Wednesday, July 1, 2009

Health Care: It's Not About Money (Part 2)

posted by Armadillo Joe

Just like
last week, I'm still arguing with that guy on Facebook. Here's the latest exchange:
corporate lawyer/former high-school debater:

When you were talking about the economics, you dropped the inflammatory rhetoric and the ad homs. When you got back to the moral arguments, you started shouting and accusing again. Why is that?

Whether the US government should adopt a single-payer system for health care is not a moral issue, it is a public policy issue. It's an economic question: how much should the gov't tax people, and how much should it pay for their health care?

If you have a single-payer system, then the government will still have to make decisions about what to pay for and how to apportion the money it spends on health care. People who can't afford to pay for additional coverage still suffer and die in systems with government as a single-payer. You seem to imagine that if the gov't is paying, then everyone will get all of the care that they need, but when pushed on that you say you don't imagine everyone will get cradle-to-grave care for everything that affects them. You can't have it both ways.

The unavoidable fact is that resources are scarce, which means decisions must be made about how to apportion them. I get that you want to have the government raise taxes (or borrow money today, then raise taxes on future generations) and use more money on paying for health care. That's fine. I disagree with you that this is the best public policy, or that it will even have the great results you imagine.

The point about DDT is simply this: I think it is bad public policy to ban DDT when it could be used to effectively eliminate malaria-carrying mosquitos and thereby save hundreds of thousands of lives annually. You disagree with me. I don't think that this disagreement makes you an amoral, parsimonious tree-hugger.

The language of morality shouldn't apply because it obscures and inflames the debate. It should be possible to disagree about how governments should spend and regulate without attacking the character of those who disagree.

Armadillo Joe:

Shouting? Ad hominem? Please. This is a spirited exchange of ideas. If I was shouting - I'D BE USING ALL CAPS.

That said, however, please refrain from trying to bait me by disingenuously including a flashpoint like DDT, because we both know that a debate over its use has raged across the political spectrum for decades. Inserting a reference to it is not value-neutral, it is a red-herring that deliberately chums the water.

Also please, stop attaching claims I've never made to my viewpoint via hedging phrases like "you seem to imagine..." then attacking that characterization instead of the specific claim I advance: the definition of a straw man argument. As much as you may wish that I had claimed everyone would get ALL the care they EVER need in life from cradle-to-grave if only the stoopit gov't would just pay for it, because that would be easier for you to rebut, I never did. I'm not a hippie-dippie moonbat imagining a world with no possessions, pining away for a money-free utopia.

Yes, people suffer and die and single-payer will not end that. I'm not trying to have anything both ways. I never claimed that universal coverage was a panacea but a government safety-net can moderate that suffering for the purpose of social stability and distribute the burden of the costs to promote the general welfare. And furthermore, I ask you, how is government bureaucrat making decisions about apportionment any different or worse than the current collusion of income-based rationing with insurance company bureaucrats operating under a steep financial disincentive to provide effective care? Any amount of nationalized health-care -- however mediocre for those who need to use it -- is still 100% better than no care at all and has proven elsewhere in the world to be better than the uneven, unfair, inefficient, often dangerous and grossly expensive system we enjoy now.

France spends half of what we do per capita on health-care and they not only get universal coverage for that money, but also cheaper drugs, lower infant mortality rates and greater life-expectancy. Those who want more coverage (and can pay for it) do so and almost everyone in France so chooses, which has resulted in a robust and very profitable private health-care sector parallel to and largely integrated with the public one. However, those who can't pay anything at all at least have a third option besides death or economic ruin when faced with mounting medical bills. The social instability engendered should that kind of human suffering metastasize should be easy to imagine.

And, finally, you dismiss the use of moral language as obscuring and inflammatory, but I posit that as long as the debate remains a dry, measured exchange of policy prescriptions -- as though we're debating a change in library hours at a town council meeting rather than mitigating preventable suffering -- we ignore to our peril the deeper structural inequities in American life as embodied in our broken health-care system. Moral language clarifies the stakes, whereas your framing of the issues -- trying to make it about nothing more than policy and economics -- obscures the deepening supremacy of this issue in so many American lives.

