Healthy Nation

Kate Sheppard reads Foreign Policy on what makes a country healthy:

A lot of the key strengths come from policy initiatives: government-sponsored pre-work workouts in Japan; extensive, government-funded prenatal and natal care in Iceland as well as three months of paid professional leave for both parents; holistic social care in Sweden, which includes comprehensive health care and safer streets for evening strolls; and a high number of doctors per-capita in Cuba. The biggest threat to the health of three of the five they list: the importation of the American diet.

Kate's takeaway is that "even with a shiny, new, comprehensive, universal health care plan in place sometime soon, it's going to take a lot more to make Americans healthy." Mine is a bit different. Basically, insofar as we want to improve public health we should worry primarily about ways to improve Americans' diet and exercise and so forth. The case for reform of the health care finance system has more to do with the finance than with the health, we're talking about a redistributive reform that would give peace of mind to a broad swathe of the population that they could avoid illness-related financial catastrophe and would encourage labor market flexibility and entrepreneurship. There are ways for health care reform to make people healthier (statins, more aggressive prenatal and preventive care, etc.) but realistically health care systems aren't that important as a determinant of aggregate health outcomes and the case for reform is primarily about other things.

Photo by Flickr user Jeff Kubina used under a Creative Commons license

Comments

Watch a few minutes of Jerry Springer, you know, just as an experiment in social observation. His audience is fairly representative of the U.S. citizenry. Fat, dull and a fan of geeks. THESE are the people you're going to somehow steer into a healthier lifestyle?! HA, HA, HA! I suppose you could dangle a pole in front of their head (a la a mule and carrot) holding a carton of Marlboro and 6-pack of Budweiser and they might wheeze a few more feet than their usual trek to the fridge. All the screeds I read about deterioration of people living within a declining empire fit the U.S. in spades.

Posted by steve duncan | October 17, 2007 10:05 AM

While I take Matt's larger point here about lifestyle and related social policies, I think it would be a huge mistake for progressives at this juncture to cede to health policy anti-reformers the notion that current health and health-insurance arrangements are not significantly detrimental to people's health. Exhibit A in the counterargument: Why is the American Cancer Society speaking up with an ad campaign for health-policy reform? Because they believe tens of thousands of people are dying of cancer because of our health insurance and delivery system. Don't back down from that, Matt!

Posted by elle loco | October 17, 2007 10:14 AM

"Because they believe tens of thousands of people are dying of cancer because of our health insurance and delivery system."

Modern medicine has done little to stem the tide against cancers. A few have benefitted greatly, mainly due to luck in finding a target for specific medicines to work, but most end up killing you. I highly doubt that tens of thousands extra people have died due to lack of insurance.

Posted by JordanT | October 17, 2007 10:29 AM

Only 1 out of 3 Americans exercises

1 Out of 5 is morbidly obese.

In real terms, that's if you pass 10 Americans at any giving moment; 2 will be huge fatties while 6.6 of them don't do so much as take a mile walk a day. This isn't even accounting for those who are "overweight"

We need smaller portions, less calories, more exercise, and for the love of god get corn syrup out of our food supply (it's in EVERYTHING)

I'm glad my company offers a subsidized gym in it's main office. 35 bucks a month for a smaller sized private gym, a trainer/nutritionist on hand who will work out diets and exercise plans, and several classes thought the day. Although it's small, I don't see many people there at all, so it works for me for now. I think for most America's, time is a big issue. And when you're already stressed from a job, trying to slip in an hour at the gym seems even more stressful (but once you get started, it actually reduces stress).

Oh, and beer/alcohol doesn't make you fat if you exercise regularly. Alcohol calories are turned into acetate by the liver, then used directly as energy. It can't be turned into fat. Any real calories are negligible.

this could have the effect to burn less fat during a period of alcoholic consumption, as your body would burn the easiest fuel first, but if you say drink on the weekends and eat healthy, you'll never see a net gain in weight.

Posted by BudMan | October 17, 2007 10:33 AM

The picture is what's wrong with America: People on a street ... riding FUCKING STATIONARY BIKES. Comparatively few Americans would even consider something as beneficial (on many levels) as biking to work. We have a generation that views exercise as something that comes from a gym, not from daily activities; that water is something that comes from bottles, not from shared public resources, like streams and resevoirs (that are, in turn, affected by our actions).

