Why we need universal health insurance in one reasonably brief blog post.
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The Gospel According to Jon (Cohn)
17 Oct 2007 05:21 pm
Comments (22)
Cohn's argument (1) just doesn't address the basic question. If, as seems likely, other policies would produce a greater improvement in health at lower cost than expanding health insurance, why shouldn't we pursue those other policies instead? Cohn asserts that universal coverage will "at some point" save more money than it costs. But even if that's true (and he offers no evidence that it is), that still isn't an argument for pursuing expanded health insurance over more cost-effective alternatives.
And his argument (2) is an empirical claim for which he again offers no evidence. Bankruptcy studies strongly suggest that the influence of health insurance on health-related financial risks is modest.
Here's a nonempirical argument: We can argue over how to do universal heath coverage along any number of policy vectors--but one overarching a priori principle is that, at this point in the history of medicine, government, and civilization in a wealthy nation such as ours, IT'S THE ONLY FUNDAMENTALLY MORAL APPROACH TO HEALTH POLICY.
Cohn writes,
(3) Although I'm a pretty unrepentant liberal, I tend to be skeptical about government's ability to change people's behavior.
This is a very strange statement for an unrepentant liberal to make. Does Cohn really believe that the dramatic decline in the rate of smoking over the past 30 or 40 years has little or nothing to with government anti-smoking policies? (higher tobacco taxes, public information campaigns on the dangers of smoking, increasing restrictions on smoking in public places, etc.)
For a dissenting opinion, check out the second post by "dtohmatsu" in the comments section of the Plank post. He/she lays out a pretty good argument. I don't know too much about the underlying issues, but liberals should address his/her criticisms.
"Megan would probably argue that the savings I anticipate are illusory, making it impossible to really cut down on spending without sacrificing innovation, worthwhile high-tech medicine, and such. I disagree -- but that's a debate I'll have to have with her another time."
In other words, let's just skip right over the main issue in our proof. With that standard, I could prove all sorts of utter nonsense.
Re: As I noted in a couple of the posts below, this is sillier than the Laffer crap peddled by the right. You'd have to be a complete fool to believe it.
Except that its has worked in every country that has tried it. Do you suppose that the laws of economics, or maybe even basic arithmetic, are somehow different in the USA?
Re: Bankruptcy studies strongly suggest that the influence of health insurance on health-related financial risks is modest.
Bceause much of our health insurance is inadequete so that even people who think they are well-insured end up bankrupt if they fall seriously ill or are seriously injured. Moreover your bankruptcy studies err in looking only at direct medical debts; they ignore the fact that many people charge their medical bills onto their credit cards (or sometimes HELOCs) first and only later go bankrupt under the weight of that high interest debt. If you take that into account about a third of all personal bankrupticies involve health care debt.
Jonf,
Bceause much of our health insurance is inadequete so that even people who think they are well-insured end up bankrupt if they fall seriously ill or are seriously injured. Moreover your bankruptcy studies err in looking only at direct medical debts; they ignore the fact that many people charge their medical bills onto their credit cards (or sometimes HELOCs) first and only later go bankrupt under the weight of that high interest debt.
No, they don't ignore that.
If you take that into account about a third of all personal bankrupticies involve health care debt
You made this same claim in the other thread. Actually, your claim there was even stronger. You said that health care debt is a "major" factor in "at least" a third of all personal bankruptcies.
I asked you for evidence to support this claim. You haven't responded. I'm asking you again. Show us the evidence.
Mixner,
It's time for you to start your own blog if you don't already have one. Your posts on health care and health insurance in demonstrate a grasp of the facts and a level of rational thinking missing in liberal bloggers like Matt and putatively conservative/libertarian bloggers like Megan.
This is a very strange statement for an unrepentant liberal to make. Does Cohn really believe that the dramatic decline in the rate of smoking over the past 30 or 40 years has little or nothing to with government anti-smoking policies?
One could rightly be skeptical in the manner described while acknowledging that government sometimes is quite effective in changing people's behavior (but not usually). Or, perhaps what the author means by "skeptical" is that he doubts the results typically realized by government behavior modification efforts are worth the price -- even if said results are measurable and substantial.
