March 11, 2004

Memories of Health Care Reform

In this morning's Wall Street Journal, David Wessel writes about the fear of rapidly-rising health-care costs: - Capital: ...anxiety about rising health-care costs could be a particular obstacle to hiring at a time when business finds it difficult to raise prices to cover higher costs of any sort. For every new hire, notes Helen Darling, president of the National Business Group on Health, health insurance now costs an employer roughly as much as payroll taxes. And none of President Bush's tax cuts have made hiring more attractive; indeed, he and Congress offered a sweet tax break to buy more machines and computers.

Skeptics cite some strong contrary evidence. The latest government data don't suggest that companies are making existing workers put in more hours. During the past year, the average front-line worker's workweek has barely grown, though an uptick has occurred recently in factory overtime. But use of temporary workers has soared. In the past 12 months, private employers of all sorts have added only 188,000 workers, an increase of just 0.2%. Economists keep predicting that businesses must be about to hire enthusiastically, given the economy's growth. Some surveys of executives suggest that's so. So far, the hiring hasn't happened.

This much is clear: Those who identify rising health-care costs as a big problem are quick to draw the link. If the joblessness of the recovery persists, the public search for culprits will intensify. Health costs are bound to get more scrutiny and might even rival outsourcing as a focus of public concern.

A decade ago, while at the Treasury, I worked on the (greatly imperfect) Clinton health-care reform effort. And I remember why many of the Republicans opposed us: not because they were afraid that health-care reform would fail to produce better health care at lower cost, but because they were worried that health-care reform might succeed. The Clinton health-care reform plan was to be opposed "sight unseen," for a successful health-care reform would "revive the reputation of the [Democratic] Party" and win the Democrats "a lock on the crucial middle-class vote."

NewsHour Online: The Healthcare Debate: December 2, 1993 - Leading conservative operative William Kristol privately circulates a strategy document to Republicans in Congress. Kristol writes that congressional Republicans should work to "kill" -- not amend -- the Clinton plan because it presents a real danger to the Republican future: Its passage will give the Democrats a lock on the crucial middle-class vote and revive the reputation of the party.... January 25, 1994: Oppose any Clinton health care reform "sight unseen" and adopt a stance that "There is no health care crisis."

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When Paul of N looks back fondly at the Nixon Adminstration for unpoliticized policy, you know it is bad.

Posted by: Stirling Newberry on March 11, 2004 11:42 AM


Ugly behavior on the part of Republicans if true, sure, but very much a part of both parties' thinking on many issues.

For a counter-example, it seems to me that the vehemence with which most Democrats attacked Bush's recent immigration reform proposals had less to do with principled oppostion (How many Congressmen, after all, have really given much though to the what a good immigration reform plan would lokk like?), than with a bone-chilling fear that Republicans might be able to position themselves to regulalrly capture a large share of the Hispanic vote, a development which would almost certainly cast the Democratic party into minority status for many years to come.

And its not entirely clear that this explanation holds anyway. I've detected a too-eager willingness on the part of many people on the left to believe all sorts of ugly things about the right because this or that individual conservative thinker/strategist advocates some off-the-wall position. In other words, I don't neccessarily believe that most Republican members of congress are pursuing a "starve the beast" fiscal policy just because Grover Norquist touts such a plan. Its seems much more likely that Republicans in congress favor low taxes on principle, increased spending based on political expediency, and don't give much thought to any long-term scheme about what government spending will look like 30 years from now.

On the healthcare issue its possible that resistance to health care reform was some sort of calculated political move on the part of Republicans to deny the Democrats long-term majority status, but it seems much more likely that the resistance came from the fact that Republicans don't tend to think that its a good idea to nationalize industries. Argue that they're wrong generally, or here specificially, if you like, but you don't have to assume that Bill Kristol is some sort of all-powerful puppet master to explain why one arty opposed the other party's policy ideas.

Posted by: sd on March 11, 2004 11:48 AM


As someone who is devoted to the concept of universal health care, I would have to add that, as I recall after reading one of the draft proposals, the Clinton health care reform would not have necessarily have ameliorated the issue of health care expenses being a drag on employment -- because it would have essentially kept the current employer provided health care "system" but would have mandated coverage. It is unclear that there would have been necessary political willpower to really keep costs down. It depends on how it would have worked in practice -- who would have been negotiating with health care providers, and whether employees, as opposed to employers, would have seen the consequences of rising costs and utilization. It was also fantastically complicated.

Posted by: Barbara on March 11, 2004 12:13 PM


Among Cancer Doctors, a Medicare Revolt

Years ago, doctors hospitalized cancer patients before giving them chemotherapy, so worried were they about the retching, dehydration and weight loss that the drugs could cause. Now, most doctors treat cancer patients in their offices, allowing them to return home quickly or even go to work.

But the federal Medicare program is changing the way it pays cancer doctors, and some oncologists are so angry that, hoping to turn patients into lobbyists, they are warning patients that they face a return to hospitalization and nausea.

In Hartford, doctors in a practice called Oncology Associates wrote a letter recently to their patients saying that because of the new reimbursement system, patients might have to "switch to older medications."