My employer subsidizes exercise-related expense to the tune $500/annum ($300 after taxes). That can be applied to gym memberships, purchase of home exercise equipment, or, in my case, bicycles and bicycle parts. It's a benefit I happily avail myself of. But it's a palliative. At best.

Posted by Ut | October 17, 2007 10:40 AM

I highly doubt that tens of thousands extra people have died due to lack of insurance.

Posted by JordanT | October 17, 2007 10:29 AM
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I imagine millions of uninsured go without screening for a variety of cancers for which tests are available, especially breast, colon, rectal and prostate cancers. How many of those people die for lack of even the most basic, rudimentary insurance and unencumbered access to testing and screening?

Posted by steve duncan | October 17, 2007 10:41 AM

We have a generation that views exercise as something that comes from a gym, not from daily activities.
Posted by Ut | October 17, 2007 10:40 AM
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Ut, riding a bike to work in northern climates might be practical for 2/3 of the year. Try taking a 10-speed to work in the bitter cold with snow and ice on every navigable surface available to ride. That's to say nothing of the more temperate season's hard rains or storms. Once you are done with that vigorous trek does your employer have a locker room and shower to rinse off the sweat and road grime (40 minutes of pedaling when it's 90 degrees and 80% humidity does not allow for a mere changing of clothes and plopping into your office chair, does it?) before you start your work day? It's an admirable aspiration but I find an hour or two at the gym before or after work much more practical.

Posted by steve duncan | October 17, 2007 10:54 AM

While I take Matt's larger point here about lifestyle and related social policies, I think it would be a huge mistake for progressives at this juncture to cede to health policy anti-reformers the notion that current health and health-insurance arrangements are not significantly detrimental to people's health.

There is little evidence that expanding health insurance would significantly reduce morbidity and mortality. Other kinds of policy may be far more cost effective at improving the health of Americans.

Posted by Mixner | October 17, 2007 11:11 AM

The case for reform of the health care finance system has more to do with the finance than with the health, we're talking about a redistributive reform that would give peace of mind to a broad swathe of the population that they could avoid illness-related financial catastrophe and would encourage labor market flexibility and entrepreneurship.

Medical bill debt appears to be only a minor contributor to bankuptcy in the U.S. Most of the debt incurred as a result of illness is not medical bills, but general debt arising from lost income when someone who is seriously ill loses their job or needs to take time off work.

So there isn't much of a case for universal health care on financial-catastrophe-prevention grounds either.

Posted by Mixner | October 17, 2007 11:18 AM

Without commenting on the policies themselves, this is the kind of talk that makes conservatives and especially libertarians go nuts. Why is it the government's job to create programs to make people healthier. Why does everything have to be top-down? Individuality is put on the backburner.

Posted by Leo | October 17, 2007 11:19 AM

Well, Matt, there you go: Jordan and Mixner smugly dismiss the American Cancer Society's notion--and they can't even be bothered to look around for corroboration. (Jordan, in particular--dude, there have been front-page headlines THIS WEEK about declining cancer mortality. Get a clue.) Whereas if you Google "cancer uninsured," you can find a grab bag of reputable analyses within minutes that should curl their hair. QED.

Posted by elle loco | October 17, 2007 11:23 AM

Without commenting on the policies themselves, this is the kind of talk that makes conservatives and especially libertarians go nuts. Why is it the government's job to create programs to make people healthier. Why does everything have to be top-down? Individuality is put on the backburner.

Posted by Leo | October 17, 2007 11:19 AM
**************************

Individuality has led to a nation of fatties. And government decisions (zoning, road construction, walking/riding path construction) are never neutral. If they're building sufficient exercise infrastructure, you call it "top-down" nanny-stating. But if no room is suitable for it and there's no way to commute without motor vehicles, does that mean the govt is laissez-faire and people are being allowed to make their own decisions, uninfluenced?

Posted by aleks | October 17, 2007 11:30 AM

loco,

Well, Matt, there you go: Jordan and Mixner smugly dismiss the American Cancer Society's notion

I haven't said anything about "the American Cancer Society's notion," whatever that's supposed to be.

If you dispute something I said in my posts, then tell me what it is, and we can go over it. Be specific.

Posted by Mixner | October 17, 2007 11:30 AM

Mixner, the ACS is running a widely-noted and commented-on ad campaign that calls for broad, wholesale healthcare reform on the premise that our uninsured and poorly-insured population is dying from cancer measurably more often than the other 3/4 of us. If you didn't glean that general premise from the last three lines of my initial post above, then you aren't reading very closely, or at all. Maybe that's it!

