on health care now versus decades past is not an apples-to-apples comparison: the demand curve has shifted for several major reasons.

If we are going to quote just parts of things and present those out of context, though, at least you agree that "certain facts are 'misleading' because, if they were properly understood, most people would not think they raise serious public policy concerns."
11.4.2007 8:54pm
Bottomfish (mail):
To not a lawyerbut: you say: ...Mankiw doesn't seem to think that government has an role to play in problems like obesity and the diabetes, despite the billions of dollars that the food industry spends each year to persuade consumers to eat poorly. There's plenty of food advertising everywhere, in Europe just as much as here, right? And if you think the food industry isn't trying to show how organic and artificial-ingredient-free their stuff is (assuming that's your idea of eating properly), why not just look at the labels?
11.4.2007 8:56pm
Crunchy Frog:
As I am far too lazy to look it up myself, I'll just wonder aloud:

How much of that increase in infant mortality is due to illegal alien anchor babies, born to women (or more realistically, teenage girls) who came here in month 9 and received no prenatal care at all?
11.4.2007 9:33pm
noname (mail):
Crunchy Frog:

I highly doubt that there are any reliable numbers on that.
But, do you really think that it's a significant amount?

Are people THAT terrified of the illegal immigration bogeyman?
11.4.2007 9:43pm
MDJD2B (mail):

According the the CIA World Fact Book that was updated in Nov 2007 the infant mortality rates ranged from 2.3 per 1000 live births in Singapore to 184.4 in Angola. The rates for Canada and the US are 4.6 and 6.4 respectively so it is true that Canada has a lower rate but is the difference significant when the range is from 2 to 184? Not all infant mortality rates are listed because some counties do not report them. I suppose Darfur has the highest unreported infant mortality rate.


In addition to what thoughtful said, I'd point out that the lower limits of infancy (as opposed to miscarriage) vary from country to country, ranging from 500 to 1000 grams. The higher the divide, the lower the infant mortality, for obvious reasons.

The efficiency of reporting also varies. the latter is influenced by all sorts of things. When I was in the Army, I served in a state that required burial of all dead people over 500 grams-- at the expense of the parents. Our NCO patients did not make a ot of money, and many were on food stamps. There were many 475 gram miscarriages, and very few stillbirths under 750 grams. I suspect that there are many other factors that can lead to this sort of phenomenon.
11.4.2007 9:43pm
Hoosier:
"By forcing hospitals to take emergency cases, especially where federal funds often cover a fraction of the costs, we force them to eat the expense and redistribute those costs to the paying patents. If you have insurance You're already paying for those uninsured, you're just doing it via the high price of hospital visits."

Another result of this requirement: Private hospitals move out of areas where the walk-in rates of uninsured emergencies are high. (It's happening in my city now: A hosptial that's been here since just after the Civil War is moving to the wealthiest suburban area in the region.) In a number of neighborhoods in Chicago, for instance, it is simply impossible to find a hostpital.

As for infant mortality: The US counts this differently, in a way that includes significantly more non-viable babies as live births. So comparisons between us and nations with similar levels of health care will always make us look worse.
11.4.2007 9:45pm
K Parker (mail):
Are people THAT terrified of the illegal immigration bogeyman?

Nice ad hominem. But I think a much more interesting question is, what if it turns out to be the case?
11.4.2007 10:02pm
Zacharias (mail):
Part of the higher infant-mortality rate in Amerika is attributable to the fact that 55% of Amerikans mutilate their baby boys' genitals shortly after birth, while the rate in Canada and in other parts of the civilized world is very much lower.
11.4.2007 10:54pm
Eli Rabett (www):
The infant mortality rate for non-hispanic white mothers in the US exceeds that of Canada for all births. According to a 2002 table (you can google), the US ranks 27th for infant mortality, if you only include births to non-hispanic white moms, the US makes it to about 24th.

If anything, the statistics say that the difference between races pretty much goes away if you control for income. You may resume ranting.
11.4.2007 10:55pm
Eli Rabett (www):
Oh yes, there are also quite a number of US citizens who have become medical tourists
11.4.2007 11:01pm
Dave D. (mail):
...My doctor, a Canadian by birth, recently told me that his uncle, a retired professor in Canada, had a PSA test, results elevated, and was referred for a biopsy. But he was not scheduled for many months. By the time the biopsy was done, it had matastasized. With tears in his eyes my Doc told me his uncle probably lost 5 years of life.
...One anecdote does not constitute evidence, but socialized medicine is a failure in many contries, Canada included. 70,000 Brits elect to pay out of pocket every year for surgery they have already payed for but cannot get from their NHS. If you want to subject yourself to the U.S. Postal service of healthcare, join the military and get the V.A. But I don't.
11.4.2007 11:08pm
AF:
Michael Poole: What gives your argument away as a strawman is the fabricated quotes, which you call his assertions and defend as accurate summaries.

First, please don't accuse me of fabricating quotes. I state very clearly in my post that the "assertions" I am attributing to Mankiw are not quotes, but my "rephras[ings]" of Mankiw's points.

You have yet to identify a single inaccuracy in my characterization of Mankiw. My post states that the "primar[y]" (ie, numerically most significant) reason Mankiw gives for calling the 47-million-uninsured figure "misleading" is that 18 million of the uninsured have household incomes above $50,000. I did not address his other, smaller reasons. As you yourself recognize, Mankiw's implication is that the 18 million uninsured middle class people (among others) should not be seen as people "for whom the health care system has failed." Which is the argument I am attributing to Mankiw.

Similarly, Mankiw endorses the view that the rising cost of health care "is not a problem: It is the modern form of progress." He does not present any alternative explanations of rising costs or any reasons that they should be of concern to public policy makers. Thus, his implication does seem to be that public policy makers should "dismiss sharply increasing health care expenditures simply as a sign of economic progress."

A straw man is, by definition, a weak argument. However, it does not appear that you disagree with the arguments that you are calling straw men. Either the 18 million uninsured people with household incomes over $50,000 and the rising costs of health care are serious public policy concerns, or they are not. If you agree that they are, then those facts are not "misleading." If you think they are not, then you agree with my characterization of Mankiw's arguments, and should not call them straw men.
11.4.2007 11:39pm
Montie:

The infant mortality rate for non-hispanic white mothers in the US exceeds that of Canada for all births. According to a 2002 table (you can google), the US ranks 27th for infant mortality, if you only include births to non-hispanic white moms, the US makes it to about 24th.


Eli, you should be very careful comparing statistics. Different countries regarding how they define infant mortality. Moreover, a lot more goes into infant mortality than just health care (e.g., maternal age, maternal obesity).


Second, the rising percentage of GDP used for health care doesn't bother Mankiw, and at first look that makes sense - it's simply consumer choice. BUT the fact that the U.S. spends a much higher percentage of the GDP than other industrial countries - that is NOT mentioned, though that puts us at a competitive disadvantage (and argues strongly that there is a lot of waste in the U.S. health care system). And, of course, we don't have better health outcomes than France, or Switzerland, or Sweden, despite spending much more - but let's not mention that.