If, as seems likely, other policies would produce a greater improvement in health at lower cost than expanding health insurance, why shouldn't we pursue those other policies instead?
a) Why is this an either or? The evidence looks pretty overwhelming that improved hygiene and better infections management will save lives. We certainly ought to pursue this course of action. But why can't we also get everybody insured?
b) Megan makes the mistake of reducing the case for universal healthcare to a question of saving lives. But I support universal healthcare primarily because I think its successful implementation will give most Americans an increase in quality of life. I think at heart the argument for universal health care is one of utility maximization.
Jasper,
One could rightly be skeptical in the manner described while acknowledging that government sometimes is quite effective in changing people's behavior (but not usually). Or, perhaps what the author means by "skeptical" is that he doubts the results typically realized by government behavior modification efforts are worth the price -- even if said results are measurable and substantial.
Smoking causes more than 20 times as many premature deaths in America as inadequate health insurance. Poor diet and exercise, another 20 times as many. Motor vehicle accidents, around 1.5 times as many. And many other features of our lifestyle and environment contribute far more to poor health and premature death than inadequate health insurance. Even a small reduction in the rate of smoking would prevent more premature deaths than providing adequate health insurance to everyone. It therefore seems unlikely that universal health insurance would be a more cost-effective way of improving Americans' health and longevity than targetted interventions to reduce smoking, or adopt healthier diets, etc. Keeping people healthy is in general a much more cost-effective approach to health than trying to fix them after they get sick.
Why is this an either or? The evidence looks pretty overwhelming that improved hygiene and better infections management will save lives. We certainly ought to pursue this course of action. But why can't we also get everybody insured?
Every spending decision involves a choice. We can spend the next dollar on health insurance for Joe Sixpack, or we can spend it on discouraging tobacco use. It seems likely we'll get much more bang for that buck if we spend it in the second way.
Megan makes the mistake of reducing the case for universal healthcare to a question of saving lives. But I support universal healthcare primarily because I think its successful implementation will give most Americans an increase in quality of life.
How would it do that, exactly? There's little evidence that it would improve health much, and there's little evidence that it would improve economic security much.
Except that its has worked in every country that has tried it. Do you suppose that the laws of economics, or maybe even basic arithmetic, are somehow different in the USA?
You are joking, right?
Every country that has tried universal health care has had their health care costs go UP, not down as Jon Cohn idiotically states.
Take Canada, where Medicare was passed in 1966. In 1966, health care costs were 5.9% of GDP. By 1970, they were 6.9% of GDP.
Or take Australia, which passed its universal health care in 1973. Health care costs went up from 5.3% of GDP in 1973 to 7.0% of GDP in 1975.
So it is clear that ignorance of the facts is rampant on the left. The only thing I can conclude is that the push for universal health care among the left wing is simply borne of ignorance.
And, pathetically, you have idiots like Jon Cohn who are pushing proposals so foolish that it makes rightwingers pushing the Laffer curve nonsense look abolutely brilliant in comparison.
Every country that has tried universal health care has had their health care costs go UP, not down as Jon Cohn idiotically states.
Take Canada, where Medicare was passed in 1966. In 1966, health care costs were 5.9% of GDP. By 1970, they were 6.9% of GDP.
Or take Australia, which passed its universal health care in 1973. Health care costs went up from 5.3% of GDP in 1973 to 7.0% of GDP in 1975.
Cohn doesn't deny health care costs will go up, he says "over time universal coverage should reduce the cost of health care relative to what it might have been."
This source has Canada, from 1970 to 2003, going from 7% of GDP to 9.9%, Australia going from 5.4% to 9.2%, and the US going from 7.0% to 15.2%, by far the largest spike in any country.
Health care costs are going to rise worldwide, no matter what the system, as new technologies are developed, etc. However, there's certainly evidence that those costs will rise less in countries with universal health care. At least that's what has happened historically.
I think the idiot liberals promoting universal health care as a way to control relative health care costs are on safer ground than the idiot conservatives and their Lafferism.
