Wednesday, June 17, 2009

A Few Words On Health Care

In my use of the word "liberals" I should stress that I am refering to some sort of core liberal: a person who is not just likely to vote for Greens or Democrats because he thinks they are nicer, somehow, but a person who follows at least a handful of issues with some attention and comes out pretty regularly on the liberal side. Often I will use the term progressive for this. It is seldom a pure situation. Nearly everyone has an issue or two where we break ranks with our fellows, and a few more which we care less about than others in our political corner.

Progressives have for years advocated for some sort of universal health care, health insurance, socialised medicine, single payer plan of various designs. This has nearly always been portrayed in social and moral language - that they are ashamed or embarrassed to live in a country that does not have this, or that it is unfair that anyone be unable to get needed care. In my multipart series on liberal values I will be touching on this, and the weaknesses of those arguments (there are some strengths), but for now I have a different observation.

The argument has suddenly shifted to exclamations that we must have one of these national systems for economic reasons. That only some such system will save us money, which will in turn stimulate the economy which is in CRISIS. I don't believe them. They cannot have switched ground so quickly and completely. They still want this for the same reasons they wanted it five, ten, and thirty years ago. They are using the language of saving money in hopes of throwing a fast one past us. I dislike that on principle.

No doubt there are some progressives who were quickly convinced of this - some folks of any belief are easily persuaded by leaders. But I think most aren't. I think most are being sly. For a good cause, they think. In order to speak the language of conservatives and finally convince them on other grounds, perhaps. Good PR and all that.

But separating these two streams of persuasion allows us to look at both more clearly. And the second one is merely insane. Creating more jobs by creating nationalised health care is like saying "We can't pay the rent, so let's order out for Chinese." It's bizarre. There is a stretch at making a connection by tying it in to cost savings on medicine and procedures because of government contract and economy of scale. Or that old favorite, preventive care, which works great when you have a time machine, and have full benefit of retrospection, but in real time always costs more. Cutting out the waste will somehow make the whole economy more efficient, so there will be more left over - somewhere - for someone to hire someone else.

Yet this is the government. Even if they could legitimately find some places to streamline things and save some money, everyone knows that this is a government program. It is not going to ultimately cost less. It might do some other things that progressives like, such as guaranteeing care to people between jobs or getting dental care for lower-middle-class kids, but it is emphatically not going to save money, no way, no how. You know it. I know it. Obama knows it. If they could save money this way, they would have already done so with the VA and Medicare systems, because that would be a primo sales pitch.

All these great proposals where we could save money, if we just let the government do its thing are purely hypothetical. If everything goes according to plan, it will work. Dude. Not gonna happen.

What other similar countries spend and what they get for it is interesting and partially relevant, but never even a close match. We have a different legal climate that drives up costs. (It does some very good things as well, but it does drive up costs.) We have all the expensive equipment much more available here. It's much easier for a doctor to resist ordering an expensive test that is mostly precautionary when it is 50 miles away than when it is on the next floor above.


karrde said...

I think there is a dangerous blurring of categories between "insurance" and "care".

At least one M.D. blogger has gone through the maze that is insurance billing (and the not-paying-in-full system known as Medicare).

He convinced me that the last thing needed in medical care is more lawyers and more complexity in the billing process.

ELC said...

I think there is a dangerous blurring of categories between "insurance" and "care". Absolutely. One can hardly encounter a discussion of the subject in which the separate issues are not confused.

Dubbahdee said...

Your point about blurred terms is good, but easily understood. For most of us insurance is the portal through which we access care. When the only access to care is through the door of insurance, insurance becomes confused with "obtaining care."
The controversy occurs because some portals are wide and easy to use. Others are harder, and for some they really can't properly access care except in the direst of emergencies. It becomes not health care, but triage and trauma medicine.
The reasons for the differences in access do not always seem to be logical or helpful. And here is where a broader sense of economics and cost comes in. If we can consider roads and sewers (government projects all) as an investment in national wealth, a commonly held asset that benefits all, could we not also consider the aggregate state of health of it's citizens a similar sort of asset? If we can improve that state by providing an more effective portal available to a wider cohort of the population, one that is consistent and well designed to deliver care to the broadest segment of the population, would that not be a valuable investment?
Viewed this way, the issue is not some much cost savings as return on investment.
I know...I'm taking the side of the progressives here, eh? Skin me if you must but this is not a problem so easily dismissed.

copithorne said...

I saw an article recently about how the VA system has created cost efficiencies while producing the best outcomes:

The article notes that investments in information technology accomplished this.

My understanding is that liability insurance/torts are a pretty marginal costs. Wouldn't hurt to get it under control. But it is not the reason our health care costs twice as much as Europe's.

But basically I agree with the point of the post that short of single payer, I'm skeptical that any plan is going to make things cheaper.

karrde said...

When you refer to single-payer care, are you thinking that the recipient pays?

Or do you refer to a third party who has the opportunity to become the most powerful agent in the transaction?

copithorne said...

karrde, I am thinking of how health care is managed in the civilized world outside the United States.

And yes, increased centralized negotiating power is a powerful advantage of that approach.