And though those drugs "may be more toxic or less convenient for you," the letter said, "we will be financially unable to give chemotherapy medications which cost us more than the reimbursement." To get proper care, patients might "have to be hospitalized," it added, though "this approach will likely not be usable due to the large number of patients and limited facilities."

The doctors acknowledge that it would not be ethical to switch to more toxic therapies based on a change in reimbursement rates.

"But if Medicare makes it impossible to do what we've been doing, then I don't know what to do," said Dr. Robert Siegel of Oncology Associates.

Next year, their letter warns, they may refuse altogether to treat Medicare patients, who make up a large portion of those suffering from cancer....

Posted by: anne on March 11, 2004 12:19 PM


My resistance to "health care reform," which is code for "government monopoly health care," is not that it will give Democrats a political boost, it's that it will cause this nation, already heading for a Medicare financial hole in the tens of trillions of dollars, to go broke.

Even assuming you can nationalize health care successfully, despite the fact that centralizing almost anything doesn't seem to work, you are left with trying to effectively manage a universal health care system for a nation whose population is almost the equal of the entire European union. I'm getting a bit tired of being inundated with foreign examples of socialized medicine from nations with populations less than that of California.

As for employer problems with insurance, I would really like to know how much of this benefit, or other benefits for that matter, is mandated by local or Federal government. I do know that in California it appears to be illegal to offer health benefits that do not provide certain features.

Posted by: tbrosz on March 11, 2004 12:21 PM


"The Clinton health care reform would not have necessarily have ameliorated the issue of health care expenses being a drag on employment...."

Spending on health care is one of the great employment generators for America, and I do not know why that should not be true for decades. From hospitals to drug and biotech companies to medical equipment companies to independent medical offices, from life saving to cosmetic treatment, what better employment generator could there be? What I would like, however, is to have far less spending for insurance administration. Insurance administration costs are the problem.

Posted by: anne on March 11, 2004 12:29 PM


"I'm getting a bit tired of being inundated with foreign examples of socialized medicine from nations with populations less than that of California."

Say Germany and France and Netherlands and Italy and Sweden and Belgium and Denmark and Norway and Japan and Canada and Australia....

Posted by: anne on March 11, 2004 12:34 PM


tbrosz, your comments are disingenuous, as they often are. Every other industrialized country has a national health care system, and considering our worldwide standing in most indicators of health, it would certainly be hard to argue to argue that they 'don't work'.
If you believe in the religion (yes, religion, for it's nothing but a faith with people such as you), truly open the market. Don't require prescriptions for drugs. Don't require any certifications for drugs, doctors, or treatments. Legalize ALL drugs (antibiotics, etc., included).
You know, if you believe in total social Darwinism, why don't you move to Somalia, or the Sudan? I hear their governments (such as they may be) aren't very effective at regulating anything, or collecting taxes. Should be Libertarian Paradises, no?

Posted by: Jeff Lawson on March 11, 2004 12:41 PM


What national health care systems of various sorts allow is substantial cuts in insurance administration costs without cuts in quality and extent of care.

Posted by: anne on March 11, 2004 12:49 PM


This is another one of those issues on which we ought, at least at a classy joint like this one, to take stock of what we know and what we don't, just to save time. I am by no means an expert in health care issues, but my impression is that the argument over which sort of system provides the best health care is often one of definition. The US can claim the best high-end care, but falls seriously short on issues of availability. That provides both sides with the opportunity to count coup, but if that leads to both sides claiming "best" without being clear about what they mean, the discussion stalls.

On the cost issue,...stop me if I get this wrong,.. the idea is that a single provider cuts sales and overhead costs, duplication of services and functions and the like. Thus the cost savings come from reducing the large part of insurance premia that does not go to paying medical costs.

The connection that Wessel points to, between insurance costs and hiring, seems to me to have the potential to change the medical costs debate substantially. If, after the distractions of outsourcing and the hang-over from a period of slow output growth are past, we begin to see health care costs as a major impediment to employment and wage growth, health care cost containment could grow a serious set of teeth. Job growth is the holy grail of politics in all but the best of times. No more legislation preventing the government from negotiating over medical costs if medical costs are defined as the culprit in slow job growth.

Posted by: K Harris on March 11, 2004 12:55 PM


What you may be failing to consider is how much employment there is and can still be in health care fields. Fine employment. Then, make health care more affordable to private employers and watch employment grow both for those employers and for health care providers. The key here strikes me as controlling health care insurance administration costs.

Posted by: anne on March 11, 2004 01:02 PM


Like K Harris, i'm no expert on health-care and health-care costs, but i am sufficiently informed to know that tying health insurance to your job is deranged policy of the worst sort, a carryover of WW II wage-and-price controls.

And i'm sufficiently informed to know that anne is right about the delta between american medical administrative costs and those of european countries (but then, as i've said, anne is virtually always right).

Posted by: howard on March 11, 2004 01:02 PM


Dan, it's off-topic, but if you think that bush is going to bring in the "adults," you're delusional. Bush hates adults.

Posted by: howard on March 11, 2004 01:04 PM



I'm quite skeptical of the notion that controlling insurance administrative costs is somehow a panacea. Yes, there is a lot of red tape in the private insurance system, but why do you think that is? If there were an easy way to eliminate much of this red tape, then it would very much be in the interests of the insurance companies themselves to do so - they'd make higher profits.