Posted by elle loco | October 17, 2007 11:37 AM

I know nothing about government sponsored pre-work workouts in Japan, but I guarantee you they have almost nothing to do with Japan's health advantage v. America. Japan is healthier than us because they have less poverty and eat better.

People in America are living longer than they ever have, but we aren't as healthy as we might be. In particular, we have very high infant mortality among low SES people, and we have a high prevalence of risk factors for heart disease. The first of those is susceptible to improvement by the healthcare system partially, while the second is not. People eat badly and exercise too little. Those are personal choices. There is little the government can do about that.

Does anyone want to get behind a party whose platform is "get up and walk around you lazy asshole"? No one wants the nanny state telling them what they already know--they're fat and ugly. The government can undertake some reforms that make it easier and cheaper for people to live healthily: eliminate all subsidies for high fructose corn syrup inputs, encourage walkable development and mass transit, and encourage health insurers (and federal agencies) to continue educating people about this stuff.

MattY is right about the argument from health financing. We should help people cover catastrophic health expenses so that they aren't impoverished by a bad hand of life's cards, not because we can prevent any and all illness everywhere.

Posted by TimG | October 17, 2007 11:42 AM

What makes a nation healthy?

Well, certainly keeping certain people from wearing that shade of yellow-orange would go a long way toward creating a healthier nation ;)

Posted by DAS | October 17, 2007 11:47 AM

"I imagine millions of uninsured go without screening for a variety of cancers for which tests are available, especially breast, colon, rectal and prostate cancers. How many of those people die for lack of even the most basic, rudimentary insurance and unencumbered access to testing and screening?"

How many of those would have died at about the same time whether or not the cancer was detected? How many insured people aren't screened for the same cancers, just because they don't go to the doctor? Just because a cancer is detected doesn't improve the outcome of the patient. I'm saying that health care is important, but it doesn't impact life expectancy by nearly as much as fitness, proper diet, safe food and good sanitation. No amount of health care is going to overcome our poor fitness and diet.

Posted by JordanT | October 17, 2007 11:48 AM

Re: diet

Exhibit A as to why Americans are overweight: pop.

A friend of mine worked at the Toronto office of an American firm. He regularly traveled to the Buffalo and NYC offices for meetings, and was amazed that *everyone* drank soda when thirsty - as if there was something wrong with water. That's a whole lotta empty calories and refined sugars.

Posted by McKingford | October 17, 2007 11:48 AM

Mixner, the ACS is running a widely-noted and commented-on ad campaign that calls for broad, wholesale healthcare reform on the premise that our uninsured and poorly-insured population is dying from cancer measurably more often than the other 3/4 of us.

What kind of health care reform is the ACS calling for? (You say "broad, wholesale," but what does that mean in terms of the reform of coverage and funding?)

And what is the differential in cancer mortality rates based on insurance coverage? How big of a problem is this? You say "measurably more often," but a "measurable" difference isn't necessarily a big one.

Posted by Mixner | October 17, 2007 11:54 AM

Modern medicine has done little to stem the tide against cancers. - JordanT

I didn't hear the whole story, but NPR had a bit on how actually as of late modern medicine has made great strides in terms of cancer. I guess it depends on which kind of cancer, though -- and anyway, just 'cause someone's survived cancer doesn't mean they won't die of something else.

But, in particular, a lot of cancers striking children and young adults that were pretty much death sentances even 20 years ago are now often curable.

*

Re: riding a bike to work vs. the gym -- other problems with riding a bike to work: having to share the road with drivers who pretend not to see you (and thus can get you killed), having hoodlums beat you up on your way to work (happened to my dad on a bike trail when he rode to work) ...

the big problem with the "I go to the gym" approach to exercise, from what I've seen, is that people think that going to the gym is enough. IIRC, two hours every three days in the gym doesn't actually burn that many calories -- so if you go to the gym but are otherwise sedentary and still have a salad ("it's so healthy!") loaded with fatty dressing -- you won't loose weight.

OTOH, what regular aerobic exercise does is help keep your metabolism up (which, perhaps, is why many of us instinctively don't like it -- from an "in the wild" perspective, having too high of a metabolism is wasteful) ... so when you go to the gym regularly, even little things -- like parking a little bit further from your office* and walking a bit or having a slightly healthier diet -- make a bigger difference.