Let's not bash high health care spending too much. I agree that there are several inefficiencies in the U.S. system. However, in the end, health care has been called the ultimate luxury good. We should not be surprised that, as people become more wealthy, the percentage that they spend on health care tends to increase.
11.4.2007 11:54pm
JBL:
Mankiw is correct to point out that the statistics by themselves don't say much, especially if you don't analyze the underlying data.

The problem with the health care debate is that people tend to use the data to argue about whether we should keep the existing system but tweak it slightly, get rid of medicare completely and see what happens, or socialize the entire system. Since none of those options is the optimal solution, which one is preferable is largely a matter of personal preference.

In order for a market to function properly, consumers need four things: accurate information about the product or service, accurate information about cost, freedom to choose, and sufficient resources to effectively participate. Providers need accurate information and the freedom to innovate.

Health care in the US doesn't completely meet any of these requirements. Complete information about medical outcomes over the full cycle of care, broken down by provider and condition, is only available for a few specific conditions. The system of running everything through insurance and the externalities of the uninsured mask the real cost information. That being the case, although we are free to chose providers to some extent, in practice the choice is usually constrained by the health plan or the provider group, not based on the information the consumer should consider most relevant. And although the number of people who can not afford effective health care is probably less than 47 million, it is still significant.

Eliminating the HMO/PPO/Medicare structure would help clarify costs, but wouldn't address the other issues. Government-run universal care would improve some aspects of the system, but would interfere with doctors' and patients' ability to improve quality or reduce cost. Pick your poison.

The ideal solution involves two elements (and a lot of implications). First, we need to require providers to report outcomes, but not mandate particular procedures. Over time, that's the only thing that will allow us to improve value. And second, we need to require, and where necessary subsidize, something like the HSA/High Deductible Health Plan arrangement for all citizens. That's the only way to make sure that everyone can effectively participate.

Until those two things are out on the table as real options, the whole debate isn't properly framed and most facts will be somewhat misleading one way or another.
11.5.2007 12:01am
Montie:
AF, you are clearly taking Mankiw out of context.


Similarly, Mankiw endorses the view that the rising cost of health care "is not a problem: It is the modern form of progress."


No, he is not endorsing this conclusion rather he is refering to a paper that shows that health care as a percentage of GDP will increase over time. Anyway, an increase in the share of GDP going the healthcare is to be expected because (i) richer people spend a higher percentage of their income on health care and (ii) medical advances will provide new treatments.

Regarding the latter point, consider tthat President Eisenhower recieved for his heart attacks (bedrest and asprin) to the treatment that Vice President Cheney recieved (angioplasty, implantable defibulator). We could mandate that every heart attack victim recieve the Eisenhower treatment and save a great deal of money. However, I think most heart attack victims would prefer the Cheney treatment.
11.5.2007 12:07am
A. Zarkov (mail):
Eli Rabett:

If anything, the statistics say that the difference between races pretty much goes away if you control for income. You may resume ranting.

The Congressional Budget Office has published a report on the US ranking for infant mortality as a CBO Staff Memorandum. The following statements from this report are noteworthy.


* "… very premature births are more likely to be included in birth and mortality statistics in the United States than in several other industrialized countries that have lower infant mortality rates."

* "Variations in infant mortality rates among the states and between different racial and ethnic groups in this country are greater than the differences between the United States and many other countries."

* "Low birth weight is the primary risk factor for infant mortality …"

* "… low birth weight newborns have better chances of survival in the United States than elsewhere."

* "The U.S. infant mortality problem arises primarily because of its birth weight distribution; relatively more infants are born at low birth weight in the United States than in most other industrialized countries."

* "White infant mortality rates ranged from 7.2 in Massachusetts to 10.1 in Idaho…"

* The United States, however, is unusual in placing responsibility for reporting births and deaths on hospitals, health care professionals, and funeral homes rather than on individual families.

* The available data suggest, however, that some of the disparities in infant mortality rates between the United States and other industrialized countries may be attributable to different resuscitation policies for premature newborns, resulting in different classifications of live births and fetal deaths.

* "Teenage pregnancy and birth rates in the United States are significantly higher than in many other industrialized countries …"

* The extent to which higher rates of teenage child-bearing affect the U.S. infant mortality ranking is unclear and must await more detailed risk factor studies by the ICE participants. Nonetheless, U.S. data suggest that this could, indeed, be an important factor.



Thus we see that comparing the US infant mortality rate to other countries is difficult to impossible for a variety of reasons. Even limiting the comparison to white people still leaves many important differences.
11.5.2007 3:51am
Tom Cross (www):

Smokey:
2. Some 47 million Americans do not have health insurance.
Don't you just love how they conveniently frame the argument?

More honest to ask: How many Americans are denied access to a doctor?

The answer is, of course: zero. It is against federal law to turn anyone away because of inability to pay.

Smokey: Your characterization of this is deeply wrong.

My mother has an unusual chronic health condition. As a result, she is unable to purchase health insurance from any provider at any price. Conservatie pundits are often quick to quip that "insurance" is not for expenses you are certain to have. Our family has no interest in purchasing "health insurance" to cover her preexisting condition. We can afford to cover that ourselves, even paying the "over the counter" rates that uninsured people pay and not the far lower negotiated ones that are paid by people with insurance.

We would like insurance to cover the same sort of unpredictable risks that other people have insurance to cover: accidents, cancer, liver, lung or heart disease.... While there is no casual relationship between her condition and these kinds of health risks, apparently there is some sort of statistical correlation (which no one in the underwriting industry has ever been willing to explain for us) as she is completely unable to purchase individual coverage on the free market at ay price.

The fact is that without government healthcare, if she developed one of these conditions she simply would not have access to the kind of care that is given to the majority of the people who live in this country, in spite of the fact that at the moment of a heart attack they'd have to admit her into the ER and try to defribulate her even if we couldn't afford to pay for it.

Conservative pundits are constantly screeching about how people who are uninsured are lazy, or they simply don't want coverage. That isn't true. The linked article suggests that: "Of course, millions of Americans have trouble getting health insurance... Any reform should carefully focus on this group to avoid disrupting the vast majority for whom the system is working." I agree with this conclusion, but inevitably any solution which targets this group will be publically called "socialist" by the people for whom this article resonates, regardless of how minimal it is, and it is not at all clear having wrestled with these issues for decades that it is possible to build a solution that only targets this group without incorporating other aspects of the healthcare system.
11.5.2007 8:07am
Richard Aubrey (mail):
Tom Cross.