I suspect that much of the high insurance administrative costs are a direct result of an information infrastructure problem that isn't going to be solved anytime soon. Because healthcare has traditionally been radically fragmented in the United States, hospitals and clinics have accumulated (and come to depend on) hundreds, maybe thousands of quirky legacy IT systems. These systems don't talk to one another very well, and as a result its exceptionally difficult for information to flow around the healthcare system.

Over the past several decades the financial services industry has on the whole spent about 10-15% of revenues on IT systems. Healthcare delivery, which is every bit as informationally complex as financial services, has spent about 1%. The results are obvious: I can go to any of probably a few million ATMs in the US and the developed world and instantly call up account information down to the penny, transfer funds around accounts, get cash, etc. But if I go in for several hundred dollars worth of medical tests, the bill might be months in arriving, if it ever comes.

I think that the bigger bang for the buck, long term, would come from doing actual healthcare outcomes research. We like to tell ourselves that because there have been so many stunning advances in medicine over the past few decades that modern medicine is somehow a rigorously scientific enterprise and that doctors know what they are doing. The frightening truth is that there has been very little high quality research on which medical practices actually work and which ones don't.

Posted by: sd on March 11, 2004 01:19 PM


Same same same Howard.
Must have a smile metaphor.

Posted by: anne on March 11, 2004 01:29 PM


I'm no expert either, and am not a doctor but talk with them all the time for my work. I think that sd's statement is true in some ways, but is a little misleading

"We like to tell ourselves that because there have been so many stunning advances in medicine over the past few decades that modern medicine is somehow a rigorously scientific enterprise and that doctors know what they are doing. The frightening truth is that there has been very little high quality research on which medical practices actually work and which ones don't."

there is a body of historical epdimiological research that indicates that about half the increase in population health (or proxy measures such as life expectancy) is due to high-tech medical advances, and half is due to higher standards of living (less crowded living conditions, better overall population hygiene) and public health measures (sanitation, mass vaccination against contagious diseases). Most estimates put the latter at between 50-60%. Do not have citations, but could find them. Will be gone most of next two weeks, so be patient and check back. There are real statistical studies on this.

Currently the big worry among clinicians and epi people is chronic disease management. Tobacco health costs starting to go down, but overweight, inactivity, Type II diabetes, congestive heart failure costs going up repidly. Some advances in medicine generate more costs latter on. For example more people surviving heart attacks, so that sets up huge increase in congestive heart failure costs in ex-heart attack victims later on. So there needs to be more emphasis on preventing heart attacks in order to save money over lifespan.

One big problem is unresolved tension between need for consumer choice and incomplete contract design. If turnover rates in health care plans is on order of 25%, why should HMO A pay for tobacco cessation or weight control, or diet modification/exercise therapy now, when there is 25% chance HMO B will enjoy return in investment.

So lots of dollars go into walking-disaster-waiting-to-happen management (trying to save bucks on diabetic hypertensive smoker who can't seem to quit).

So we don't know alot, that is true. But we do know where a lot of costs coming from, and how to fix. Big effort now by clinicians, epidimiologists and actuaries to implement population based health care, make plans co-operate on smoking exercise, life style stuff best handled by co-operative population based public health efforts.

Yeah yeah, some of the published estimates of cost of overweight and inactivity that are shopped around in media are loony and way too high, but that doesn't mean it ain't expensive. You can hear all about it at HMO and hospital industry clinician and epidemiologist conferences.

Posted by: jml on March 11, 2004 01:40 PM



Nicely argued. My argument would use GEICO as an example. The insurance industry as the mutual funds industry does all it can not to compete on costs. A GEICO or a Vanguard are an exception. When New Jersey ordered the only state malpractice insurer to stop issuing policies, and insurance costs were supposed to soar, Berkshire Hathaway offered to enter the business. Why can GEICO generate a fine return for Berkshire shareholders and offer attractive rates and fine coverage? Why can Vanguard offer fine funds for a fraction of the costs of Merrill Lynch or Franklin Resources?

Then, there is the Medicare experience. Administrative costs for Medicare are far less than for private health insurers.

Now, I am arguing an idea. The idea is either figure out how to make private insurers cost competitive or think about public insurance with incentives to be cost efficient.

Posted by: anne on March 11, 2004 01:50 PM


What is interesting is how the "possibility" of health care reform in Bill Clinton's administration was incentive enough to hold costs down. Of course, I am being simplistic, but there is also substantial room for cost control among the drug makers. For all the fine research, the marketing costs for drugs leaves substantial breadth for limiting price increases. When pressed drug companies suddenly found they could limit price increases after 1992, and earnings were quite fine.

Posted by: anne on March 11, 2004 01:58 PM


Penny wise pound foolish. American health care is beset by a lot of preventable disease. If people would take better care of themselves not smoke, exercise more, and eat healthy, costs could be dramatically reduced. This would be both a social benefit and a quality of life benefit.

Why not have denistry associated with schools? We spend a fortune on correcting dental problems that could more cheaply be prevented. Health care is also an area where traditionally government has had zero or near zero role. Who needs to work out if he spends 8 hours a day on the hay wagon behind a kick baler. Health/exercise at our schools is a joke. With a little additional investment, our school system could double as a public fitness outlet at night. Extended hours could provide real fitness programs/rec sports for school kids.