Dave White,
When you consider how much we spend on health care versus other first world countries, you have to consider how much they free-ride on our R&D. The M.D. Anderson Cancer Center in Texas, for example, spends more on cancer research in a year than all of Canada does.
Also, the market prices Americans (or their insurance companies) pay for drugs finance much of the R&D for American and foreign pharmaceutical companies alike.
There's no question we could save money by instituting nationalized health care, slapping price controls on drugs, slashing reimbursements to hospitals, cutting physician and nurse salaries, and rationing care. But research into new drugs, equipment and procedures would slow to a crawl and most of us would end up with worse health care, including months-long waiting periods for cancer treatment. Whether it's worth doing is another issue. There's also the political question of whether America's politically-powerful elderly would settle for worse care than they get now, since most cost cuts would come out of their treatment.
There's no question we could save money by instituting nationalized health care...whether it's worth doing is another issue.
I agree with you here (though I think it is worth it, while I imagine you don't). I just think it's worth pointing out that the concept of universal health care reducing costs isn't some sort of pathetic and/or idiotic idea.
"I just think it's worth pointing out that the concept of universal health care reducing costs isn't some sort of pathetic and/or idiotic idea."
Clearly, if nearly all health care dollars are spent by the government in a nationalized system, and the government decides it's going to reduce the total amount it spends by x%, then you will reduce costs. But you will do so by rationing care and reducing incentives to discover new medical advances.
Of course, this assumes that it would be politically possible for the government to reduce spending in a nationalized system in America. As I suggested in my previous comment, this is unlikely due to the political power of our senior citizens and the high level of care they are used to. Considering the trajectory that Medicare spending has followed, it's unlikely that the U.S. government would have the political will to cut health care spending significantly, even if we had a nationalized system.
"though I think it is worth it, while I imagine you don't"
I don't think a nationalized or single-payer system is worth it at all, since it will do more harm (to R&D incentives and quality of health care) than good (in insuring the 15% of people here without health insurance). I would prefer more targeted approaches to dealing with the uninsured:
I don't think a nationalized or single-payer system is worth it at all
Oh I didn't mean to imply that I did either, just by citing Canadian statistics. Universal coverage (low costs and all) can be achieved without a single payer system, and single payer just wouldn't work here in the US.
Your list is actually a good start; I'd probably go further, especially with regards to pre-existing conditions. I think it's also pretty necessary to work on health plan portability.
Health care costs are going to rise worldwide, no matter what the system, as new technologies are developed, etc. However, there's certainly evidence that those costs will rise less in countries with universal health care. At least that's what has happened historically.
There doesn't appear to be any clear relationship between the rate of increase in spending on health care per capita and whether a country has universal health care.
See, for example, Exhibit 3 in this document. There is huge variation in the rate of increase among nations with universal coverage. And although the U.S. had the second highest rate of increase between 1980 and 2003, for the more recent period of 1990-2003, the U.S. rate is somewhere in the middle. Britain, Norway, Luxembourg, Ireland, Belgium and Austria all increased their per capita health care spending at a higher rate than the U.S. during this period.
And although the U.S. had the second highest rate of increase between 1980 and 2003, for the more recent period of 1990-2003, the U.S. rate is somewhere in the middle. Britain, Norway, Luxembourg, Ireland, Belgium and Austria all increased their per capita health care spending at a higher rate than the U.S. during this period.
As the article points out, that US growth rate from 1990-2003 slowed, in part, because the rate in 1990 was already so high. In 1990, the US was already at 11.9% of GDP, which is still higher than any other country is today. Those countries you listed had %s in 1990 that were just over half that of the US. It would make sense that growth would slow as it approached 15%-20%.
That said, it looks as though every country that has instituted universal health care has seen it's % of health care spending as share of GDP rise at a much slower rate than the US over the same period since the day those plans went into effect.
Dave White,
As the article points out, that US growth rate from 1990-2003 slowed, in part, because the rate in 1990 was already so high. In 1990, the US was already at 11.9% of GDP, which is still higher than any other country is today. Those countries you listed had %s in 1990 that were just over half that of the US. It would make sense that growth would slow as it approached 15%-20%.
