Reform: it's about economics

After a panel discussion on healthcare, a Denver business leader told me that his group, which pushes subsidization of healthcare and private insurance expansion, cares more about the economics, whereas single-payer supporters are so about expanding access.

I thought about what I had said, and reassessed my talking points. Most of them were about the economics. He didn't hear that, though. For many mainstream business people, universal healthcare is about access -- like Food Stamps are about access to food. Very nice, of course you don't want people starving in the streets of Cleveland or dying outside hospitals in Muskogee, but he's hearing bleeding heart do-gooder while I'm talking economics.

In the same vein, Ezra Klein writes that he doesn't make that point often enough: "Health reform, which is what we mainly talk about, is about economic security more than it's about health improvement. It's about ensuring people don't go bankrupt when they need care, and ensuring the country doesn't go bankrupt in 30 years beneath the burden of health costs."

Klein goes on to write that the real gains we'll make in health improvement will be due to public health gains. I'd add that a lot of our losses in recent decades have been because of a lack of investment in public health and a willful refusal to acknowledge the damages we've done to our environment through industrialization.

Americans favor mandates

Ezra Klein reports on a poll finding that 68 percent of Americans agree that "individuals should be required to have medical insurance, with government help for those who cannot afford it."

So 68 percent agree that underinsurance and gouging is the answer?

I don't think so. I think that people just really want this to be someone else's problem. Like -- the uninusured!

Ezra Klein on insurance reform

Ezra Klein is the best. He's got a couple good posts today, one on the malicious side effects of our perverse health insurance industry, and the other on our cutting off our noses to spite our faces in not giving immigrants health care, which is a disaster for public health.

His post on the insurance market is a link to news that it just became impossible in Washington State for many more people -- including people who've had breast cancer -- to buy insurance on the individual market. Ezra writes,

This is the real problem with reform plans that lack a full coverage component (be it a mandate, voucher systems, automatic enrollment in a national market, or whatever). The issue isn't the folks who will be uninsured, but the damage that does to your ability to reform how insurers work. To create a working market you need to create a fair market. And that means setting up the rules such that neither insurers nor individuals can game the system.

It's probably obvious I think people concerned with single-payer should just go to Ezra's site on a daily basis. He's the best.

Ezra's vision of health care

Ezra Klein spells out his vision of the best health care system possible in this imperfect world:

... a substantially public health care system in which government provides a guarantee of basic services, heavily regulated private insurers fight to compete against the basic plan, and somewhat less regulated private insurers compete with a public insurer to provide supplementary coverage to those who can afford it (those who cannot would be subsidized into the public insurer). ... all this because ... the profit motive is largely pernicious in the delivery of heath care, but nevertheless ... fears ... "no exit," ... it's possible insurers will come up with good ideas that it's worth forcing government to adapt against .... folks should be able to spend as much money on health care as they please -- health care should have a floor, but not a ceiling.

Ezra on healthcare comparisons

Ezra's evidently back from New Hampshire, and reading the new Health Affairs study "Measuring the Health of Nations" — which shows 101,000 excess deaths annually due to "amenable mortality -- 'deaths from certain causes that should not occur in the presence of timely and effective health care'." He notes,

Every other country posted significant progress in reducing amenable mortality. Save for us. In 2002-03, for both males and females aged under 75, America had the highest rate of amenable mortality -- which is to say, preventable deaths -- in the OECD. That means we were behind Canada, behind the United Kingdom (whom we'd beaten in 1998), behind France, behind Ireland. And not by a little -- France's preventable death rate was only 58 percent what ours was. Had we achieved the average gains -- not their rates, but simply the improvements -- posted by the other countries, we would have saved 75,000 lives. Had we achieved the gains of the top performers, we would have saved 101,000 lives.

Repeat that to yourself: 101,000 lives. That's more than the total population of Boulder, Colorado.

Conscience of a liberal

Paul Wellstone died with his wife, daughter, and campaign aides five years ago today, in a plane crash disturbingly reminiscent of the crashes used to kill South American progressives who wouldn't go along with the corporate program.

Ezra Klein writes a fine tribute to Wellstone in The American Prospect, including these lines:

"Politics is not about power," he would say. "Politics is not about money. Politics is not about winning for the sake of winning. Politics is about the improvement of people's lives. It's about advancing the cause of peace and justice in our country and the world. Politics is about doing well for the people."

Because of this, Wellstone had an immunity to the political trends that few politicians exhibit. When liberal was an epithet, Paul Wellstone wrote a book called The Conscience of a Liberal. When unions were in deep decline, Wellstone stood with them, and now the AFL-CIO now gives an annual award in his honor. After the Clinton health plan was crushed and Democrats retreated from health reform, Wellstone pushed for single-payer....