Having a nursing program to assess health and triage cases before they become expensive can be cost effective. Many places in the US have no primary care. The US needs more primary (inexpensive) care and less remedial (expensive) care. A low birth weight baby can cost several hundred thousand dollars. A wellness program for expecting mothers can be run for a few thousand, per patient. The benefits of dropping the rate of problem pregnancies by a couple percentage points is obvious. We lack the political will to do it.

Posted by: bakho on March 11, 2004 02:04 PM


sd- I hope you are right about the average republican congressman. That they are guided by a mild right of center instinct and are willing to change when it doesn't work. My question then becomes, how do you explain the venimous nature of the leadership? Delay, Hastard, Gingrich, Gramm. Some of the ideas and policies these guys championed are just plain nasty. Is it just the rigours of having to win? Having to please the base and wedge the democrats out of office with "hot" issues?
Maybe moderate conservitaves will start voting for certain Dem candidates as the Dem leadership has a base that is under control?

Health Care -
USA spends a higher % of GDP than any other industrialised nation for a service that is not as universally availalble. It is a cadillac service, but not everyone can ride in the cadillac. This is not all bad. If you have the money you are getting the best treatment in the world. My comment is that it must just be murder on the lower middle class to stay insured.

In Canada the Provincial Governments have a monopoly on healthcare. It is availalble to all. But, there is definately rationing. Interestingly not so much rationing that the system is under political attack. It enjoys 85% public support and even Canada's right of center party supports it basically as is (Is this why the GOP in 93 was afraid of the Clinton Plan?)

There is a big debate going on in Canada on how we are going to accomodate the medicare expense bulge coming through in the next 20 years. The majority posiiton is that we just have to put more money in, EVEN IF this crowds out military and education expenditures in the federal budget. The minority position is that we need to look at allowing the private sector to enter into the system. The counter argument is that if we allow the private sector in the whole thing will

Two retired federal politicians - equivalent in presitge to retired senators - conducted inquires. One came down on the side of more tax money the other came down on the side of private sector involvement.

My personal view is that we need to keep the contibutions (ie taxes) monopolised by the government but increase competiton in the provision of services. If a doctor wants to buy an MRI machine and set up a specialised clinic on his own initiative and with his own capital, let him. We should also let the sick spend their own money if they want services above and beond the basic. Apprently both of these measures are allowed in European systems and I don't see any collapsing going on there. I think some people are simply afraid of change.

Whenever I travel to the USA people always ask me about "that Healthcare up there" like it was some sort of miracle. And in a way I guess it is a POLITICAL miracle that it was established at all. (God bless Tommy Douglas and the province of Saskatchewan)

Maybe time for the USA to have a political miracle?

Posted by: Scott McArthur on March 11, 2004 02:07 PM


My recollection of the era was that the big industries saw the future and did not like it. I was still subscribing to the WSJ at the time and there were articles about the impending skyrocking costs to corporations for empoyee and retiree healthcare. I thought the Clinton efforts were trying to address those concerns. Too bad it failed. Otherwise maybe by now we would have worked the kinks out of the plan and gotten a better handle on costs and a better system to deliver healthcare.
I can dream can't I?
I think that sometime in the future business will get out providing retirement and healthcare insurance. I don't know what will evolve but I do know business wants out of these responsibilies.

Posted by: dilbert dogbert on March 11, 2004 02:37 PM


" A decade ago, while at the Treasury, I worked on the (greatly imperfect) Clinton health-care reform effort. And I remember why many of the Republicans opposed us: not because they were afraid that health-care reform would fail to produce better health care at lower cost, but because they were worried that health-care reform might succeed."

Or, the Republicans knew instinctively what the spiffy color graph shows at the following:

Described by George Mason's Russell Roberts as:

In 1960, a dollar of health care cost the average consumer about 50 cents. Today, that "price" is down to about a dime. For very dollar I spend on health care, someone else (the government, my insurance company) pays 90 cents and I pay ten. So it's not like a normal price where lower mean better. Lower here only means lower to the individual. Someone else has to make up the difference.

Not surprisingly perhaps, as Alex [Tabarrok] points out, when price falls, people want more than they wanted before. That explains the blue line, a lovely application of what economists call incentives. The five-fold drop in price has resulted in about a five-fold increase in real per-capita spending.

Posted by: Patrick R. Sullivan on March 11, 2004 02:41 PM


Howard is right that we are now paying for the 1945 regulations that encouraged providing health care as an employee benefit. We don't get fire, auto, or most other kinds of insurance from our employer, why this? Don't think there's any way to change now.

I'm afraid there's no way to convince enthusiastic socialists that a government monopoly on health care

Someone had a discussion once with a fervent Green Party person, and asked him what he thought of our current government.

He went into a long tirade about the rampant corruption, corporate control of the legislators, lobbies running everything, and congressmen who listen only to the highest bidder. A cesspool of greed and sellouts.

Then he was asked what he would do to solve the health costs problem. The answer was immediate: Single payer health care. Give it to the government. The two concepts passed each other smoothly in his brain like ships in the night.

Do we really want the government responsible for our health? Think long and hard on this.

