The Sovereign Mind

Free thought on politics and real life

Posts Tagged ‘health care

How to Fix the Health Care Fix

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Now that health care reform is passed and signed into law, Republicans say they will try to repeal the law when they are back in power. Repealing isn’t going to happen, since it would take a super-majority that the Republicans won’t have for a long time. By that time the law will have become settled along side Medicare and Social Security. But, it might be feasible to adjust the reform, since even some moderate Democrats might come on board for that.

So, how would I fix the health care fix?

The way I see it, the main problem with the reform is its cost. If we could provide good insurance to all Americans without breaking the bank, I’d be all for it. The CBO scored the bill as a deficit reducer, but it also raised a number of questions about how the funds are raised, and whether the proposed savings could be realized. I won’t go into the details of that discussion since the argument has been laid out elsewhere.

We should keep the measures that seek to eliminate waste in Medicare. However, considering that Medicare is underfunded, the money saved from those measures should be used to extend Medicare’s solvency, not fund a new entitlement program. That blows a huge hole in the funding mechanism used to pay for this reform, so we’d have to scale back the bill’s spending. The bulk of the spending in the bill is for subsidies for people to buy insurance. Instead of subsidizing comprehensive health care insurance, we could pay only for catastrophic plans. For the poor who don’t qualify for Medicaid, the government would pay 100% of a catastrophic plan, which would include coverage for people with chronic illnesses. The subsidy would be on a sliding scale, with those making 400% of the poverty line not getting any subsidy. Of course, if we are only subsidizing catastrophic plans, we cannot mandate that everyone buy a comprehensive plan, so the mandate to buy insurance would have to be scaled back as well. Individuals would only be required to purchase a catastrophic plan.

Of course there are some objections that can be raised to my plan, but before I get to those, let’s look at some of the supporting points:

First, this plan maintains several of the positive aspects of the current reform, but with a lower price tag. Having everyone covered with a catastrophic plan would ensure that those who get diagnosed with serious illnesses do not get forced into bankruptcy due to their health status. We would not be paying for people to show up in the emergency room to get uncompensated care. People with chronic illnesses would not be denied supplemental insurance since care related to their condition would already be covered by their catastrophic plan.

Second, giving people the choice to buy supplemental insurance, or pay for preventive care themselves, will make them more cost conscious, thus reducing the cost of health care and reducing the demand for unproven treatment and technology, which the CBO says is a major driver of health care costs. To enhance this effect, I’d also support ending the tax exempt status of employer-based health benefits, but that can be a separate discussion.

Lastly, some people choose not to go to doctors except for in emergencies. Your or I might not agree with that lifestyle, but why should those people be forced to buy something that they will choose never to use?

Now, on to the obvious objection: subsidizing and mandating only catastrophic plans will leave some people without coverage for routine, preventive care. However, more prevention (at least the kind that you pay for) doesn’t actually lead to lower health care costs. Sure, treating someone with a serious illness is expensive, but so is testing millions of people who won’t ever get the illness. Of course, cost aside, most of us want to do what we can to avoid serious illness, but shouldn’t we be free to make that cost-benefit analysis for ourselves? However, it is true that there will be some lower-income Americans who want supplemental insurance to cover routine care, but can’t afford it. I’d love to be able to give them that coverage, but we simply can’t afford it. We support the poor in many ways through many welfare programs. In fact, we help the poor so much that the effective marginal tax rate can actually exceed 100%. We can’t afford yet another welfare program.

I doubt I’ve convinced everyone, but I hope I’ve at least helped the discussion get started. Many on the left will object to stripping out the generous subsidies, and many on the right will object to any proposition that doesn’t have the word “repeal” in it. So, it would be a tough sell, but hopefully most of us can agree that any “fix” to this health care fix has to be focussed on making it more fiscally sustainable.

Written by Mike

March 28, 2010 at 9:56 pm

How to Mislead with Graphs: Health Care Edition

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People don’t like looking at big tables of numbers, which is why people invented graphs. Looking at a graph can often make the meaning behind a large set of numbers become much clearer. However, we mustn’t confuse clarity with accuracy. A graph can make a set of numbers much more easily understood, but if those numbers don’t tell us the whole story, then the graph doesn’t either.