Policy and economics are but tools, means to an end. Morality is the impetus.

Thus, what you characterize as impugning the character of the opposition is in fact a reaction to complacency -- whether from apathy or smugness or fear or parsimony -- in the face of overwhelming evidence for action.


Matt Osborne said...

Where's my kudos button??

Ed Darrell said...

Not only a red herring, but a false herring at that.

[quote]The point about DDT is simply this: I think it is bad public policy to ban DDT when it could be used to effectively eliminate malaria-carrying mosquitos and thereby save hundreds of thousands of lives annually. You disagree with me. I don't think that this disagreement makes you an amoral, parsimonious tree-hugger.[end quote]

It would be difficult, but not necessarily bad public policy were it true that DDT could be used to effectively eliminate malaria-carrying mosquitoes. But that is not accurate: DDT cannot, by itself, nor in general broadcast use, stop malaria; nor is there a ban on using DDT to fight malaria.

You're right that this horse has been flogged unnecessarily and unmercifully. I think your opponent's use of the example shows a disregard for science and history both, and that of course is a major problem with most debates with people who cannot be persuaded by the facts of the situation.

Good luck.

Ed Darrell said...

I regret I haven't looked at the whole discussion y'all have had, and I apologize if I'm being redundant, but there are a couple of things that should be considered, especially with regard to costs of the entire system.

First, we're spending nearly a quarter of every "health care dollar" on private insurance programs that are designed to make sure no one gets free medical care. For the amount we pay to figure out how to keep people from getting care they didn't pay for, we could easily provide gold-plated insurance policies for every uninsured person in America, including illegal aliens and wandering terrorists, and still have money left over. The question is, since resources are limited, should we allow so much money to be used to frustrate medical care and line the pockets of insurance company executives instead of providing medical care? Let's discuss the real economics, please.

Second, you mention France, wisely. A few years ago I did a study for a major American corporation on health care policy and competitiveness, and a couple of things popped up of interest. Among industrialized nations, the U.S. is lowest in annual visits to the physician per patient. Under the screwed up system we have, insurance executives call this a great victory.

In Canada, people tend to visit their physician about twice a year. As a consequence, all preventable disease rates are much lower in Canada than the U.S. -- especially heart disease and cancer. Also, diseases are caught earlier, treated more effectively and for much less money. So Canada gets a double whammy for health care spending we do not get, where people are encouraged to stay away from health care until diseases are progressed to the very expensive and perhaps untreatable point.

Most other industrialized nations have even more visits to the physician. In France, people visited on average four times a year. Lower disease rates, quicker treatments, cheaper treatments, better outcomes. My recollection is that only Israel beat France, with six annual visits per patient. Similar good results.

We need to change the structure from discouraging people from seeing a doctor, to encourage them to go early and often. That's a corner we can't turn without law, I fear.

[More, next post]

Ed Darrell said...

[continued from previous post]

Third, we need to be clear: No private insurance company is anywhere nearly as effective and efficient at handling claims as is the federal government. When I did the study for that corporation, it cost the best U.S. insurance companies $7.50 every time they touch a claim -- and the average claim required three people to review it before paying. In contrast, the claims-handling branch of HHS, processing Medicare and Medicaid claims, paid $0.75 per claim. Per claim.

I understand costs have rocketed in HHS, and it now costs almost $3.00 to process a claim. Meanwhile, costs in the private sector have doubled. I suspect your friend can't do the math (or he would have already) -- that's about $3.00 per claim on the government side, up to $42.00 a claim on the private side.

Do you know how much medical care we could deliver for the $39.00 difference?

Single payer or not, the most important thing we could do is make sure that health care is not rationed by wallet biopsy. Forcing real competition into the system, making the private companies work as efficiently as the government, would be another huge cost saver.

Who says we need to raise taxes to pay for it?