As for "efficiency," socialists in my college used to complain about the wastefulness of our society. Their favorite thing was going through a grocery store, and pointing out dozens of different kinds of soap. If there were only a couple, look at the resources that would be saved.

And what brand would be selected, and how? Unclear, although it usually broke down to some brand he liked. Also missed in the equation were the thousands of people employed making the soaps he thought were unnecessary. Modern socialists are more sophisticated than this, but not much.

Posted by: tbrosz on March 11, 2004 03:17 PM


I have no idea who this Russell Roberts that Patrick Sullivan cites is: he could be a right-wing hack, and he could be someone who knows something.

But i do know that if Patrick Sullivan thinks that the only thing that has changed in health care since 1960 is the ratio of the total cost that government covers, he should leave the discussion now. The fact is, health care is markedly better is all kinds of ways (including prolonging existences that otherwise would have mercifully ended). It's not merely a case of price no longer serving a "signalling" function.

Posted by: howard on March 11, 2004 03:49 PM


K Harris writes
" care cost containment could grow a serious set of teeth."
But will it? bakho thinks not --no political will. (And this is a matter of scale that goes way beyond the 4 yr election cycle to change. The politician who thinks and votes beyond the short term is a rare bird with a very short political career.) Instead, the wealthy will receive one level of care and the rest, another. Mirroring income distribution, no?

I note that now GM's pension funding problems are solved ( the $13B bond issue), their health benefits liabilities are more than $60B. There is no limit on our good will here to keep these retirees in good health. Not yet anyhow.
In the private sector lately, there seems to be no funding problems, so why not just print more money like everybody else? (Times will get better eventually as you suggest"...after the distractions of outsourcing and the hang-over from a period of slow output growth are past,...")Or do you think those bonds are only a temporary fix? You wouldn't hold back a new set of dentures for a Chevy builder would you? Better pony up for the next GM bond issue.

K, "the containment" you speak of is coming IMO but it is a reduction in health care. The retired GM worker will get less than promised. So will we.

Posted by: calmo on March 11, 2004 04:29 PM


A comment on the post from Canada on the fear of the medicare bulge, and bakho's comments on population based health care in schools -take and elderly woman who has been a non-smoker, only a light drinker, has controlled weight and exercised regularly since early middle age, and average to low fat diet. That elderly woman has health care costs only about 1/2 of average risk and 1/4-1/5 of high risk elderly women.

So people are not endless consumers of health care. It is not an addictive good. The underlying health status does make a difference.

Seems to me that regardless of you prejudices -either liberal or conservative -you have to admit there are very serious moral hazard and selection bias problems in US medical care system that raise costs and cause finance problems to providers. Market fanatics can talk all they want about free choice and health care not a right, and the evil of social engineering. But the US as a society has made a decision to care for pretty much anyone who finds their way to a clinic or hospital door. That means your tax dollars at work on mess cases. So a bum wanders around with a foot infection and takes a zoo of antibiotics borrowed and begged off of whoever until he develops an antibiotic resistant infection, and finally limps into the ER on the point of collapse -the hospital will dump a heap of money on that guy. Same with the hypertensive diabetic smoker. Some one will try to fix them up. Same with uninsured working stiff who starts putting off routine health care and exercise in middle age and gradually forgets about it. Same with middle age guy who has avoidable heart attack and turns into an elderly money sink with congestive heart failure.

So you pay one way or the other. Unless you can persuade society to let those kind of folks die in misery. So until we decide to let people die in misery with no help at all, then you will have the kind of problems we see with aging population and exploding costs. It is not all inevitable progress of medical technology junkies and people who like to have x-rays and doc appointments for amusement.

Posted by: jml on March 11, 2004 04:40 PM


Re your comment about using schools as a delivery system for health care. Years ago when California was poor I and all my class mates got our teeth checked yearly, IIRC. Mine were always in good shape but maybe the dentist was doing this to drum up business?

Posted by: dilbert dogbert on March 11, 2004 05:12 PM


tbrosz says above:

My resistance to "health care reform," which is code for "government monopoly health care," is not that it will give Democrats a political boost, it's that it will cause this nation, already heading for a Medicare financial hole in the tens of trillions of dollars, to go broke.

I've heard this not only from him but from people who should know better.

Among industrial nations, percent of GDP spent on health care is negatively correlated with percent of health care expenditures that are spent by government. This has held true for a while now. And, of course, they have universal coverage, better results, and an incentive to do low cost preventative care.

If the aggregate cost of health care to the country comes down, money can be found to pay the lower cost.

There is also the question of who pays if the government does not. I think the Republican answer is that if you can't pay you die. I'm a little queazy about this.

A point I don't see often made is the gains from breaking capital lockin. Repubicans often say that eliminating capital gains taxes will free capital to move to more productive uses, resulting in economic gain. But human capital is the most important kind, and it can get locked in by needing health coverage. This prevents people from changing jobs because they can't get care due to pre-existing conditions, or because they fear the new enterprise won't be stable, or it dosen't offer benefits. Such movement of human capital should realize gains much more tangible that a capital gains tax cut.

And, it becomes politically much easier to promote sensible trade policies if those thrown out of work don't need to worry about heath insurance coverage.