* there are many things in between being sedentary and being an exercise nut. part of the problem with we Americans is -- outside the political sphere where we worship "a pox on both of your houses" mealy-mouthed, split the middle exactly mushy centrism, much to our detriment as we shut out too many interesting and fruitful ideas but rather get stuck with stupid wars supported by all the moderate, serious people -- we are extemists ... we don't see any middle ground between being an exercise fanatic and being completely sedentary. OTOH, in many other cultures, the middle ground is the most common -- people might not be fanatic work-out nuts, but they do take a little bit of time to take a walk after meals, etc. ... which gets them off their asses and makes them much healthier than any extreme behavior would!

Posted by DAS | October 17, 2007 12:01 PM

I dunno, Mixner--go do your own homework! The hallowed, nonpartisan ACS's word is good enough for me (since I'm admittedly inclined to agree with their argument, anyway). I don't think their message is more prescriptive then the general notion that the wealthiest nation in the history of the world should somehow find a way to provide timely medical care (including cancer treatment) for everyone. Maybe that sounds absolutely insane to you. Anyway, like I said, go Google "cancer uninsured" and school up. Good luck with it.

Posted by elle loco | October 17, 2007 12:10 PM

Just because a cancer is detected doesn't improve the outcome of the patient.
Posted by JordanT | October 17, 2007 11:48 AM
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Please readers, don't take Jordan's medical advice.
There are reams of data corroborating the relationship between early detection of some cancers and their subsequent elevated cure rates. Then again, maybe I don't know what the hell I'm talking about. Maybe Jordan can cite studies indicating early detection and cure rates are mutually exclusive for such a high percentage of cancers that getting screened or tested for the presence of ANY of them is a waste of time and money.

Posted by steve duncan | October 17, 2007 12:22 PM

loco,
I dunno, Mixner--go do your own homework!

It's not my homework, loco, it's your homework. Your assertion, your homework.

steve duncan,
There are reams of data corroborating the relationship between early detection of some cancers and their subsequent elevated cure rates.

How do U.S. rates of cancer detection and cure compare with those of other countries?

Posted by Mixner | October 17, 2007 12:44 PM

Here's a paper by two University of Chicago health economists that evaluates the evidence regarding the effect of health insurance on health: What Do We Really Know About Whether Health Insurance Affects Health? (pdf)

The authors conclude:

We are left with the conclusion that health insurance can improve health but remain unable to say exactly which interventions related to insurance will do so most effectively. This uncertainty is even greater when we consider interventions directly targeting health or access to medical care as well as those aimed at expanding insurance. Expanding insurance is not the only way to improve health. There is no evidence at this time that would allow us to say whether money aimed at improving health would be better spent on health insurance or on inner-city clinics, community-based screening programs for hypertension, or advertising campaigns to encourage good nutrition, to name just a few possibilities.

Posted by Mixner | October 17, 2007 12:50 PM

steve duncan,
There are reams of data corroborating the relationship between early detection of some cancers and their subsequent elevated cure rates.

How do U.S. rates of cancer detection and cure compare with those of other countries?

Posted by Mixner | October 17, 2007 12:44 PM
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Hmmm, I guess the variables affecting that comparison are almost limitless. I'd have to have access to the research. How quickly do non-U.S. doctors and their patients respond to the detection? How aggressively? With what treatments? How many patients choose to forgo treatment altogether? What regimen of follow up and post-treatment detection is practiced? There may be enough differences between the U.S. and other countries to render the discussion an apples and oranges discourse.

Posted by steve duncan | October 17, 2007 1:17 PM

The assertation was that millions of Americans do not have their cancer detected early enough, and that leads to tens of thousands unnecessary deaths. My point is that I think we're overstating the power of modern medicine to treat cancer.

Take prostate cancer. The US has longer term survival from detection to death for prostate cancer compared to European countries. However, we test far more frequently than European countries and detect at an earlier stage. However, the end is all the same because the total outcome of the patient is unchanged. The longer term survival rate is only because we detected it earlier. If it's detected at 60 and you live to 70 that's a 10 year survival. If it's detected at 65 and you live to 70 that's a 5 year survival. However, in the end both people lived to the same age.

Please note that this viewpoint on the study is used by people in favor of a universal health care plan as an example of American waste in health care.

Posted by JordanT | October 17, 2007 1:43 PM

Hmmm, I guess the variables affecting that comparison are almost limitless.