HIPAA mandates that each state have an insurer of last resort. They do not underwrite or refuse applicants.
Your mother should qualify.
11.5.2007 9:45am
JosephSlater (mail):
It is, of course, important to make sure cross-country comparisons are measuring the same thing, and I hope everyone remembers that when we compare U.S. unemployment figures to those in European countries.
11.5.2007 9:47am
Montie:

It is, of course, important to make sure cross-country comparisons are measuring the same thing, and I hope everyone remembers that when we compare U.S. unemployment figures to those in European countries.


Absolutely. However, I do know that there has been great deal of harmonization of unemployment calculations. The OECD does report standardized figures.
11.5.2007 10:19am
Dan Weber (www):
Tom Cross does point out a failure of the market: that it's hard for chronically ill people to insure against other health risks.

Why hasn't the market addressed this? Are people like his mother just too rare? I know the ability to purchase individual insurance has become a lot easier in the last several years, so will the market be providing her mother with the product she wants to buy in a few years?

Would it be possible (even if annoyingly cumbersome) for her to buy that coverage piecemeal? Buy catastrophic insurance from one company, cancer insurance from another, etc etc?
11.5.2007 10:28am
JosephSlater (mail):
Montie:

There are attempts to standardize, but also a number of factors that make it hard to standardize, as I'm guessing you know. I won't push the point any more here, because it's off-topic in this thread.
11.5.2007 10:32am
rarango (mail):
A few points re the Mankiw article: Good discussion, but incomplete. The issue re infant mortality is on the reporting side and measures about what constitutes a live birth. Countries reporting viability do not all comply with WHO criteria. Second, the use of an ordinal measure to assess health care is foolish in the extreme--mostly for reasons Mankiw describes: Epidemiology relies on using similar numerators and denominators. Aggregate numbers simply dont do that. Moreover, ordinal measures might be worthwhile is we used, say the mode as a measure central tendency and then looked at how many countries were outside the first standard deviation. As it is, an ordinal measure necessarily reflects differences in very small amounts (79.3 versus say 79.2 years of life expectancy), and those differences are not statistically significant. Finally, there are numerous measures related to measuring the effectiveness of the health care system ranging from access to healthcare, to customer satisfaction, to years of survivability following medical intervention. Aggregate statistics are not very good measures, and terrible epidemiology.
11.5.2007 10:38am
rarango (mail):
Eli Rabett: You have to control for age, gender, and ethnicity to change crude rates to adjusted rates for purposes of epidemiological comparison. The use of SES gives you some second order insights, especially as to questions of access, but basic biological differences remain the most significant factors. (With respect to SES, there are some studies that suggest the education level of the mother correlates most positively to good birth outcomes, and, of course, education level does in turn correlate to SES--but when you get to the R^2 level of variance explained, these arent all that significant.)
11.5.2007 10:46am
AnonLawStudent:
Tom and Dan,

I'm going to offer a bit of speculation as to the source of the market failure you describe. Many (if not all) states strictly regulate the terms of insurance contracts. State statutes often require that ANY health insurance include [insert popular political cause here], e.g. birth control. So unlike title insurance, for example, it may not be possible to purchase insurance subject to the exception you want.

We can debate the value of state regulation of insurance contracts, but for these purposes, the important point is that regulation also imposes costs. I would also point out that in unregulated (or less regulated) parts of the insurance market, anything can be insured for the right price. A billion dollar satellite atop a poorly tested rocket? No problem - just a matter of cost.
11.5.2007 10:56am
Hoosier:
"55% of Amerikans mutilate their baby boys' genitals shortly after birth"

"Mutilated" is not a word that Mrs. Hoosier has ever used to describe the equipment. But thanks for your concern.
11.5.2007 11:00am
uh clem (mail):

Shorter Greg Mankiw: "Move along folks, nothing to see here."

I can only hope that he continues to provide this out of touch advice to his advisee, Mr. Romney. "We'll just say that healthcare is not a problem. No problem."
11.5.2007 11:07am
Andy Freeman (mail):
> I said Canada more closely resembles the US demographically than any other country does, I didn't say they were demographically identical.

However, you also wrote that they were "fairly close", implying that they were close enough the comparisons that you want to make. 3% vs 13% black isn't "fairly close".

> As for percentage of "white" versus "hispanic" I've never understood why "hispanic" counts as a race or why some of them count as white and others don't or what the proportion is, so I don't think a percentage of "non-hispanic whites" really means much.

Not so fast. Much of the illegal immigrant argument assumes that Hispanic whites are visually distinguishable from other whites.

Feel free to show that the percentages of Hispanics in Canada and the US are comparable. If not, that's another huge demographic difference.

Minorities matter. Disagree? We'll swap.
11.5.2007 11:16am
rarango (mail):
Re our Hispanic population: the Hispanic population (at least that with some native american genetic component) is genetically prone to diabetes which is a significant chronic condition. Moreover, hispanic women are some 50% more like to be overweight or obese than their caucasian counterparts--in short, a significant Hispanic population affects our health status (as long as you are wedded to aggregate statistics).
11.5.2007 11:21am
wfjag:
On another blog run by a medical researcher/ professor, describing a different issue in which statistics are misused by advocates and mis-reported, he used the term "scare-stistics" to describe what is done. It's an accurate description, and should be added to the dictionary.

Thoughtful and Hoosier both noted that what is counted in the US, isn't counted in other countries. See the following article from stats.org:

www.stats.org/nota_bene.htm

The math behind infant mortality
October 10, 2006

From US News and World Report a rebuff to the idea that the U.S. is especially bad at keeping newborn babies alive compared to most of the developed world.

"First, it's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.

Infant mortality in developed countries is not about healthy babies dying of treatable conditions as in the past. Most of the infants we lose today are born critically ill, and 40 percent die within the first day of life. The major causes are low birth weight and prematurity, and congenital malformations. As Nicholas Eberstadt, a scholar at the American Enterprise Institute, points out, Norway, which has one of the lowest infant mortality rates, shows no better infant survival than the United States when you factor in weight at birth."

There are links in the article which provide additional information for those who wish to take the time to learn the underlying facts and what the "statistics" actually mean. Simply put, any attempted comparison between the US statistics and European or other countries' statistics on infant mortality is as valid as comparing oranges to bowling balls. (Both are round, but the similarities are otherwise illusionary).

The CDC Factsheet also shows that there are huge differences based on ethnic/ racial background:

www.cdc.gov/omhd/AMH/factsheets/infant.htm

CDC Fact Sheet

"What is the Burden of Infant Mortality?

Infant mortality is used to compare the health and well-being of populations across and within countries. The infant mortality rate, the rate at which babies less than one year of age die, has continued to steadily decline over the past several decades, from 26.0 per 1,000 live births in 1960 to 6.9 per 1,000 live births in 2000. The United States ranked 28th in the world in infant mortality in 1998. This ranking is due in large part to disparities which continue to exist among various racial and ethnic groups in this country, particularly African Americans.