Those who interject at this point that individuals can buy their own health insurance need to look up asymmetrical information, or go to the Noble Prize site and take a look at the Economics awards for 2001.

On another topic:

The statement above that, given a 25% churn per year, preventative care stands a 25% chance of benefitting someone else is wrong. It's much higher. Remember that that's 20% in the first year. If action now can save a heart attack five years later, that savings is almost certain to benefit someone else.

Posted by: Jonathan Goldberg on March 11, 2004 05:38 PM


Most of this is way over my head, but I do know health care, having worked in it for 40 years before I retired.

I remember hearing some pundit say that if the Clinton plan was defeated we would end up with National Health Insurance within ten years. Well, the ten years have passed, and it is not here, but we are certainly facing a crisis. I'm one of those who believe that part of the jobs problem (including outsourcing) is related to the relentless increase in health care costs.

I have seen first hand the "administrative costs" of private insurance companies. When you take a dollar of Medicare you get over 90 cents in services. When you take a dollar for a private insurance company, you get ????

There is no question in my mind that this country's "wonderful" health care is not available to all of it's citizens. And the gap between the haves and have nots is widening.

Posted by: JWC on March 11, 2004 05:41 PM


The entire point of insurance of any kind is to spread the cost/risk of a service. If you only insure healthy people, the risk will be low, naturally. The same for education, if you only accept good students, the costs to educate them will be relatively low. These 'spreading of risk' functions, government is well suited for.
I haven't heard even rabid republicans/libertarians calling for privatizing city streets, for example...why electricity, or telecoms, both 'natural' monopolies?
The lack of overhead, due to the need to make a profit, would seem to imply that government could do these things rather efficiently, to me.
I haven't seen anyone declare that, yes, by Gawd, I'm Somalia-bound, I've seen the light...

Posted by: Jeff Lawson on March 11, 2004 05:45 PM


Ah, Health Care Insurance Coverage. What a magnificent drama, one with no heroes, many villians and more dupes.

Clinton (and his administration presumably including Brad) simply blew it. He had the opportunity to reform the system and make dramatic progress and as a result of inept political and policy analysis, set the effort back at least two decades. (Certainly there were those who pounced on this ineptitude, but any decent politician should have won this battle hands down.) Of several political failures, this may be his worst. I would be delighted to give you chapter and verse.

As a former CEO of an insurance company selling health care insurance in 48 states, let me assure you that extending Medicare to the entire population would save 10-20% of the health care dollar in marketing and administrative costs for those under age 65 without changing much of anything else that could not be fixed fairly simply. With no change in costs, we could increase the payout to those who actually provide care and cover everyone. Some marketers, underwriters, licensers and commission payers would be out of work, but the administrators would be absorbed by those who administer Medicare as it exists today, and that's most of the people if not most of the compensation (marketers make a lot of money).

Given the reality of the globalization of markets, outsourcing, etc., for the US to not provide health care coverage to all unrelated to employment is economically insane. This stupid policy reduces job mobility, increases resistance to "free" trade (of which I am a supporter) and creats human misery in the wealthiest nation state in the history of mankind.

Rather than pragmatists who attempt to balance the long term benefits of free and open international trade in goods and jobs with the short and intermediate term pain of lost jobs and attendant protection against bad health luck, we seem to be faced with mindless ideologues who rail about "socialized medicine" or other non real problems.

While perhaps one could expect political posturing from all too many knee jerk political ideologues, one would expect rationality from the economics profession. But no, most economist are wedded to the Anglo-American school which can only make its sums work by assuming some mythical free market governed by rational expecations. Robert Heilbroner got it mostly right in his succinct 1995 book, "The Crisis of Vision in Modern Economic Thought".

I apoligize for the tirade, but I do become exercized by this issue.


Posted by: Sam Taylor on March 11, 2004 05:47 PM


Scott has given you a fair description of our Canadian single-payer system. it does allow the poorest of the poor to enter a doctor's office, get tests at a lab, and go on to further procedures without a financial worry. But the waiting lists, even for potentially serious diagnoses, can be frighteningly long.
Last summer I had a suspicious result from a test. The doctor entered my case as moderately urgent. But I had to wait seven weeks for a cat-scan to get some reassurance that my malady was not life-threatening.

Posted by: gb on March 11, 2004 05:57 PM


A point which gets lost is the connection between high court awards for injuries and the lack of universal health care. If the US had universal health care, juries would be far less inclined to award millions of dollars in birth defect/auto injury/etc. cases.

Posted by: Eli Rabett on March 11, 2004 06:24 PM


There will probably never be a solution to the medical-care-rationing-game, that satisfies everyone. At least not with not with present technology. The system we have now, more and more people are finding decidedly unsatisfactory, howevever.
A representitive government functions best with a large middle class, people who have a stake in society as it is. When too many people many people feel that they have no material stake, or that their stake is too insecure, armed, violent revolutions happen. It can't happen here? Look up Washington, George.

Posted by: Jeff Lawson on March 11, 2004 06:29 PM


One important factor in the increase in health care is securitization of many health care provider organizations, from hospitals to insurance companies to HMOs to medical administration companies. Not to mention drug companies, technology manufacturers and so on.