Fourth -- and this is particularly poignant this year -- one of the major competitive advantages foreign car makers have, and almost all foreign manufacturers who compete with U.S. manufacturers have, is they don't have to count health care costs in the price of their products. Not only do we pay a lot more and get a lot less for our health care dollar, it cripples our competitiveness. Last time I looked, critics of unions noted that U.S. cars cost up to $1,000 more each, just to cover health care costs. In Japan, that number is $0. Zero yen, too. Same in Germany. Same in France and Italy. Same in Sweden, and Britain, and Korea. Same in China.

Opponents of single-payer health care plans, or opponents of getting the government to expand coverage to all residents of America, should be forced to detail why they hate U.S. automakers so, and why they wish to put that burden on U.S. exports when we so badly need to boost exports.

Policy and economics are tools. People discussing them should not act like tools, however.

Armadillo Hussein Joe said...

Ed -

Wow, thank you for all of that ammunition. I have been ramping up by health-care arsenal because I was ill-prepared when this whole discussion got started on Facebook. It was an off-hand comment linking to an article which resulted in a wolf-pack jumping down my throat. Within a few hours, I was researching stats and anticipating objections from his side. To this point, I have been fighting him somewhat defensively only because I never expected to be embroiled in this discussion.

That said, I hadn't considered coming back at him with the salaries and bureaucracy expenses when he whines about resources. Thank you for that.

Second, where are your numbers on this issue? Are they online and linkable? At this point he will either give up and this fight is done for now (possible but not likely, former High School debaters/corporate attorneys don't like to lose or be bested by anyone, especially a wild-eyed hippie) or he will come back in another day or so. When he does, I want to have more stuff to throw at him. I'm not an expert on anything, just an informed citizen with a grudge.

Third, as to your point about car manufacturers, don't hate U.S. automakers, they hate autoworkers and their pain-in-the-ass labor union. This one is an old fight -- going back to the days when Walter Reuther was head of the UAW and the most hated leftie the right had in the 1950's and 1960s' -- and because these people are perpetually stuck in the past, they can't get away from a pathological hatred for autoworkers that they inherited from their intellectual ancestors. The origins of it are clouded in mystery for them, like Hatfields and McCoys, because they are ignorant of history. But that history is still, in a word, present.

Thanks again for everything. I will copy and paste the comment discussion up to now on this blog so that you can experience the sheer stupiduty of what I've been arguing against up to now.

Ed Darrell said...

When I did the study, I had access to the corporation's balance sheets and insurance agreements, and bids from other insurance companies. I also was just a couple of years out of the Senate staff on the old Labor and Human Resources Committee, where we worked those issues. It was -- then -- easy to pick up the phone and get the figures. Since then most of my contacts on the committee have moved on to lobbying positions (though David Kessler, David Sundwall and Toni Novello stayed in public service mostly). When I left the company, I left the footnotes.

I've seen a couple of cost comparisons on processing fees in the current discussion, but I didn't bookmark 'em. I'll see what I can dig up, but they're out there.

The international comparisons on health care have been available in several different sources constantly -- but I'm not sure they're easy to get on-line. Take a hard look at recent GAO audits and reports, and see if you can find the pirated papers from the Congressional Research Service online.

Was Robert Reich the last one I heard discussing the health insurance problem in international competition? If so, his articles are available at his blog.

I'm not helping you out much on documentation, but the fact is that there is no documentation from your opponent's side to support his claims. He's assuming no cost savings -- as are the conservative CBO estimates, mostly -- because he doesn't want to concede them. But consider one case: A manual laborer who lacks health insurance, and doesn't get his allergies treated; when he at last gets a roaring sinus infection that puts him flat on his back, he goes to the Parkland Hospital emergency room, at a cost to the public of at least $1,000.

If it were you or me, we'd call the physician and get a prescription, maybe over the phone; if an office call were involved, that would be about $50 (including the insurance company's portion), plus $15.00 for prescriptions. It doesn't take many of those cases to wildly inflate health costs -- and Parkland, to pick one example, sees thousands of those cases every year. It's difficult to achieve millions of dollars in savings without having it show up for the accountants to see, eventually.