I don't think that does necessarily make sense, but if it does we should expect further slowing of spending increases in the U.S. in the future. If the rate of increase in per capita health care spending is inversely correlated with the per capita share of GDP consumed by health care spending, then the rate of increase in other countries should exceed that of the U.S., because they spend a lower share of GDP on health care.
That said, it looks as though every country that has instituted universal health care has seen it's % of health care spending as share of GDP rise at a much slower rate than the US over the same period since the day those plans went into effect.
It doesn't look like that at all. Where is your data showing rate of increase in health care spending in countries with universal health care since it went into effect? Britain, for example, has had universal health care since the 1940s. Show me your data on health care spending in Britain since the 1940s.
Keeping people healthy is in general a much more cost-effective approach to health than trying to fix them after they get sick.
Without question you are correct in this assertion.
Every spending decision involves a choice. We can spend the next dollar on health insurance for Joe Sixpack, or we can spend it on discouraging tobacco use.
Or we can spend it on discouraging tobacco use AND spend another dollar still on health insurance for Joe Six pack. The choice to spend two dollars rather than one is still a choice.
How would it do that, exactly? There's little evidence that it would improve health much, and there's little evidence that it would improve economic security much.
I think the strongest evidence that Americans are not content with their healthcare delivery system is the simple fact that healthcare continues to register as one of the two or three biggest concerns raised in opinion polls. I find it hard to believe this is solely an issue manufactured by politicians. The reality is America is the only rich country where people face the possibility of being denied coverage because of pre-existing conditions, and children go with out preventative medical care, and millions of middle class citizens go without any coverage at all. And then there's the uniquely American phenomenon of insurance-related job lock, and the increasing competitiveness problems suffered by American employers because of health insurance costs. Some of these issues appear to be bleeding into US attitudes toward trade and globalization: American workers -- lacking the robust and effective safety nets enjoyed by residents of the rich world -- understandably have grown lukewarm in their support of trade and free markets. It would be very sad indeed if the country better poised than any other to exploit the benefits of globalization failed to do so because of ideological aversion to "socialized medicine."
American healthcare is often the best available anywhere on the planet -- but the system for delivering that healthcare is creaky, expensive, and woefully inefficient. I'm not one of those who wants the country to make a precipitous lurch into NHS-style single payer. But I think we are in need of major restructuring, and I can't imagine a set of substantive reforms that doesn't involve pushing the country toward universal insurance coverage, if only because any such scheme is likely to be unfordable without the participation of the young and healthy.
Jasper,
Or we can spend it on discouraging tobacco use AND spend another dollar still on health insurance for Joe Six pack. The choice to spend two dollars rather than one is still a choice.
Then you need to justify spending two dollars instead of one. If the argument is "Universal Health Care (UHC) is justified because it will produce benefit X" and the response is "Benefit X can be produced more cheaply with Policy Y" it doesn't make any sense to reply with "We should do both UHC and Policy Y." If you can achieve the desired benefit more cheaply using a different policy, why do UHC?
I think the strongest evidence that Americans are not content with their healthcare delivery system is the simple fact that healthcare continues to register as one of the two or three biggest concerns raised in opinion polls. I find it hard to believe this is solely an issue manufactured by politicians.
And I think the fact that UHC of various forms has been proposed for almost a century but has never survived the political process shows that there just isn't the demand for it that you would like to believe there is, and that it just wouldn't be nearly as beneficial (if it would be beneficial at all) as you think.
By the way, the rest of your post contains a number of factual assertions that simply are not true. For instance, your claim that "America is the only rich country where... children go with out preventative medical care" is just flat wrong.
Comments closed October 31, 2007.
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Heads in the Sand
Cohn: "But over time universal coverage should reduce the cost of health care relative to what it might have been, for a variety of reasons with which many readers here are by now familiar."
Hahahaha! As I noted in a couple of the posts below, this is sillier than the Laffer crap peddled by the right. You'd have to be a complete fool to believe it.
Posted by Al | October 17, 2007 5:39 PM