Recently, I came across this stunning graph. Take a few moments to absorb its beauty:

According to this graph, the measure of the goodness of the health care system correlates with the slope of the line. If the line goes up, that’s good, and the more it goes up, the better it is. If the line goes down, then… you get the picture.

Before I get to the criticism, let me say that I agree with the general point: health care costs too much in the US, and I believe we do need to do something about it. But scale matters. It matters whether we think the current system is so bad that we need to completely gut it and start over, or whether we think it just needs a few tweaks (for the record, I think it’s somewhere in between). Looking at this graph might lead you to believe that our system is entirely without merit and should be discarded immediately, so it’s worth considering whether that graph really does represent an accurate picture of the situation.

First, since we are to measure a health care system based on the slope of the line, that implies that there is some way to balance the value of lifespan against the value of dollars. The graph implies that every year of lifespan is worth about $200 a year for that person in health care spending. Is that about right? Is the relationship even linear? That’s a tough thing to measure, but that’s the implication of the graph. As a thought experiment, imagine that the average lifespan in the US was 85, putting us higher than any other nation. What would the slope look like? It would still be the most negative slope on the graph. But would our extra spending on health care be worth it then? Maybe. What if our average lifespan were 90? Would it be worth it? According to the graph, we would still be the most inefficient system, since our slope would be the most negative. To further illustrate the point, look at Mexico’s line. Their efficiency is pretty impressive. Should we be switching to their model? Thus we see the difficulty in trying to equate dollars with life-years, and we see that we can’t really judge the scale of our problem based on the slope of these lines, because the authors of the graph have arbitrarily decided how much a life-year is worth.

Second, looking only at the left side of the graph, we have to ask: why does health care cost so much in the US? Is it all just waste and inefficiency? Should we really be shooting to spend the average amount of $3,000 per person? It turns out that it may not be fair to compare countries in this way, because richer nations tend to spend more on health care. Of course that makes sense: if you have more money, you’ll spend more on everything. But the effect is even greater than that because if you have more money, you are likely to increase your health care spending by an even greater degree than other spending. The additional spending is less likely to have a major impact on life expectancy because of the principle of diminishing returns, but that doesn’t mean it isn’t worth it to the person doing the spending. In the US, we like our technology and advanced tests, even if that technology and those advanced tests only buy us a marginal gain over less expensive alternatives. Whether that is good or bad is a debate we ought to have (or better yet, let’s just let people decide for themselves), but the graph above ignores the question entirely. In addition, wealthier countries have to pay their medical professionals more, because there is more competition for high-skill labor. And the same principles applies to prices of medical supplies and pharmaceuticals, as I’ve described before. The bottom line is that you can’t just take the total spending per capita as a comparison between nations without considering all of these complicated and inconvenient factors that don’t fit so nicely into a pretty graph.

According to the report from OECD linked above, the US is overspending by $2,500 per person, when adjusting for our wealth. So, we’re still overspending, but by much less than the $4,000 depicted in the graph. To be a fairer comparison, you’d have to adjust the left-hand side of the US line down a good bit, thus decreasing the slope of the line quite a bit. Remember, scale matters.

Lastly, let’s look at the right half of the graph. I think it’s pretty obvious that health care spending is not the major factor in average lifespan. Sure, it is *a* factor, but not a major one. This graph itself is evidence of that. With lines crossing every-which-way, there appears to be almost no correlation (although of course there is some). It’s not a stretch to argue that a good portion of our lower lifespans is due to our unhealthy lifestyles and risky behavior. How much would our lifespans go up if Americans made the same lifestyle choices as Europeans or (better yet) Asians? Who knows, but it would certainly go up, thus decreasing the downward slope of the line.

So, am I arguing that we have nothing to worry about? Of course not. We need to reform our system to be more efficient and less expensive so that more Americans can afford it. But understanding the scale of the problem matters. It matters when figuring out how to fix it and what we are willing to sacrifice to do it.

Written by Mike

March 12, 2010 at 11:57 pm

Posted in politics, Uncategorized

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The Tragic Miscalculation: Where Democrats Went Wrong on Health Care

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Last August, as health care town hall protests broke out across the country, the Democratic National Committee issued a statement which included these words:

The Republicans and their allied groups – desperate after losing two consecutive elections and every major policy fight on Capitol Hill – are inciting angry mobs of a small number of rabid right wing extremists funded by K Street Lobbyists to disrupt thoughtful discussions about the future of health care in America taking place in Congressional Districts across the country.