Examples of Important Disparities

Infant mortality among African Americans in 2000 occurred at a rate of 14.1 deaths per 1,000 live births.2 This is more than twice the national average of 6.9 deaths per 1,000 live births. The leading causes of infant death include congenital abnormalities, pre-term/low birth weight, Sudden Infant Death Syndrome (SIDS), problems related to complications of pregnancy, and respiratory distress syndrome. SIDS deaths among American Indian and Alaska Natives is 2.3 times the rate for non-Hispanic white mothers." (footnotes omitted).

In discussing various national health care proposals, it is sobering to note that those groups who are the largest recipients of "free" government health care programs are the ones whose problems are the worst. Is this what should be provided for all Americans, or, should our politicians look at fixing what appear to be deeply flawed government programs? Or, should they divert the issues by using scare-stistics?

I don't pretend that the US health care system isn't without it problems. But, before deciding to scrap it, consider the decline in infant mortality rates in the US "from 26.0 per 1,000 live births in 1960 to 6.9 per 1,000 live births in 2000." Any honest discussion of the issues also has to include that the US health care system has delivered great benefits. This is seldom noted.
11.5.2007 11:26am
Andy Freeman (mail):
Under the current US system, smokers, overweight, and older people pay more for health insurance.

Will they pay more under "single payer"? Will their above average costs be completely subsidized? Will they receive "average care" (which is less than their above average needs)? How about all three, or two of the three?
11.5.2007 11:31am
Tom Cross (www):
Richard: Thats an important point. The state in question is Tennessee. A few years ago they dropped people in my mother's category (not poor, not insurable) from the roles of their "Tenncare" system. In response to Dan's question about the size of the market failure, that was about 300,000 people. While HIPPA required local insurers to cover those people, we were informed at the time that we had 60 days from the closure of Tenncare coverage to sign up for this HIPPA coverage and that if we failed to do so there was no other option. This would imply that new people moving to the state, for example, don't have an option under similar circumstances. Tenncare has recently reopened a "high risk" program called "AccessTN." However, it only has a few thousand slots (leaving, again, the vast majority without an alternative option), and it carries a very low maximum lifetime benefit. Certainly one you'd hope you'd never need, but low enough that it might not cover something catastrophic like cancer or a serious organ problem.

Having said all of that, either way, if my mother has insurance it's because the government offers or requires it and not because the market offers it freely.

The HIPAA mandated coverage is quite expensive and the AccessTN program only a bit cheaper. Certainly the actual money my mother will pay into these programs vastly exceeds her likely expenditures, and subsidizes the health care of numerous others in the program whose actual expenses are high.

All insurance involves the distribution of risk. The real question here is how broadly to distribute the risk of health expenditures from people who are both high risk and are not covered by a large employer or professional organization's plan, as well as people who are too poor to afford healthcare. Right now my family bears a far greater percentage of that financial burden than most families in America. We're fortunate that we have the means to afford those payments, and that today we're not on the receiving end of the benefits. The situation could be much worse for us. I'm not convinced that our circumstances are fair, but they are not intolerable. I suspect that for many others they are.

AnonLawStudent: Thats an interesting observation. I'm not sure why the market failure exists but I have other theories as well. One is simply an inability to properly assess risks. Some of these patients may be low risk and others may be high, but there is no way to reliably differentiate them. Another is incentives for insurance companies. If the government is going to force you to make a high risk pool wouldn't you want that pool to be as big as possible so you get the largest amount of people paying the highest rates? If those people can't choose an alternative, normal competitive constraints don't apply, and you need to offset the costs as much as possible.
11.5.2007 11:36am
SIG357:
"Some 47 million Americans do not have health insurance."

It may well be true that there are 47 million people living in America who do not have health insurance, but a large number of them are not Americans.
11.5.2007 12:16pm
AnonLawStudent:
Tom,

Your 11:36AM post raises another issue. Regulation of terms and coverage is not the only way that costs are imposed. You note that "[a]ll insurance involves the distribution of risk," but that is only part of the story. As various commenters have discussed in other threads, "distribution of risk" can take at least two forms - risk spreading and risk shifting. Under risk spreading, premiums are based upon individual risk. However, due to various statutes, particularly anti-discrimination statutes and community pricing regulations, large portions of the consumer insurance market involve risk shifting. Under this paradigm, policy holders pay relatively equal premiums, regardless of risk. One of the tradeoffs under the risk-shifting paradigm is insurance companies must exclude those with very high risks in order to keep the cost at least somewhat contained for everyone else. Again, as noted in other threads, catastrophic insurance should be very cheap, particularly for young people. But it isn't - those low risk young people are forced to pay for both coverages they don't want and part of the risk that is actuarially attributable to other segments of the population.

To the degree that there is an insurance problem in the country, significant parts of it are attributable to government interventions in the market. Now politicians are using the effects of those interventions to justify even greater interventions.
11.5.2007 12:22pm
calmom:
Bottomfish:

Healthcare systems could be compared by medical outcome. For instance, what was the average life expectancy for all patients diagnosed with stage II breast cancer in Canada, Great Britain, France, etc. I think that the staging for cancers is uniform throughout medicine and that would be a way to compare life expectancies. What is the life expectancy for 45 year olds with kidney failure requiring dialysis? For 50 year old insulin dependent diabetics? Etc. Comparisons could be devised that didn't take into account lifestyle factors. Genetics could be factored out by comparing Europeans to Americans of European ancestry.

These sorts of studies will be very important in the health care debate for obvious reasons.
11.5.2007 12:32pm
markm (mail):
Tom, I suspect that the problem is that state and federal laws do not allow the insurance company to indefinitely exclude her chronic health condition. That is, they could sell you one year of coverage with pre-existing conditions excluded, but they are allowed neither to exclude them forever nor to just cancel the insurance when it's about to get costly. So, the second year and every year after that they'd get hammered - and quite likely not just for the expenses you're paying out of pocket now plus administrative costs, but also for more expensive treatment options that your mother doesn't consider cost-effective now.

And I also think that in most states, the maximum cost of health insurance is capped - even if you could pay the real cost, they can't raise the rates that high. There should still be a state insurance pool she could get into, for the maximum rate the state allows with other insurance customers picking up the rest of the cost, but don't expect an insurance company to want to sell you that.

Folks, don't call it "market failure" when there's no free market!
11.5.2007 12:54pm
Tom Cross (www):
With regard to community pricing regulations... There are many poor black men who live to a ripe old age. An actuary may accurately conclude that poor black men are collectively more likely to develop heart disease than rich white women. But there is no direct causal relationship between being black and having heart disease. An individual poor black man (lets call him Jim) who doesn't smoke, eats well, and runs every day probably won't get heart disease, but he'll always be black, and he'll only escape poverty if he plays his cards right over a long period of time.

The argument (often offer by Cato) is that it shouldn't be illegal for insurance companies to constrain the distribution of the risk that poor black men will develop heart disease to other poor black men. This would benefit Jane, our rich white woman, who would pay a lower premium. But it would hurt Jim, who would pay more money due to other people's irresponsible behavior. Either way, people who are unlikely to get heart disease end up subsidizing others who are. I'm not sure one of these is more fair than the other.