Assistant Village Idiot said...

dubbahdee - if I thought it would work, I might be in favor of it. The collective health of a citizenry might indeed be a form of wealth for a nation. I don't think any of the universal insurance proposals get us there - I think there will be marginal improvement at best, with a risk of considerable deterioration. Weighed against that must be the loss of new techniques and medicines. While it is certainly not obvious that the US system would not produce improvements as well if we changed methods to something more like a European health care system, it is nonetheless painfully obvious that our current system has provided the bulk of medical improvements over the last fifty years. Risking the disappearance of that would be a high cost indeed.

Copithorne, you seem to have slid past karrde's description of the government being the most powerful player by reframing it. Yes, economies of scale are nice, and one can certainly drive prices of existing care down by government fiat on a temporary basis. But the other implication of karrde's statement, that the government will become the most powerful player, can you see no possible difficulties with that?

copithorne said...

AVI, sure there are severe difficulties for insurance companies and moderate challenges for doctors and hospitals and pharmacuetical companies.

But if the conversation is about driving down costs or finding savings, then the negotating power of single payer is just one of the virtues of that approach. It is a distant second behind the savings possible in replacing the agonizing administrative complexity of our current system.

Medicare is great at negotiating reimbursement rates. Too good even.

Assistant Village Idiot said...

Ah, I get it. You'd rather not answer.

copithorne said...

You started the conversation that Democrats/liberals were disingenuous in changing the rationale for health care reform by saying now it was necessary to save money.

In a short time, I have outlined four ways that true healthcare reform could save lots of money. Integrated MIS might save more than 10% and improve outcomes. Better negotiating power might save more than 10%. Reduced administration costs might save 20%. And I’ll throw in a package of tort reform and say maybe you’d save 10% on that. I’ve cut America’s medical bills in half!

But now it is you who is changing the subject. You won’t say what it is you are changing the subject to. But now, cutting costs is no longer the subject.

So, now, to turn the tables, we say that Republicans have always opposed health reform for the same reasons. They may make noise about costs, but that’s not it. What is the REAL reason that Republicans oppose health reform?

I know. Do you?

Assistant Village Idiot said...

So it's worse than I thought. You actually have fallen for the idea that they will be saving money. If you believe that, what the Democrats are promising makes eminent sense, of course. Everyone wins.

My original point was that the actual saving of money is in no way possible. Witness Medicare D, NCLB, and Homeland Security - all Bush programs, BTW, so I'm picking on government, not just Democrats. Everyone sees the low-hanging fruit at first and figures once they've fixed that they're halfway home for not much money. But it's the second half of the problem that's expensive, harder to solve, and government can't stop itself.

Even if you examine the numbers and conclude that there likely will be savings, modest or great, the question of "yet, what if it doesn't" remains to be answered.

As to the REAL reason Republicans oppose health reform, I would find your answer amusing. You have framed it as "opposing reform," which is campaign rhetoric. The reasons for opposition to these expansions are varied, so I would be curious how you bind them together under one vast mind-reading of their nefarious motives.

copithorne said...

You believe that Medicare Part D, NCLB and Homeland Security are health care reform?


I take Medicare Part D to be adding a prescription drug benefit for seniors. That's going to be expensive. Now, we could have done it cheaper if we empowered the government to negotiate reimbursement rates from pharma companies. But the Republicans nixed that idea.

We don't need to go far to demonstrate the power of this. Drugs in Canada are vastly cheaper than drugs in America. We'll do it the same way they do it in Canada and realize huge savings.

I credited your idea of tort reform. You said it was worth something. Now you deny it?

I provided documentation of the power of MIS investment in the VA system. You didn't respond. But if you look at the article, you can see how much sense that makes. Now, what if that MIS system was fully integrated into the single payer system?

And then, yes about a third of expenses in our health care system are UR offices interfacing with insurance company administrators. There is a completly unnecessary skull splitting complexity to our current sytsem. True single payer reform can all but eliminate that.

Now, from what I see true reform isn't quite on the table this year. But really, there is no intrinsic reason why our health care needs to cost twice as much as in every other country.

I understand that for Republicans, there is no health care problem and they have no health care solutions. I disagree.

Assistant Village Idiot said...

Thanks for not even making an attempt to understand. This is just nuts. I gave examples of government programs that turned out to be more expensive than planned - because that was my point - and you object that they are not health care. I, uh, knew that. You don't get it, and you don't see that you don't get it. Can't help you there.

copithorne said...

I guess if you don't believe it is possible to save money on health care in America you won't have any ideas on how to do it and you won’t be able to consider how it could be done.

That does seem to be the complete sum of what Republicans have to contribute to the conversation.

But the status quo is untenable and so we’ll have to press forward without you.

Dubbahdee said...

Ahhh...yup. Between you, you have managed to encapsulate the current state of national argument on health care.

It is fundamentally a philosophical difference. One side believes government is the only entity that CAN solve the problem. The other believes that government is the one entity that is incapable of solving the problem. This seems to me to be why you keep talking just past each other.

Are these truly parallel lines? Shall ne'er the twain meet?