You could start with the following data for the top 10 or 20 most common and/or most serious types of cancer.

1. Estimated incidence of the cancer in the national population. This may vary significantly between different countries, of course. For example, lung cancer incidence may vary dramatically based on the nation's smoking rate. Skin cancer incidence may vary dramatically based on the nation's climate.
2. Rate of detection/diagnosis.
3. Survival rate at 5 years after diagnosis.
4. Survival rate at some longer period after diagnosis (10 or 20 years, maybe).
5. Other metrics of the quality/effectiveness of treatment. This might include things like the amount of pain and suffering, or disruption to the patient's life, that the treatment causes.

Posted by Mixner | October 17, 2007 2:01 PM

I really hate the word "re-distributive." What's "re-distributive" about at least making sure everyone is protected against financial catastrophe from a health catastrophe?

The point of introducing national health insurance is not to make the public healthier. The point is to make sure everyone has health insurance. We can set the "deductible" (for "gap" or "supplemental" insurance, or self-insurance for the wealthy) wherever we want and think we can afford. Someday, we might feel flush enough as a country to bring it down some more. But gotta keep that private sector involved.

Posted by urbanlegend | October 17, 2007 2:08 PM

Re: Comparatively few Americans would even consider something as beneficial (on many levels) as biking to work.

Because most Americans have jobs that, in effect, forbid it by enforcing (even in the age of bsuiness casual) strict dress and hygiene codes than are not conducive to biking. I think we had this argument elsewhere a while back? Also to be considered: long commuting distances (bikes cease to be practical for distances greater than 5 miles); the need some people have to transport children to and from daycare during their work commute; the safety factor (most main highways are decidedly unsafe fro bikes, especially at dawn and dusk) and of course the fact the US has much more extreme weather (both with heat and cold) than much of Europe does.

Re: Medical bill debt appears to be only a minor contributor to bankuptcy in the U.S.

You are misinformed. Medical debt (meaning money owed to healthcare providers (directly to them or indirectly via credit card payments) is a major factor in at least 1/3 of all personal bankrupticies.

re: A friend of mine worked at the Toronto office of an American firm.

???
Toronto? There's not a dime's worth of difference between Canadian diet and exercize practices and US practices. We really shoudl be talking about North American diet and health here since Mexico is pretty much on the same page too, with adjustments for higher poverty rates.

Posted by Jonf | October 17, 2007 2:16 PM

I really hate the word "re-distributive." What's "re-distributive" about at least making sure everyone is protected against financial catastrophe from a health catastrophe?

Er, no health care system in the world protects its people against financial catastrophe from a health catastrophe. Most of the costs arising from serious illness are not medical bills, and the evidence suggests that "universal health care" would do little or nothing to reduce the size of this problem.

Posted by Mixner | October 17, 2007 2:21 PM

Jonf,

You are misinformed. Medical debt (meaning money owed to healthcare providers (directly to them or indirectly via credit card payments) is a major factor in at least 1/3 of all personal bankrupticies.

Evidence, please.

Posted by Mixner | October 17, 2007 2:23 PM

What's "re-distributive" about at least making sure everyone is protected against financial catastrophe from a health catastrophe? - urbanlegend

Maybe the word is bad politics (because of the degree to which financial elites control the terms of our political discourse) -- but it sure is re-distributive.

Somewhere in our society there are the resources to pay for health-care. But I, e.g., as an individual do not have those resources (even to pay for decent insurance). That means the resources must be re-distributed, at least in case of if I (keynanhora) get very sick.

I stand by "re-distributive" as the right word. For now, at least.

Posted by DAS | October 17, 2007 2:46 PM

Re: Most of the costs arising from serious illness are not medical bills, and the evidence suggests that "universal health care" would do little or nothing to reduce the size of this problem.

Obviously that means we need to vastly improve our disability payments system too. I'm sure you'll support that? But first ytinmgs first: let's fund people's basic healing then we can address their income needs during the convalescence period.

Re: Evidence, please.

A study I read back in 2005. It was critical of claims that medical costs accounted for over 1/2 of bankruptcies (a figure being widely floated at the time) and pointed out, as you note, that this included loss of income and even funeral costs. However when you also include medical bills that have been charged on credit cards and home equity lines then it turns out that about 1/3 of personal bankruptcies (not including business BKs obviously!) involve principle debts, and the accrued interest thereon, that are at least 50% or more from a healthcare source. Such sources includes physician bills, Rx, hospital bills, ancillary healthcare services (radiology, labs etc.), skilled nursing care, ambulance transport, durable medical equipment and rehabilitation costs-- but not lost income, funerals, childcare etc.