The only fair kind of risk assessment is a causal one. Anything else is just an argument about how big to draw the circle of collective responsibility. Unfortunately, we don't have the ability to make precise causal risk assessments for most of the things that we have to insure.
11.5.2007 1:19pm
Feckletarian:

Tom Cross: The argument (often offer by Cato) is that it shouldn't be illegal for insurance companies to constrain the distribution of the risk that poor black men will develop heart disease to other poor black men. This would benefit Jane, our rich white woman, who would pay a lower premium. But it would hurt Jim, who would pay more money due to other people's irresponsible behavior.


In the absence of a Universal program, Jim has the option of "insuring" his healthcare needs by the more rational approach of saving, rather than paying premium. As a cash customer, he'd even have considerable leverage in negotiating rates for preventive care with his local provider (before you claim that the uninsured pay higher rates than the negotiated HMO/PPO rates, realize that you're thinking of credit and emergent care customers).
11.5.2007 1:37pm
rarango (mail):
Tom Cross: As you correctly point out, in a perfect world we would know "causality." Unfortunately, we really only can produce correlation, or in epi terms, "relative risk." Causality is indeed the gold standard, but, regretably, seldom knowable.
11.5.2007 2:19pm
cjwynes (mail):
Tom,

If we hadn't dumped all those people off TennCare, we'd probably have a state income tax right now to go along with our ridiculous 10% sales tax. The line has to be drawn somewhere. During the 90's, the state was flush with cash, so they spent more on that program (partly because the federal matching funds make it LOOK like you're increasing health spending by twice as much as you actually are, so legislators can sound like great humanitarians.) During the lean years, the state can't keep covering the same number of people they did when they had more money.

And whether a risk assessment is "fair" or not isn't the issue. If you want to pay for it, do so. If you think it's "unfair", then don't buy it. Somebody buying health insurance has the same options as somebody shopping for a mortgage or car loan, if you don't want to pay the ridiculous rates then don't make the agreement. Just as I can save my cash to make a big purchase if I'm not credit-worthy, people can save cash in health savings accounts if they are in high-risk groups where the insurance costs are likely to exceed the benefits they would be paid.
11.5.2007 2:43pm
Dan Weber (www):
Jim has the option of "insuring" his healthcare needs by the more rational approach of saving, rather than paying premium.

Ooh, I'm gonna start insuring my house against fire that way. What could possibly go wrong?
11.5.2007 2:43pm
A.C.:
My main problem with making health insurance mandatory deals with all those people who COULD purchase insurance but choose not to. At the end of the day, I don't think it's my business to tell them they must spend their money that way. They may have other priorities, for example moving to a safer neighborhood or paying for education so that they can get better jobs and purchase health insurance at that time. A lot of people who choose not to carry insurance are young and healthy, and these are legitimate choices for young, healthy people at the start of their careers.

I'm not sure it's a good idea to force them to buy health insurance (and subsidize older people) when they still haven't got their own financial legs under them. Student loans, payroll taxes, and ridiculous housing prices are steep enough hills to climb without making entry-level workers subsidize health care for their boss's kids.

This argument doesn't apply to people with chronic conditions who are uninsurable in private markets, or to people who are severely disabled and will never make enough to cover even their routine medical costs. I'm not opposed to a government program for people like that -- we're all one car accident away from falling into that category ourselves. I would have the program charge premiums and copays for those who can pay, but I'm also arguing for flat-out public charity for those who cannot. Not an insurance-based risk shift, but an actual subsidy funded out of general revenue. There but for the grace of God...

Obviously, we can't provide such a subsidy to everyone who would rather get free health care. We may or may not have the social desire to offer it to the healthy poor, but I can't see any argument at all for offering it to the healthy non-poor.
11.5.2007 3:00pm
AnonLawStudent:
Or, if the regulatory burdens weren't so severe, Jim could either (1) buy only catastrophic health insurance at an affordable rate, or (2) join with other low-risk individuals in nominally high-risk groups and form a mutual insurance pool. For example, USAA (a mutual insurer for military personnel) started in 1922 when a group of only 25 Army officers decided to form an insurance pool for their automobiles.
11.5.2007 3:01pm
Elliot123 (mail):
Can someone tell us why we should care how much is spent on health care? I notice this same concern does not extend to things like pork rinds, gas, restaurants, blue jeans, jewelry, vacations, autos, movies, houses, or attorneys. Should we also be comparing the amounts spent on these things to other industrialized countries? If there is a difference, should we then strive to bring our spending in line with Canada or France?
11.5.2007 3:27pm
Feckletarian:

Dan Weber
Ooh, I'm gonna start insuring my house against fire that way. What could possibly go wrong?

Health coverage isn't health care, and fire insurance isn't the only way to get protection against fire.

If you can't find an insurance company that gives you suitable rates despite having the only concrete house in town full of wood houses (the equivalent of Jim the healthy guy), it has a good chance of working out to your advantage, with the upside that you (rather than some insurance company) can profit if you manage to avoid a loss over a long enough period.
11.5.2007 3:54pm
A. Zarkov (mail):
This article from the National Center for Policy Analysis quoting from Lancet Oncology (2007 No. 8, pages 784-796) provides a comparison of cancer survival rates of the US, Europe, Canada and the UK. The US beats the European average for 13 of 16 specific cancers. The US also beats Canada for overall survival rate. Thus at least for cancer survival, the best current statistical evidence indicates that the socialized systems in Canada, Europe and the UK do worse than the US despite the large pool of uninsured in the US.

Now let's get political. In the last week of Oct. 2007 the Giuliani campaign put out a radio ad where Rudy quoted superior prostate cancer survival rates for the US versus the UK. Immediately the left wing spin machine went into hyper drive accusing him of making up numbers. Too bad for them as Giuliani's numbers are correct as they match OECD data, where the UK official statistics (used by the spin machine) are misleading as discussed by Gratzer (the original source for Giuliani). The newest study published in Lancet (see above) provides even more evidence that one is much better off getting treated in the US for prostate cancer than in the UK or Canada.
11.5.2007 4:17pm
Anon1ms (mail):
"The infant mortality rate for non-hispanic white mothers in the US exceeds that of Canada for all births. According to a 2002 table (you can google), the US ranks 27th for infant mortality, if you only include births to non-hispanic white moms, the US makes it to about 24th."

Then I guess the problem is that the United States is populated by too many non-non-hispanic whites.

As long as you are creating a new population for the United States, why not make up with a statistic that would take us to the top?
11.5.2007 4:22pm
Tom Cross (www):
cjwynes: I must be missing your point. You seem to be saying that it would be unfair to ask the taxpayer in Tennessee to cover these people. Thats what "the line has to be drawn somewhere" means, right? That if you don't stop somewhere the tax burden becomes unreasonable... unfair?