In each case there is a push for annual increases in profits, which must pay for the increased administrative overhead associated with being a public company, the radical increase in salaries to all administrators and eventually dividends. These are significant numbers, and huge changes from 40 years ago.

The private sector imposes its own costs, and someone has to pay. Hospital Corporation of America is a classic example. Every time it engages in one of its mergers, go private, go public, sell hospitals transactions, it incurs huge costs along with whatever money might come in. The only consistent winner is the Frist family. Some sick person is paying for every nickle they have.

A huge number of offenses have been asserted against HCA, which has paid huge fines without admitting any liability. We can assume that it has the usual number of internal costs, like jets and lovely conventions. Sick people are paying for these as well, but the money counts as health-care.

We have to ask if the costs of privatization as it currently exists are worth whatever benefits might be asserted. There have been a number of posts and comments which suggest that the costs are much higher than usually thought.

Posted by: masaccio on March 11, 2004 06:45 PM


The current lax attitude of the government towards mergers of all kinds is interesting. Comparisons to the Gilded Age are easy. We need another Rooseveldt, either Teddy or F.D., I don't care. Remember the Bonus Army!

Posted by: Jeff Lawson on March 11, 2004 06:49 PM


gb wrote, "Last summer I had a suspicious result from a test. The doctor entered my case as moderately urgent. But I had to wait seven weeks for a cat-scan to get some reassurance that my malady was not life-threatening."

In which case the system worked perfectly well. Sure, you lost some piece of mind, but compare how much GDP the US spends on health care to how much Canada spends.

Posted by: liberal on March 11, 2004 06:51 PM


Too much discussion is focussed on insurance and not enough about efficiencies of providers.

What makes anyone think that doctors have any ability at all to make rational cost/benefit decisions? Studies have shown that they're incapable of probabilistic reasoning.

bakho wrote, "Having a nursing program to assess health and triage cases before they become expensive can be cost effective."

Therein lies the clue. What would happen if you gave more of a role to nurses? Doctors would go on strike.

Another example: press reports of doctors complaining about all the paperwork they have to complete. (Some now will charge patients.) If the medical profession allowed a more rational division of labor, someone *else* would fill out the paperwork.

But in a rational system, doctors would capture far less economic rent and make much less money. God forbid.

Posted by: liberal on March 11, 2004 06:57 PM


jml wrote, "there is a body of historical epdimiological research that indicates that about half the increase in population health (or proxy measures such as life expectancy) is due to high-tech medical advances, and half is due to higher standards of living (less crowded living conditions, better overall population hygiene) and public health measures (sanitation, mass vaccination against contagious diseases). Most estimates put the latter at between 50-60%. Do not have citations, but could find them. Will be gone most of next two weeks, so be patient and check back. There are real statistical studies on this."

Depends on what baseline you use. I would be *very* sceptical of any numbers that put the contribution of higher per-capita GDP and better public health measures as low as 50-60%. I'd guess more like 80-85%, maybe even 90%.

Posted by: liberal on March 11, 2004 07:06 PM


sd wrote, "I think that the bigger bang for the buck, long term, would come from doing actual healthcare outcomes research. We like to tell ourselves that because there have been so many stunning advances in medicine over the past few decades that modern medicine is somehow a rigorously scientific enterprise and that doctors know what they are doing. The frightening truth is that there has been very little high quality research on which medical practices actually work and which ones don't."

My favorite example is, if I recall correctly (details may be wrong, but overall thrust is correct), bone marrow transplant/high chemotherapy treatment for metastatic breast cancer. After they finally did a randomized trial, they found the outcome was no better than less novel procedures. And what did some doctors highly invested in this treatment protocol do? Push to keep treating patients this way. (A canonical example of doctors being the villains and insurance companies the angels---the latter refused to fund the treatment once it was scientifically shown to be no better than cheaper, conventional treatments.)

What I find scary is that doctor friends of mine---ones with very good technical (mathematical) backgrounds---refuse to yield to this kind of reasoning and results. I guess the power of collecting rents can warp even the strongest of minds.

Posted by: liberal on March 11, 2004 07:13 PM


I would just like to second the praise of Tommy Douglas. What a great little man he was, bad teeth and all. When he finally got his health care program passed, the first thing the doctors did, of course, was go on strike.

Posted by: john c. halasz on March 11, 2004 08:19 PM


I've often found modern doctors to be just as scary as evangelical Christians, myself. And just about as moral/ Fallwell, Jim Baker, et. al.

Posted by: Jeff Lawson on March 11, 2004 09:24 PM


Er...Tommy Douglas was a Baptist minister.

Posted by: john c. halasz on March 11, 2004 11:01 PM


hi liberal:
you probably misunderstood the intent of my comment a bit. it has brought tears to my eyes to when i have seen very poor people sitting and waiting with me in the same clinic. there have been a few instance in our locale where treatment delayed was treatment denied. but help was not denied because i had a fatter wallet than the shabbily-dressed person sitting near me.
yes, tommy douglas was a Baptist minister and evangelical reformer. peace to his dust and honour to his memory.

Posted by: gb on March 12, 2004 08:29 AM


Defenders of Medicare need to be careful not to under play or dismiss the "difficulties" in the system. The fact that GB had to wait that long is a problem. Not a OH MY GOD ITS HOPELESS LETS SCRAP IT ALL kind of problem, but a problem never the less.