Posted by JonF | October 17, 2007 7:47 PM

Jonf,

Obviously that means we need to vastly improve our disability payments system too.

No, it doesn't mean we "need" to do anything. It means that universal health care would probably not significantly reduce the problem of illness-related bankruptcy, and therefore cannot be justified on those grounds. Matthew's claim that universal health care would "give peace of mind to a broad swathe of the population that they could avoid illness-related financial catastrophe" just isn't supported by the evidence.

A study I read back in 2005.

What study?

This 2006 study found that medical bills are a contributing factor (not necessarily the biggest factor, just one factor) in only 17% of personal bankruptcies. The authors cite other studies with similar findings. I am not aware of even a single study supporting your claim that "Medical debt ... is a major factor in at least 1/3 of all personal bankrupticies."

Posted by Mixner | October 17, 2007 8:03 PM

I am not aware of even a single study supporting your claim that "Medical debt ... is a major factor in at least 1/3 of all personal bankrupticies."

But the article you link to is an (apparently unpublished/un-peer reviewed) paper reexamining the data/methodology of a study published in the Health Affairs Policy Journal which found that 54.5% of personal bankruptcies in the US are illness-related.

Does that not count?

Posted by Dave White | October 17, 2007 8:36 PM

Dave White,

"Illness-related" could mean that someone didn't work because of illness, and because of that, they fell behind in their bills. If that's the case, this isn't something that health insurance prevents.

Posted by Juan | October 17, 2007 8:41 PM

Dave White,

But the article you link to is an (apparently unpublished/un-peer reviewed)

It was published in Health Affairs, the same journal that published the other study you mention.

Does that not count?

No, it doesn't. That study doesn't support Jonf's claim either. Moreover, a large majority of the bankruptcy cases cited in that study applied to people who had health insurance when they became sick, which is also evidence that expanding health insurance is unlikely to have much effect on the rate of illness-related bankruptcy.

Posted by Mixner | October 17, 2007 9:00 PM

Fair points all around, just scanned through both articles. 17% is still nothing to sneeze at, though I likely wouldn't quite describe it as a "broad swathe" either. To be honest, though, as JonF hints, the evidence that universal health insurance does not prevent against illness-related bankruptcy seems more like a call for universal federal disability insurance (ala France) than a call against universal health insurance.

I'd be curious to see a similar study where the sample was limited to those without health insurance; the Millenson article indicated that the 17% of medical expense-related bankruptcies were closer to poverty level, not sure how strongly that correlates to "uninsured." (Maybe that's in there somewhere, or someone knows of a study).

Posted by Dave White | October 17, 2007 9:38 PM

Dave White

To be honest, though, as JonF hints, the evidence that universal health insurance does not prevent against illness-related bankruptcy seems more like a call for universal federal disability insurance (ala France) than a call against universal health insurance.

The evidence that health insurance does not prevent against illness-related bankruptcy isn't a "call" for anything. It is evidence against the premise of Matthew's argument for universal health insurance. If the premise is false, the argument fails.

Whether we should expand disability insurance to the level needed to fully compensate for income lost due to disability or illness, or at least to compensate for lost income sufficiently to prevent bankruptcy, is a separate issue. I can't imagine this would be remotely feasible politically. As far as I'm aware no presidential candidate has proposed it, not even those furthest on the left.

Posted by Mixner | October 17, 2007 10:18 PM

I say "a call" only in so much as that evidence caused me to consider the problem in a different light, and to ponder different approaches to a problem universal coverage apparently doesn't solve. Though I suppose flexible bankruptcy law itself may be solution enough.

Maybe I'm revising Matthew's point, but I don't think the premise is entirely false. Do you know of any studies comparing the medical cost-related bankruptcy rate of the insured vs. the uninsured? If catastrophic financial ruin is a disproportionately larger concern for those without insurance than those with (not to say it wouldn't be somewhat of a concern for all) then a system in which fewer and fewer people are insured (such as the one we currently have) would be problematic, in part, because of the swelling ranks of those faced with higher risk of financial ruin as result of unmanageable medical expenses.