However, much like we saw at the McCain-Palin rallies last year where crowds were baited with cries of ‘socialist,’ ‘communist,’ and where the birthers movement was born – these mobs of extremists are not interested in having a thoughtful discussion about the issues – but like some Republican leaders have said – they are interested in ‘breaking’ the President and destroying his Presidency.

Of course, hindsight is 20/20. As it turns out, that group of “right wing extremists” just won a senate seat in blue Massachusetts. Tragically, the Democrats underestimated the public discontent with health insurance reform from the beginning. Instead of downplaying and marginalizing the opposition, they should have taken it as a signal to moderate. Instead, they dug in even more, and that is tragic, not only for Democrats but also for the American people. Although I don’t support health insurance reform in its current form, I do want something productive done. Unfortunately, thanks to the Democrats’ fumble, we might have squandered our opportunity.

Written by Mike

January 19, 2010 at 10:19 pm

Why Does Health Care Cost So Much in the US?

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Matthew Yglesias cites an NPR prodcast exploring the question: Why does an MRI cost 10 times as much in the US as it does in Japan? (Note: I haven’t listened to the podcast but the same question is explored by NPR in text form here).

This question is a variant of one that has been asked before many times: Why does health care cost so much in the US, compared to other nations? Many times the assumed answer is that the difference is because of waste and excess profits in the system. While I don’t dispute that there is some of that, there are also many other logical reasons why health care costs differ from country to country. The argument from those who propose a single-payer system, or at least that we move in that direction, are based on the implied assumption that our costs would be as low as other nations if we would just mimic their system. That is not true because there are factors that influence the price that are completely independent of the health care system itself.

The two main components of health care costs are technology and people. Let’s look at each one individually.

Technology

The CBO estimates that the adoption of new technology is the leading contributor to rising health care costs. However, rising costs isn’t the question here. The CBO also says that health care costs are rising in all nations. The question here is not the increase in costs, but why there is a difference between costs in the US and elsewhere.

There are a number of reasons for this, some of which were touched on in the NPR article above. I want to explore one of them that also applies to the pharmaceutical industry. When NPR asked US doctors and hospitals why MRI machines cost so much less in Japan than in the US (emphasis mine):

Japan sets the price they pay for MRIs super low. And so to get into the Japanese market, the manufacturers lower their prices. They charge more here in the U.S. because we will pay more. How come? Well, I called a number of American hospitals and doctors and I got basically two reactions. The first and most popular: a shrug. We could never get those prices.

So, MRI manufacturers are selling the machines in Japan at a lower price than they are selling them in the US. Why is this? Maybe it’s the same reason that drugs cost less in Canada:

They are engaging in what economists call “price discrimination”–that is, charging different prices to different buyers of the same product. Price discrimination works in the drug industry because drugs are very expensive to develop, but fairly cheap to manufacture. As long as companies can recoup their research and development costs by charging high prices in the United States, they can make a profit in Canada and elsewhere by merely covering the cost of making the pill (or tube of ointment or whatever).

To restate, developing a drug (and I imagine the same hold true of advanced medical equipment like an MRI machine) the cost to develop the product itself is high. Once you have a design that works, you can crank them out on the assembly line relatively cheaply. So, if there is a market that is only willing to pay a certain price you can still make a profit by selling to them, but only if you have another market that you can sell to for more in order to recoup the cost of R&D. In other words, if the US set price controls for MRI machines like Japan does, or if Americans were not as wealthy and could not afford the high cost of the machines, there wouldn’t be any MRI machines because manufacturers wouldn’t be able to recoup the cost of R&D and therefore they would not be profitable.

We should not expect technology to cost the same in different countries. There are many factors that play a role in the cost, and this is just one of them.

People

The second major component of health care costs is people: doctors, nurses, lab technicians, and many other high-skill professionals. Health care is inherently a labor-intensive industry, and not just any labor: high-skill labor. According to the International Average Salary Income Database, general physicians and nurses in the US make about 75% more than their Japanese counterparts. Although the numbers for more specialized physicians aren’t listed, we know that in the US they make much more than general physicians and so the gap is likely to be even larger.