As I mentioned earlier the issue all G7 countries face is the aging baby boomers and the question becomes how do we pay for it all? This question applies to all health systems, private and public. For Canada, my point was that we should be open to using market forces. Let the ill spend more if they wish to spend more and absorbe SOME of the rising health costs. Yes, healthcare costs as a total % of GDP will rise, but they are going to rise in a single pay system too. With a blended public private system we can keep the budget from being monopolised by healthcare.

Take the case of GB. What if he could spend 100$ more to see a MRI clinic and get an answer sooner?

Now I haven't done a cost benefit analysis or read all the relevant litterature so hey, I just don't know. But as I see it the only real risk is political. Hundreds of GBs will pay for quicker service and bitch about having to pay taxes for basic coverage and then still having to pay access fees. Then a political party comes along and promises to reduce the taxes or rebate the fees through the tax system AND THEN THE PUBLIC SYSTEM DOES FALL APART.

As long as politically both sides of the spectrum agree that fees are part of the triage process then I think we need to be open to experiments. In my opinion I think the saviest thing for the Feds in Canada is to be flexable with the Health Act and let the province of Alberta try some free market experiments. Then we can see what happens. Three years later we can judge if it was a success or a failure and take it from there.

Perhaps this is asking too much of our politicians to be this mature. Then again they did manage to pass free trade, kill the deficit, and stabalise the Canadian Pension Plan in the last 15 years. Maybe they can do it.

In the USA the problem is reverse. How to you get a minimum single pay system in place to work within a market system for health. I would be interested in hearing how that can be done. Do the politics of "property rights or death" make that impossible? Can you win one state at a time? Don't some states have pretty good public health systems now? Like Vermont? Why can't other states imitate the successful ones? Why does the federal government have to be involved? Money?

Posted by: Scott McArthur on March 12, 2004 02:38 PM


"I have no idea who this Russell Roberts that Patrick Sullivan cites is..."

Even when I identified him as "George Mason's"? And gave you a url to click on where you could read about him?

"But i do know that if Patrick Sullivan thinks that the only thing that has changed in health care since 1960..."

Speaking of people who ought to get out of the conversation, where did I OR Russell Roberts say that?

" the ratio of the total cost that government covers, he should leave the discussion now. The fact is, health care is markedly better is all kinds of ways..."

Which is changing the subject. A classic logical fallacy.

Posted by: Patrick R. Sullivan on March 12, 2004 04:00 PM


I did read somewhere- (sorry I don't recall where, so no citation)- that much of the problem with Canada's national health service is that they don't spend quite enough on it as a % of GDP and many of the problems would be alleviated with a 1% of GDP increase- (I believe the current figure is about 9% of GDP). But I do think, as a non-Canadian, that marketizing the system would create the danger of developing a two tiered system that might lead to the decay and eventual collapse of the system as the lower tier comes to become increasingly substandard and as doctors increasingly attempt to boost their income by bucking the system, (though, to be sure, there is already a significant brain drain to the U.S.A.) What a unitary national system does allow is systematic utilization review, such that resources can be prioritized with respect to the distribution of health problems and the efficacy of treatment outcomes. And, of course, it is only the government, qua death-dealing sovereign, that can make its decisions stick, provided matters don't degenerate into political football. As costs rise with an aging demographic, a deliberative determination as to just how much of an increase in spending relative to GDP is warranted needs to be arrived at, since it is the alleviation of unnecessary suffering and not the promise of immortality that is at stake. Similar concerns have been voiced over Blair's "foundation hospitals" in the U.K. Also, as for demographic projection and their economic effect, I suspect that the case is overstated, especially for the U.S.A. and Canada, as I think those projections will be counter-balanced with increased immigration. That is probably the case with Europe, as well, although there the demographics are much starker and the cultures have much more difficulty dealing with immigration.

Posted by: john c. halasz on March 12, 2004 04:24 PM


John C. Halasz:
No chance that Canadians could add 1% of GDP to support health-care. High-income earners are already taxed(all taxes fed to local) at very near 50%. Only a few disgruntled socialist professors call for still more taxes.
The Canadian armed forces, with missions in Bosnia, Kabul, and Haiti are near the breaking point. Sars and Mad cow require contingent planning for future emergencies.
And pre-baby boomers like me are now seeing the doctor more often. Have to go take the high blood pressure pill I forgot to take this morning.

Posted by: gb on March 13, 2004 09:07 AM


I agree that there is a general concensus to keep the top rate below 50%. But there are ways to get the revenue.
You could collect the money from the middle and lower tax bracket, it doesn't HAVE TO come from the top. There is some logic to this in that it is for universal medical care, not only the wealthy mus pay Health Care.
Or you could up the GST to 10%
OR lower the GST to 5% but extend it to all items including food.

I would also bet that the high blood pressure pill you are taking PROBABLY costs you less because you live in Canada and the provincial gov had the muscle to negotiate a better price for its citizens.

I still think we will see some private participation in the system in the next 5 years.

To US readers: when you add up all taxes fed to local what is the top marginal rate on average? Isn't it like 45%?

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Some things cannot be taught, only discovered.

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