That is to say, just because those with health insurance are still at risk for illness related bankruptcy doesn't necessarily demonstrate that health insurance itself doesn't help prevent catastrophic financial ruin for a broad swathe of the American public.

Posted by Dave White | October 17, 2007 10:42 PM

Dave White,

That is to say, just because those with health insurance are still at risk for illness related bankruptcy doesn't necessarily demonstrate that health insurance itself doesn't help prevent catastrophic financial ruin for a broad swathe of the American public.

It does help. It just doesn't help very much, based on the evidence we have. See the D&M study for details. So expanding health insurance probably isn't a cost-effective way of addressing illness-related financial risk. Other policies, such as greater limitations on the availability of easy credit, would probably produce a greater reduction in risk at lower cost.

Posted by Mixner | October 17, 2007 11:00 PM

I'm sorry, I just don't see that evidence in this study as it doesn't seem to deal with the issue of uninsured vs. insured health-related financial risk. It actually barely mentions the uninsured.

This article (referenced by the D&M study) does deal directly with the issue, finding that 60% of the uninsured had problems with medical debt, compared with 35% of those with insurance. The study also indicates that of those 35%, many are underinsured (no Rx coverage, high deductible, limited care coverage). All of which would lead me to believe quality, full-coverage insurance helps reduce the risk of medical-related financial problems a lot more than you're giving it credit for.

Greater limitations on easy credit would certainly help limit financial risk in general, which I imagine would lead to fewer medical related bankruptcies (though I'd like to see some direct evidence. Do you have any?). But nothing in the D&M paper convinces me that insurance itself isn't a more effective way to directly target the problem of illness-related financial risk, which is the argument Matthew made originally.

(Or I should say, part of the argument, as he also included the financial benefits of a health insurance system not tied to employment).

Posted by Dave White | October 17, 2007 11:45 PM

Dave White,

This article (referenced by the D&M study) does deal directly with the issue, finding that 60% of the uninsured had problems with medical debt, compared with 35% of those with insurance.

You're moving the goalposts. The claim was that universal health insurance is important because it would allow a "broad swathe" of the American population to "avoid illness-related financial catastrophe." I think the D&M study, and the other research they cite, is strong evidence against that claim. The effect of universal health insurance on "illness-related financial catastrophe" would likely be small, and other policies could probably achieve the same benefit at lower cost.

You're now making the weaker argument that universal health insurance would merely reduce the number of Americans who have "problems" or "difficulty" with medical bills. Well yes, it probably would, but presumably you'd agree that mere "difficulty" with an expense is a much less serious problem than "financial catastrophe." Lots of people have difficulty with all kinds of expenses. Rent, mortgage payments, car payments, credit card payments, and so on.

And let's run your numbers to see just how big a difference universal health insurance would make with this issue. About 15% of the population is uninsured, and 85% is insured. 60% of 15% is 9%. 35% of 85% is 30%. So that's 39% of adult Americans who report having a problem paying a medical bill. So if we had universal health insurance, the share of Americans who would have a problem (not necessarily a serious problem, let alone a catastrophic one; just a problem of some kind) paying medical bills would drop by a whopping 4%, from 39% to 35%. Not exactly a compelling argument, in my view.

But you also say that you think there's a problem with underinsurance. So you're apparently proposing not merely to provide all the currently uninsured with health insurance coverage equal to the average of today's insured, but to raise the average level of coverage too. How much is this all going to cost? And what level of coverage are you proposing to provide, exactly? Enough to eliminate the problem of "difficulty" with medical bills entirely? Or what?

Posted by Mixner | October 18, 2007 1:01 AM

The goal posts have been moved, you're right, though I think out of necessity––I have yet to see a study comparing bankruptcy rates of the insured vs. the uninsured (that D&M article isn't it). Do you have one? (I also don't necessarily think "financial catastrophe" has to equate with bankruptcy.)

That 4% drop is definitely small, but the difference in economic security of the insured vs. the uninsured is big. For that reason, it would behoove us to develop a system by which the rate of insured individuals is sustainable and as close to 100% as possible, as the fewer the number people we have with insurance the more people we have at greater risk of medical-related financial difficulty. 85% of the current population may currently be insured, though that number is certainly dropping, and is definitely not sustainable.

You may have a more cost effective way to maintain a sustainable rate of healthy Americans and, if so, I'd like to see it. From what I have seen, universal health coverage is the best bet.