So the solution to our cost problem is simple, right? As one commenter on Yglesias’ post said (I’m not sure if he or she was serious): “force nurses, doctors and teachers to work a lot longer for a lot less money.” Not so fast. First, we need to look at the reasons why health care professionals are paid so much more here. Are they just more greedy? Well, how about we compare them to similarly educated professionals in other industries. The US pays a much higher price for high-skill labor across all industries, while the price of low-skill labor is comparable to other nations. This should come as no surprise to those familiar with the high and rising income gap in the US.

So what would happen if we force doctors and nurses to accept lower wages? Fewer post-grad students would choose to go into medicine, and instead would choose other paths such as law or dentistry. That would quickly lead to shortages of medical professionals, something already being experienced by nursing staffs. I believe one of the best ways we can combat this problem is improving our education system so that we produce more highly educated graduates to compete for those jobs, but that is a different discussion. The point is that, at least with respect to this contributor to health care costs, it is not the health care system that is the problem. The labor cost is driven by factors outside of the health care system that cannot be adequately addressed by health care reform alone.

Conclusion

Again, let me reiterate that I do believe there are steps that can be taken to lower the high cost of health care. However, comparing the cost of health care in the US with the cost in other nations exaggerates the problem since it does not take into consideration factors that are beyond the scope of the health care system itself, and some of which are not necessarily bad things. We should focus on reducing the growth of health care costs, but let’s not fool ourselves into thinking we can cut it by a factor of 10, or even that we should.

(I should note that I am doing some research on the side regarding the rising cost of health care. I was going to do a post, or a series of posts, in the future. I wanted to response to Matthew’s post, however, so my arguments in this post are a work in progress. Critique, as always, is welcome.)

Written by Mike

November 23, 2009 at 11:23 pm

The Next Best Thing for Health Care Reform

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As a supporter of the free market (although not a purist), I tend to prefer a solution to our country’s health care problems that enhances the advantages of the market, rather than places more government bureaucracy on top of it. But a bill that decreases government involvement in health care, rather than increases it, is about as likely to get passed as a white male was likely to have been nominated for Justice Souter’s seat on the bench. So that begs the question: if the conservative approach to health care reform is not viable politically, what is the next best thing we can hope for?

What about the much maligned status quo? Even critics of the reform proposals agree that our current system has problems, but would doing nothing be better than the current proposals? Even if some believe that to be the case, few politicians would admit it for fear of being labeled a defender of a broken system. But is the best option on the right to try to block reform and stall, in hopes of gaining political power in future elections, thus making a more conservative approach more viable? That might be tempting, but given the track record of Republicans on getting any major reform done in our health care system, I wouldn’t bet on that approach working out. A few of us are in the unfortunate circumstance of needing the liberals’ zeal to get something significant done and the conservative ideas to get the right thing done. It’s tough to have both at the same time.

What about a compromise approach? The Senate finance committee has recently come out with a bill that it believes to be more moderate than its counterparts. No public option. Less harsh mandates. Almost universal disapproval. Does compromise mean pulling in all of the best ideas from all sides, or the worst ones? In this case, we have none of the cost controls and all of the government bureaucracy. In an attempt to find common ground, it appears the finance committee has found no-man’s land. Worse still, if something along those lines passes, it is likely to give the impression that something has been done, when in reality nothing has been done except complicating the system even more. This impression is likely to cause real reform to be significantly delayed as we have an endless debate about whether the plan is really working or not (see the current debate about whether the stimulus is working).

How about this for the Next Best Thing for conservatives? Let the liberals’ plan pass. Yes, that’s what I said. Put in that strong public option and individual mandates. Punish those greedy private insurance companies and those evil employers that don’t provide insurance to their employees. Why might that be The Next Best Thing? Because when someone asks, “Why can’t I find a plan a low-premium catastrophic plan?” We can tell him that the government didn’t think that would be good for him. And when someone says, “I got laid off because my employer couldn’t afford the health insurance he’s mandated to pay for.” We can say, “Thanks for taking one for team.” Or when someone on Medicaid Advantage reports that their plan has been discontinued, and they are now forced to find another, we’ll just tell them they were part of the waste in the system that had to be jettisoned. Maybe then there would be more pressure to consider more conservative-minded approaches. (Or, maybe it would actually work. Either way, the American people win in the end.)