The alternative to the Tennessee taxpayer picking up the burden of these costs is that families like mine do. What you are saying is that you get to raise fairness as an objection when too much of the burden of the costs for someone else's healthcare is placed on your shoulders, but somehow this same objection cannot be raised by me when too much of the burden of someone else's healthcare is placed on my shoulders? Thats what you mean, right? You put the word fair in quotes as if its a concept that isn't real or something... as if you hadn't just used it as an objection in the previous paragraph.

No, my family does not have a choice. Healthcare savings plans do not provide coverage for catastrophic illnesses. Thats the point of insurance. Covering catastrophic illnesses is not like deciding whether or not the buy a car. You can live without the car.
11.5.2007 4:45pm
AnonLawStudent:
Tom Cross,

I hate to be the heartless one and break the news to you, but you have the option of paying for your family's healthcare. No one requires you to pick up your mother's medical bills. The fact that you choose to do so does not make it unfair. I would make the same choice, but it is still a choice, which is clearly distinguishable from having the taxman do it on threat of a prison sentence.
11.5.2007 5:08pm
JOe:
This thread has been one of the few rational discussions of how to compare socialized medicine with the US system of health care. There are lies, damn lies and statistics.
11.5.2007 5:25pm
Tom Cross (www):
ALS: The issue of fairness relates to the fact that if I want to buy health insurance for my mother I have to pay to subsidize a large number of other people's health insurance. On the other hand, you can purchase health insurance without making these same subsidies. By your own arguments the reason for this disparity is as much a product of government policy as the taxes you are complaining about.

I could recast your statement back at cjwynes and say the reason he has to pay sales tax is because he buys things. He doesn't have to buy things, and so how could the sales tax rate possibly be considered unfair?
11.5.2007 5:31pm
Tom Cross (www):
JOe: There are also actuarial tables.
11.5.2007 5:37pm
wfjag:
Tom Cross:

You also have some other options.

1. Tennessee is a long narrow state, and the surrounding states have programs with different standards than TennCare. Check those states which are within commuting distance and see what their pre-existing illness/conditions limitations are, and think about moving to another state and commuting to/from work.

2. By statute Congress requires that the various insurers that provide coverage to federal employees not include pre-existing illness/conditions exclusions. I have a spec needs child who is uninsurable under group and individual insurance policies, but is covered because I chose (after his diagnosis) to go to work for a federal agency. After he reached majority, I became his guardian, and that means that he will remain my dependent and remain covered under my insurance.

Tough facts require tough decisions. While you have my sympathy for being faced with tough facts, arguments based on "fairness" don't have my sympathy.
11.5.2007 6:44pm
Tom Cross (www):
wfjag: If fairness is not a reasonable objective of government policy than there is no reason to have a democratic government at all. The notions of justice, equal opportunity, and civil rights upon which modern western governments are based all flow from the concept of fairness. If these things don't matter, than all that is left is power, and if that's where we're at, there is no point in talking.
11.5.2007 7:35pm
cjwynes (mail):
Tom:

How about YOU pay for YOUR parents' health care, and I pay for MY parents' care?

The fundamental problem with ALL of these people who want the taxpayers to pick up all or part of the tab is that there's no logical reason that I or any other taxpayer should be considered responsible for it. I didn't make your mother sick, and neither did the guy down the street from me, but you want him and I to foot the bill for YOUR problem? How about I ask you to pay to fix my truck the next time it breaks down? I NEED it to get to work, and my NEED trumps your right to spend your own hard-earned money, right? It's not your fault that my truck breaks down, but apparently that doesn't matter, eh?
11.5.2007 7:41pm
Tom Cross (www):
cjwynes: Sigh... I don't want you to pay for my mother's health care. Do I really need to go back to the start of this thread and walk you though it again point by point?

What I would like to do is purchase catastrophic coverage for unforseen medical issues that have no relationship to her pre-existing condition at a market price that is similar to the price anyone who did not have her pre-existing condition would pay to cover those same unforseen medical issues.

No such product is available on the market.

I joined this discussion by responding to an assertion that no one in America is unable to access the health care that they need. That is not true. My mother has insurance, but only because the government requires insurance companies to make it available to her. If not for that rule, she would be uninsured, and could not cover the cost of a catastrophic unforseen health problem that is unrelated to her pre-existing condition.

I have further asserted that the price that I pay for that insurance is far larger that it ought to be, because *I* am paying for other people's healthcare, and the reason that I am forced to do so is because the rest of the state will not share the burden of paying for those people's healthcare with me.

I am not asking you to help me with MY problem. I do not want government assistance. I am asking you to stop forcing me to help other people in Tennessee that you yourself will not help. Do you understand the difference?
11.5.2007 8:05pm
Davide:
Tom,

Why do you think that your mother's risk of contracting other medical issues is not affected by her pre-existing condition?

Why do you think that someone who has a pre-existing condiction has the same risk level of contracting other health problems as a healthy person?

If you concede that the health risk is different (as it undoubtedly is), then why do you think she should be able to get catastrophic coverage for a market price that is "similar" to the price someone without the pre-existing condition obtains, even though the risk level is so different?

If you still insist she get the same coverage as the same price as a healthy person, that is a subsidy to her. Such a subsidy, I assume, has to be paid for someone. Who do you suggest to foot the bill?
11.5.2007 8:15pm
Tom Cross (www):
Davide,

Thus far everyone has been content to assume that assertion is true, and simply tell me that if I don't like it, I can eat cake instead of purchasing health insurance. I'm not absolutely sure that it is true, and I made the original assertion with reservations. However, there is a direct casual relationship between obesity and diabetes, and yet obese people can buy insurance. The price they pay is slightly higher than usual but it is no where near what one pays in a high risk pool. However, there is no relationship between diabetes and narcolepsy, or narcolepsy and leukemia, or leukemia and multiple sclerosis. While a very small percentage of people have multiple simultaneous health issues of this nature, obviously the vast majority of people who are effected by one of these issues are not effected by another. It seems most likely that there is no actuarial reason for this rule.
11.5.2007 9:34pm
Richard Aubrey (mail):
Obese people have far more orthopedic problems than non-obese people. In addition, many types of surgery are either more difficult (and more expensive), or not possible.
People with vision problems may fall or have other accidents at a rate exceeding those who can see well. Ditto those with seizure disorders.
Hypertension affects health issues in ways too numerous to mention.
Pre-ex is not a narrow concept, at least in some cases. It can be pretty wide in terms of increased propensity for other health issues.
Congestive heart failure will reduce peripheral circulation and lead to sores and such like. Which could become infected.
11.5.2007 10:35pm
Elliot123 (mail):
Fair? Did I hear someone complain that life is not fair? Does any adult here think life is fair?
11.5.2007 10:48pm
Eli Rabett (www):
This is nonsense. Yadayadayada, every possible nit being picked about infant mortality. Fact is that US infant mortality is so much larger than in advanced countries that even with the nits it still sucks.