Divide and conquer

The Atlantic Monthly continues its downward spiral with a new writer, Megan McArdle, who fits their criteria for clever writing that leaves aside those quaint notions of morality, as Alberto Gonzolez has said. Entertaining!

The benchmark for this kind of dross ran a few years back, positing that the earth could easily support 30, 50, who knows how many billions of humans! and that our human population could vary by huge amounts — 30 billion to 3 billion! — within a few generations, without problems.

Right. Unless, I suppose, you consider starvation, war, pestilence and economic dislocations problematic.

Megan performs this trick on a smaller scale in "The Morality of Health Care Finance," by accusing those of us who see single-payer financing as a way out of the immoral and deadly morass in which healthcare is now mired in the United States. We are, she thinks, simply in love with government, and would be in favor of single-payer even if it could be proven that private health insurance could do a better, cheaper, more efficient job — "as long as a substantial population remained uninsured."

What?

Huh?

Megan. How is a system better if it leaves "substantial" numbers uninsured? How could that be cheaper in the long run? How more efficient? You've been reading too much Ayn Rand.

That's like accusing progressives of being against torture, even if it could be proven that torture does a better, cheaper, more effective job — "as long as a substantial amount of the information gathered turned out to be false."

See, the fact is that torture is wrong because it's immoral AND it doesn't work. Same as our private health insurance system.

Megan's argument that single-payer is a way to transfer money from the young and healthy to the old and infirm sounds like a trial balloon from the health insurance industry. Will we learn in a few years that she was lavishly compensated by that industry for this bit of "journalism"?

The fact is that our current system transfers money from the young and healthy to the old and infirm without benefit to the young and healthy. A single-payer system does collect from everyone, but its efficiency and appeal lie in the fact that there is benefit for the young and healthy. They have the security of knowing that if they hit a tree snowboarding next winter, they'll be cared for. They have the satisfaction of knowing that if they're one of the unlucky few who wake up tomorrow morning suddenly transformed by a diagnosis of cancer, suddenly no long one of the healthy but one of the stricken, that their children will continue to have a parent, and they can concentrate on recovery, not the consequences of bankruptcy.

Shame on you, Megan, for working to divide people, to set the young against the old, and suggest to them that their interests are served by turning their backs on others. She complains that liberals have been calling her "evil," but in fact, to work to divide people, one from the other, is an evil action.

First they came for the Socialists, and I did not speak out -
because I was not a Socialist.

Then they came for the Trade Unionists, and I did not speak out -
because I was not a Trade Unionist.

Then they came for the Jews, and I did not speak out -
because I was not a Jew.

Then they came for me - and there was no one left to speak for me.

Shame. We're in this together, Megan. Because it's moral, and because it's what works.

Ezra on patient incentives

Maggie Mahar wrote yesterday on perverse incentives for physicians that drive up costs; Ezra Klein writes today in American Prospect about perverse incentives for patients.

This again offers Bush & co. an opportunity to take real facts and twist them so they'll become ammunition for their class warfare against the middle class. C'est la vie, I suppose. Iron can be used for good — plowshares, say — as well as being potential death dealers as swords. We shouldn't turn our backs on the stuff.

Klein writes that RAND's 15-year study showed that "gold-plated" healthcare coverage that gave 40 percent more care than basic coverage offered no better outcomes.

This is actually an argument in favor of single-payer. Denver Dave of HC Talk has mused that the average person, when thinking about single-payer, pictures U.S. healthcare being a finite entity that he or she has a part of through his or her insurance. If we split the pie differently in order to give some of that healthcare to people who have none now, that seems to mean that he or she would have less.

The RAND study shows that less can be better. What's more, the study also showed this: "The only exception was for the poor, whose health outcomes were hurt by cost-sharing and improved by more generous plans."

Further showing that denying healthcare to the poor (and increasingly to the middle class) is foolish, Klein links to this:

The New England Journal of Medicine... compared Medicare patients who faced heavy cost-sharing for pharmaceuticals with those who had nearly unlimited benefits. The seniors with cost-sharing cut back on pharmaceutical spending (and thus, use) by about 31 percent. The results? More visits to the emergency room, more hospitalizations, and higher rates of death. And the upshot of all this is that the costs incurred by the deterioration in health completely erased the savings from the cost-sharing.

Klein agrees with cost-sharing by patients except for chronic conditions where generous care has been proven to pay for itself and more.

"One-size-fits-all high deductible policies associated with Health Savings Accounts (HSAs) require costly tax breaks for the most affluent while unnecessarily increasing financial and health risks for low- and moderate-income families," Klein writes. He instead likes a plan from his favorite economist, Jason Furman at the Hamilton Project, who has come up with a system that he claims could save 30 percent immediately by charging co-pays adjusted by income.

Of course the only realistic way to do that would be through a single-payer system.