All this said, do you really not believe that having quality health insurance makes people healthier and/or improves their economic security? I ask for personal reasons, mainly: I'm a self-employed writer in NYC making less than $25,000 a year with asthma and a family history of heart disease. I'm a non-smoker, active and within my weight range. My COBRA benefits from my previous employer expire at the end of January, at which time I will have to decide whether to go without insurance or pay for a costly individual plan that could potentially require me to move (likely to a more dangerous neighborhood) in order to afford it. Would it really be in my best interest to simply not get health insurance? I ask in sincerity.

Posted by Dave White | October 18, 2007 1:49 AM

Dave White,

Matthew's claim was that universal health insurance would prevent "financial catastrophe" for a "broad swathe" of the American population. The evidence I have cited strongly suggests that this claim is false.

Your new claim is that universal health insurance would reduce the incidence of "difficulty" or "problems" in paying medical bills for what turns out to be (using the figures you provided) a mere 4% of the population. That is obviously a much lesser benefit than preventing "financial catastrophe" for a "broad swathe" of the population.

There is no evidence that expanding health insurance would be a more cost-effective way of reducing mortality and morbidity than other kinds of policy. See my post of 12:50pm for a study on this issue. Note the authors' conclusion that I quoted.

I can't really speak to your personal situation. My point is that there is no real evidence that expanding health insurance is a cost-effective way of improving health and reducing premature death for the population in general, and no real evidence that universal health insurance would significantly enhance economic security. There are good reasons to think that other kinds of policy targetted at disease prevention and healthier living (anti-smoking measures, promotion of better diet and exercise, etc.) would produce greater benefits at lower cost.

Posted by Mixner | October 18, 2007 3:41 AM

Matthew's claim was that universal health insurance would prevent "financial catastrophe" for a "broad swathe" of the American population.

But that's not really Matthew's argument. Matthew's argument had to do with the increased risk of financial catastrophe associated with not having adequate health insurance. He is "talking about a redistributive reform that would give peace of mind to a broad swathe of the population that they could avoid illness-related financial catastrophe and would encourage labor market flexibility and entrepreneurship." You've narrowed it down to the actual rate of financial catastrophe (or difficulty, etc.) across the entire population which is obviously much lower than that rate of those to whom that risk is troublesome.

The key phrase is "peace of mind." It would be ridiculous for me not to get health insurance, no matter what my personal situation, in large part due to the increased risk of financial catastrophe (I imagine you yourself are insured, and for good reason). The "broad swathe" is thus the percentage of uninsured and underinsured persons for whom the risk of financial catastrophe (from bankruptcy, to having to take out a second mortgage to pay for cancer treatments, to not being able to send your children to college because of multiple sclerosis) is disproportionately higher.

Being well insured, according to the "Seeing Red" article, is absolutely a safeguard against medical related financial insecurity. Developing a system by which everyone is is well insured is, therefore, a worthwhile goal toward eliminating a "broad swathe" of the public suffering from increased risk of financial catastrophe.

Posted by Dave White | October 18, 2007 7:55 AM

This should read..."which is obviously much lower than that rate of those to whom that risk is disproportionately troublesome."

Posted by Dave White | October 18, 2007 8:29 AM

Dave White,

But that's not really Matthew's argument.

No, it is exactly Matthew's argument. He said that universal health insurance "would give peace of mind to a broad swathe of the population that they could avoid illness-related financial catastrophe." That's a direct quote.

Your new claim that universal health coverage would merely reduce the "difficulty" of paying medical bills for a small fraction of the population is obviously much weaker.

The key phrase is "peace of mind." It would be ridiculous for me not to get health insurance, no matter what my personal situation, in large part due to the increased risk of financial catastrophe (I imagine you yourself are insured, and for good reason).

Huh? The increased risk to you of financial catastrophe from not having health insurance is small. You're at low risk of such a catastrophe whether you have insurance or not. So why would it be "ridiculous" for you to not get health insurance?

Being well insured, according to the "Seeing Red" article, is absolutely a safeguard against medical related financial insecurity.

It's as if you've forgotten everything we've been discussing. Being well insured is absolutely not a safeguard against medical related financial insecurity. Safeguarding against medical related financial insecurity would require insurance that goes way beyond coverage of medical bills. Most importantly, it would require insurance against most or all lost income due to illness, and no health care system in the world does that.

Posted by Mixner | October 18, 2007 2:26 PM