So lets put it this way, can anyone find a public health statistic (longevity, infant mortality, etc.) where the US does well in comparison.
11.5.2007 11:09pm
Hoosier:
Eli--So would you say "Oranges are more orange than apples, even with all the nits picked"?

I'm just curious.
11.5.2007 11:13pm
Tom Cross (www):
Richard, yes, some conditions can cause complications. The question I raise is whether these risks can be underwritten. The question is whether a condition like narcolepsy, regardless of how mild or well treated, is sufficient to make it absolutely impossible to underwrite the individual for any other medical problem, and puts them in the exact same risk catagory as someone with a malignant tumor. This doesn't seem logical to me. However, a person who, for example has had a bout with depression, cannot purchase an individual health plan on the open market in the US at any price as far as know. Any individual plan offered that person would be due to a government requirement.

Now either it is possible to underwrite these people, at least some of them, and the market hasn't tried to offer that, or something prevents the market from trying.
11.6.2007 2:23am
A. Zarkov (mail):
Rabett"

"This is nonsense."

Try again. You can't ignore the substantive differences in the definition and measurement of infant mortality including was it means to be an "infant."


"So lets put it this way, can anyone find a public health statistic (longevity, infant mortality, etc.) where the US does well in comparison."


Yes. See my post on cancer survival rates.
11.6.2007 5:31am
markm (mail):
"Ooh, I'm gonna start insuring my house against fire that way. What could possibly go wrong?"

What you could do is to buy insurance with as large a deductible as you could possibly afford to cover, which will give you substantially lower payments, then invest the money you saved from the payments. As that account grows, you can keep raising the deductible and lowering your insurance payments.

If it weren't for all the government interference in medical markets, this would work even better for health insurance - because most medical expenses are relatively small, so insurance rates can drop much faster as the deductible rises, and because your odds of requiring expensive treatment in any one year start out low and then increase as you get older, matching the growth of your medical savings account.
11.6.2007 8:22am
Richard Aubrey (mail):
Tom Cross. Insurance policies are built around underwriting. The state insurance commissioner has to approve every policy for sale in the state.
Some problems are complicated and combine the potential for high expense and low occurrence and the law of large numbers ceases to apply.
In my state, Blue Cross has been taking individual applicants without underwriting for years. They have a six-month pre-ex exclusion while other stuff is covered, and then pick up the pre-ex. The HIPAA-mandated insurer of last resort was not necessary. Blue Cross seems to be making money at it.
Maybe it's lack of imagination. Or an excess of regulation.
11.6.2007 8:38am
markm (mail):
The real problem with universal health care is that if it's implemented in a politically-popular fashion in this country, it will buy the same gold-plated care that Americans with "good" insurance programs get and costs will be virtually unbounded. Doctors will try to avoid liability by testing not only for conditions you are likely to have, but also for the 0.01% chances. Doctors will prescribe expensive new patented drugs that are no more effective than the old generics, because neither the doctor nor the patient pays. Hospitals will perform heroic rescuscitations to keep 97 year olds breathing for a few more days...

And then when it gets so expensive that the taxes to support this program become unsupportable, the government will have to start rationing care - probably after first trying to control costs in even more destructive ways. Dictate that there will be only 1 MRI for every x00,000 people, and initially MRI costs decline while inconveniencing patients only a little, but then somehow the ratio of patients to machines keeps increasing until there are long waiting lists just to get the scans doctors need before starting treatment. Cutting down on doctor's fees has seemed to work for a while in other countries, but as the profession becomes less lucrative doctors retire earlier and fewer young people make the huge investment of time and effort to become doctors, so after a couple of decades severe shortages appear in medical manpower. A governmental agency can dictate drug prices that pay for the marginal cost of producing drugs, but not for developing new drugs - and this is true in most of the world now, so USA health consumers are paying for most of the world's drug development. Cut prices here, too, and there will be few new drugs.

We really don't have to follow the UK's lead in rationing health care by, for instance, having several month waiting times before cancer treatment starts (that is, saving money because patients are dying even before they're treated). But the easiest way for this to go politically is to follow the same path that led the UK to that.
11.6.2007 8:44am
markm (mail):
My solution: a two-tier medical treatment system.

The top tier is privately-paid health care similar to what we have now, but without the tax provisions that so grossly favor employer-provided insurance over individual insurance. Make it possible for anyone to open a Health Savings Account. Money you put into your HSA is free from all payroll taxes, and interest on the account is tax free, until you die and then the remainder can be taxed before it is added to your estate. You can then buy any kind of health insurance you want with HSA money, as well as paying for care directly.

You can buy inexpensive insurance covering just catastrophic expenses and pay everything else directly, or if you like wasting money you can buy conventional pays-almost-everything insurance. If you want to spend the money on better health and can stand the lack of privacy, you can even hire a medical group to monitor your eating, exercise, etc., giving you monthly individualized advice on how to improve your health, and re-adjusting rates depending on how well you are doing. (Does anyone remember that the "M" in "HMO" was supposed to stand for maintenance?) Or you can simply stack money up in your HSA and hope that it will be sufficient when you get really sick - if it isn't, you slide down to the lower "universal" tier of care.

In the lower tier, any citizen can get care at taxpayer's expense, but costs are strictly controlled:
-- Means testing is done after, not before, care is supplied. If you're making enough money, you'll have to repay care you received, in full or in part. Age and assets are also taken into account, according to formulas that don't drain retirement funds.
-- Malpractice suits are banned. There is an administrative system similar to workman's comp that will give limited awards if medical providers fouled up, but there are no jackpots. (This system is also available for privately-funded care by agreement between the patient and providers.)
-- Doctors only request the tests that are likely to pay off, are required to prescribe generic drugs whenever possible, keep hospital stays as short as possible, etc.
11.6.2007 9:08am
Philip F. Lee (mail) (www):
I believe there is a considerable difference between the life expectancy of residents of the Northern U.S. and the Southern U.S. Some part of that difference, at least years ago, resulted from infectious diseases present in the South that were rare or non-existent in the North.

It isn't clear to me that we don't have some residual effects from such diseases. Southerners face more violent weather than Northerners, too. Relative poverty, and its effects independent of being able to afford health insurance, has an adverse effect on life expectancy on the South more than the North.

It would be an interesting comparison to make between Canada and the states bordering Canada of the various measures of health policy effects.
11.6.2007 10:57am
JOe:
Philip: Very good point on life expectancy based on the latitude of the resident - this phenomenma exists acros most of the northern hemisphere. The difference has been reduced somewhat over the last few decades but still remains - I suspect that is mostly a function of being causcasan and differences in diet.

Rabbit: This is nonsense."

Try again. You can't ignore the substantive differences in the definition and measurement of infant mortality including was it means to be an "infant."


"So lets put it this way, can anyone find a public health statistic (longevity, infant mortality, etc.) where the US does well in comparison."

Yes. See my post on cancer survival rates.