There was nothing like prohibition to solidify the idea that alcohol ought to be legal. Nothing like Vietnam to make the public wary of the casualties of war. Nothing like repealing Glass-Steagall to remind us of why it was there in the first place.

Does this idea sound good to me? No. I don’t want to see people in our country suffer. And it would likely take decades to undo the programs that would be put in place. I didn’t say it was The Best Thing. I suggested that maybe it is the Next Best Thing. If conservatives believe that liberal health care reform would be a harmful to our country, should they let the liberals prove it? Just a thought.

Written by Mike

October 23, 2009 at 10:03 pm

I Think We All Know Where It’s Coming From

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At one of Obama’s recent town hall meetings on the health care proposals, a questioner brought up the misinformation that is circulating in the debate:

You touched on this. I would like you to expand a little more. This problem with misinformation in our country, it seems to me that it’s not only just hurting health care reform, health insurance reform, it’s dividing our country. (Applause.) Is it not maybe time — I think we all know where it’s coming from.

Yes, we do. It’s coming from all sides. During that same town hall, as well as those that preceded it, Obama has been using the proposed Medicare Advantage cuts as an example of where we can eliminate waste from the system in order to pay for his plans:

So I’ll give you — let me give you one particular example. We right now provide $177 billion over 10 years — or about $17 billion, $18 billion a year — to insurance companies in the forms of subsidies for something called Medicare Advantage where they basically run the Medicare program that everybody else has, except they get an extra bunch of money that they make a big profit off of. And there’s no proof, no evidence at all that seniors are better off using Medicare Advantage than regular Medicare. If we could save that $18 billion a year, that is money that we can use to help people who right now need some help.

Medicare Advantage is a system in which seniors who would normally qualify for Medicare can instead buy private health insurance plans, and have some of the cost of that plan subsidized by Medicare dollars. In 2003, the system was changed such that private insurers are given a more generous subsidy to provide these services. It is mainly this change that has prompted the concern that tax-payers are lining the wallets of insurance company executives. That is a legitimate concern. However, it is clear that those additional subsidies have encouraged insurance companies to offer more attractive plans to seniors. According to the Congressional Budget Office:

In 2004, Medicare Advantage plans accounted for 13 percent of enrollment in Medicare, the lowest level since 1996. Over the past two years, however, enrollment in those health plans has increased to about 19 percent of all enrollment, or 8.3 million beneficiaries.19 That increase resulted from changes enacted in the Medicare Modernization Act that increased payment rates and added the prescription drug benefit to complement the medical benefits provided under Parts A and B of Medicare. CBO projects that enrollment in Medicare health plans will continue to increase rapidly in coming years, to 22 percent of total Medicare enrollment in 2008 and 26 percent by 2017 (see Figure 1).

So, the higher government subsidy to insurance companies resulted in more seniors seeking after these private plans. There’s a reasonable debate to be had to be sure we are using government money wisely. However, the debate has to recognize a simple fact: if increasing the subsidy caused more attractive plans to be offered to seniors, what will happen when the subsidy is decreased? Will private insurers still offer those same plans as the same premiums to seniors? Reason says no. And yet, there’s this oft-repeated line from the President: “If you like your health care plan, you keep your health care plan.” Unless it’s a Medicare Advantage plan. Then all bets are off.

Some mock the elderly for statements such as “Keep your government hands off my Medicare.” It is true, that statement doesn’t express the frustration well, but the underlying concern is a real one. Maybe, before mocking, we should think about the fact that these people have been around many decades, and maybe have learned a thing or two about how government works. It turns out that, despite the patronizingly reassuring words that are used to try to calm the elderly on this issue, they have good reason to be concerned. If this is Obama’s example of an “inefficiency” in the system, what else might there be?

Written by Mike

August 29, 2009 at 10:34 pm

Paul Krugman vs. Paul Curtman

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Paul Krugman, nobel prize winning economist, says that the people protesting at health care town hall meetings are anti-American and amount to a mob.

Tell that to Paul Curtman:

Our country was founded on freedom, not politeness.

For those who might be tempted to brush off his criticism, please read The Federalist #41, written by James Madison, known as the Father of the Constitution.

Written by Mike

August 8, 2009 at 6:25 am