Rabbet: The purpose of the article was to point the misleading facts and the need to use reliable data and data using the same criteria - not those cited by advocates of either the socialized medicine crowd or the so called neocons.
Unfortunately, the advocates have over taken basic common sense analysis of the data.
11.6.2007 12:05pm
A. Zarkov (mail):
Everyone seems to have missed a looming change in medical technology and the implications for medical insurance: genetic testing. It's here. According to today's WSJ, in a few months any consumer can buy a genetic profile for an out-of-pocket cost of $2,500. The free market libertarians should take special note of the implications. Even if we can prevent insurance companies from demanding you get a profile as a condition for selling you insurance, individuals can get profiled and keep the results confidential. Those with high risks will certainly sign up for medical insurance. Those with low risks will either elect high deductibles or forgo insurance altogether. Those with good genes and the discipline for the proper diet and exercise will have an especially low risk except for accidents. Such informational asymmetries will eventually have a profound effect on the economics of medical insurance. Eventually the insurance companies will learn that most of their customers are high risk and set their rates accordingly. Thus it won't matter much if the law prevents the companies from requiring a profile. The high risk people will demand that the government regulate the industry until it goes out of business or create a universal, taxpayer funded, national health insurance mandating everyone join. Of course the government could make genetic testing illegal, in which case the vendors will simply mover offshore. All you need to do is mail them a saliva sample. One way or another, we are headed for national health insurance.
11.6.2007 1:02pm
Eli Rabett (www):
Let us see, the National Center for Policy Analysis, a truly disinterested bunch

"The National Center for Policy Analysis (NCPA) is a nonprofit, nonpartisan public policy research organization, established in 1983. The NCPA's goal is to develop and promote private alternatives to government regulation and control, solving problems by relying on the strength of the competitive, entrepreneurial private sector. Topics include reforms in health care, taxes, Social Security, welfare, criminal justice, education and environmental regulation."

not. Kind of like the Rudy Guiliani of think tanks.
11.6.2007 11:53pm
wfjag:
Tom Cross wrote:
wfjag: If fairness is not a reasonable objective of government policy than there is no reason to have a democratic government at all. The notions of justice, equal opportunity, and civil rights upon which modern western governments are based all flow from the concept of fairness. If these things don't matter, than all that is left is power, and if that's where we're at, there is no point in talking.

I'm not unsympathetic to your situation. But, I am unsympathetic to "fairness" arguments. "Fairness" is completely subjective as a standard, and almost always is based on who (else's) ox is being gored.

"All that is left is power" without fairness? Mao wasn't completely wrong about the source of political power. Then again, neither was Ayn Rand. Then again, neither was SEN Russell Long ("Don't tax you. Don't tax me. Tax that man behind the tree."). To secure greater benefits from the state for my son, I've gotten together with families who also have special needs family members and gone to our state rep. (Together we represent several hundred votes, which is enough to swing a local election, and he listens to us and has worked hard and successfully to expand benefits and secure funding.) I've never used an argument based on "fairness" with him -- rather, the arguments are based in fact (these are the services sought, this is the estimated cost, these are the projected benefits, and these are the estimated potential income and taxes by providing the services which will directly or indirectly promote work opportunites for persons who otherwise would only receive services (and, estimated savings of tax dollars by reducing the need for those services for people who don't work at all). Those facts and estimates, coupled with a few hundred potential "single issue" voters, are quite effective. And, of course, we're in contact with other families else where in the state, who do the same with their elected representatives.

The examples you cite show the elusive, ever-changing, subjective nature of "fairness." The founding fathers did not establish a democracy, they established a republic. They feared the potential of demagogues. They were classically educated and well familiar with the history of places like Athens. The Electorial College and election of Senators by state legislatures were to curb that. And, the franchise was extended to adult, white, male, free-holders. "Fair"? I guess that depends on whether you're an "adult, white, male, free-holder", or someone who believes that others would more likely vote for you.

The "civil rights movement"? I'd suggest you start with the dissenting opinions of the first Justice Harlin, who had been a slave owner. He didn't find the words "separate but" in the Constitution. When the Civil War Amendments were ratified, it was "common knowledge" that Negros just weren't able to compete on an equal basis with people of European ancestry, and so needed paternalistic protection against themselves and people of European ancestry who would take advantage of them. The same Congress that ratified the 14th Amendment also enacted laws for DC decreeing segregation. Jim Crow laws in the South, and similar de jure discrimination in the North, were justified in the best Progressive Language of the time. Justice Holmes, highly regarded even today as a great progressive thinker and writer, believed in eugenetics - racism "based" on the best (pseudo)science. We managed to get the "separate but" part down pretty well, but never managed to get the "equal" part. LBJ punched thru the Civil Rights Act of 1958 over the opposition of Senate Democrats (primarily, but not exclusively) from the South, and Senate Republicans because he wanted to run for Pres. in 1960. At least some of the Republicans went along hoping that that would split the Democratic Party, and lead to a permanent third party of Dixiecrats, so that the Republicans would be the largest party in Congress and elect the Presidents for many years. President LBJ pushed thru the Civil Rights Act of 1964, in part motivated by his running for President. For the Democratic Party to hold onto the South in the 1966 elections, he pushed thru the Voting Rights Act of 1965. So, are we talking about "fairness" or very hard-headed self-interest by a master politician? I strongly recommend Prof. Caro's multi-volume bio of LBJ.

"Justice"? Again, it really depends on your point of view. As an example, take "equal protection". Is Affirmative Action really de jure equal protection, or is it necessary because for so many decades constitutional law was mucked up by inserting "separate but", and that was taken advantage of by people who benefited significantly by that? 50+ years after Brown, should local, state and federal governments be still permitted to discriminate against those who do not qualify for Affirmative Action preferences and programs because the US Sup Ct mucked up intrepreting the 14th Amendment for so long? What is the "fair" position?

I'm unsympathetic to "fairness" arguments since they are inherently subjective and gloss over important facts and the interests of those effected by decisions based on such arguments. "The road to Hell is paved with good intentions." Or, to paraphrase Thoreau, when someone approaches you saying how much good he's going to do for you, turn and run away. When it is in my self-interest to join with you to "Tax that man behind the tree" I will happily do so, and convince others to do so, based on their self-interest. But, don't expect any mention of "fairness" (well, except in press releases. It's a nice buzz word, and reporters don't seem to want to be over-burdened with facts to report).
11.7.2007 7:37pm
A. Zarkov (mail):
Eli Rabett:

Do you actually think that your comment provides a rebuttal? Those comparisons come from Lancet, not from NCPA. Direct access to Lancet requires a subscription. You can easily find another source for the same information if somehow you think NCPA has falsified Lancet's numbers. The issue at hand is whether someone with prostate cancer stands a better chance of survival in the US medical system as whole than in the UK. If you have better data tell us. If you think Lancet's study is defective then tell us why. But you don't, instead you resort to an implied smear.
11.8.2007 7:01am