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Single-payer systems aren't so egalitarian, part II
...[compared to the United States] income plays a larger role in buffering children's health from the effects of chronic conditions in England. We find no evidence that the British National Health Service, with its focus on free services and equal access, prevents the association between health and income from becoming more pronounced as children grow older.
Here is the paper. Of course equity is not the only argument for single payer systems. Here is part I of the series, concerning Canada and the (possible) continuation of the health-income gradient there. Many of you were skeptical about the reported result, but here is further evidence. Most of all, the determinants of health are not well understood; that is itself a sobering fact no matter what your policy point of view.
Posted by Tyler Cowen on October 19, 2007 at 11:14 AM in Medicine | Permalink
Comments
I really don't think the egalitarian issue is so important to leftists like myself. What is more important, and hence is lifted in priority after the cost-benefit analysis, is the construction of a base floor of benefits for the lower/lowest cohorts of society. As long as the bottom is getting a "sufficient" amount of health care, I don't much care what excess the top helps itself to. If you care about costs primarily, then that's one obvious place to look. As I mentioned previously though, any society that can fund an endless Iraq war to the tune of 100s of billions of dollars a year without sacrifice is not financially constrained.
Posted by: Russell L. Carter at Oct 19, 2007 11:41:57 AM
"What is more important, and hence is lifted in priority after the cost-benefit analysis, is the construction of a base floor of benefits for the lower/lowest cohorts of society."
If that is the case why aren't we talking about expanding Medicade to cover all uninsured people, rather than having the government occupy the whole field in a universal health care program?
Posted by: Sebastian Ho at Oct 19, 2007 11:48:10 AM
"f that is the case why aren't we talking about expanding Medicade to cover all uninsured people, rather than having the government occupy the whole field in a universal health care program?"
In principle *I* would have no problem with this. The problem is the actual implementation; does this approach achieve a health care floor in rough equivalence to that of other wealthy countries all of which have universal coverage? I haven't seen that argument made yet. Ezra?
Posted by: Russell L. Carter at Oct 19, 2007 12:00:45 PM
Russell L. Carter,
Why do leftists want to remove all the incentives a human might have to be productive?
The poor in the U.S. receive:
1. food (food stamps);
2. shelter (subsidized housing);
3. education for as long as they take advantage of it;
4. a much better return on social security contributions;
5. heating and cooling (subsidized utilities);
6. transportation (heavily subsidized bus and train systems);
7. legal assistance ("If you cannot afford an attorney, one will be appointed for you");
8. freedom from income taxes.
I could find much more if I had the time to waste. The point is, we've been directly and indirectly throwing huge sums to the "poor" in America, and their numbers haven't changed. The problem is very simple: we are allowing the unmotivated to escape responsibility for their own welfare. Expanding Medicaid would be just one more failed government welfare program.
9.
Posted by: John Dewey at Oct 19, 2007 12:30:26 PM
Yes, I too fully support making the unmotivated not escape responsibility for their own welfare! They can get their own heating and cooling, thank you very much. And the poor are free from the burdens of income tax -- let's add some income tax along with the withholding to show them what for!
Plus they aren't using those Sixth Amendment rights anyways. Public defenders are far too good for them!
More seriously, while sympathetic to the notion of motivating the poor to be *not* poor, often its not merely a matter of motivation. I think a modern society does require a minimum standard of education and reasonably safe living conditions. I'm not sure how you "motivate" people into middle class lifestyles by jacking up their heating bill.
DU
Posted by: The Mechanical Eye at Oct 19, 2007 12:47:35 PM
I think that this all shows that the impact on average health of medical care beyond the cheap stuff (vitamins, vaccinations and antibiotics etc.) is so much smaller than other factors that it is undetectable. So to me the remaining question is: What is the best way to reduce what I will call the consumer deficit in healthcare. What I mean by the consumer deficit in healthcare is that I think that most Americans, especially later in life, would like to trade a lower their chance of surviving a very expensive disease for having more money throughout life. IMHO the average American would rather spend the amount the French spend on healthcare (7% of their smaller GDP) and get less healthcare care. For example I think that you offered Medicare recipients the value of the care that they are about to receive in dollars that most would keep a significant amount of the money and pass on the care. Like if the money was delivered to the patient on diagnosis many would take the money and deal with certain disease without certain procedures (some might also choose to go to Apollo healthcare in India and have their cake and eat it to). BTW from what I understand a significant number of Britains use Apollo healthcare in India to avoid queues for certain procedures.
Posted by: Floccina at Oct 19, 2007 12:50:09 PM
Medicaid already covers the poor. IMHO the one expansion that might make sense would be to expand it the chronically ill or those who can show that they have been turned down by multiple health insurance companies because of existing condition. These people could be charged for the coverage in means tested manor.
I do not know how you would avoid, in this case, having the insurance companies drop anybody after having to pay for their first big bill but it is an idea. Maybe it would lead to health insurance that pays a set amount on diagnosis? Which might be good.
Posted by: Floccina at Oct 19, 2007 1:01:52 PM
"Of course equity is not the only argument for single payer systems."
You frequently mention some variation of this theme. Let's suppose that a single payer system didn't change anyone's health. Suppose that all it did was a) reduce overall cost, b) eliminate the chance of financial ruin that people without health insurance currently face, and c) eliminate time wasted fighting with insurance companies over what is and what is not covered.
Wouldn't it be worth doing for these reasons? And if someone wanted to get private insurance on top of the basic universal coverage, they'd be free to do so.
Posted by: Jeffrey Miller at Oct 19, 2007 2:01:41 PM
Jeffrey,
And what if single payer did none of those things? What if it really doesn't reduce costs? What if people are still bankrupted by costs that the government program will not cover? And I don't know how you even accomplish (c) since someone, somewhere, has to actually say no at some point, if you have any hope of accomplishing (a), so you will always have arguments about what will be covered, and what will not.
Posted by: Yancey Ward at Oct 19, 2007 2:10:55 PM
The mechanical eye: "I'm not sure how you "motivate" people into middle class lifestyles by jacking up their heating bill."
First, we're not talking about jacking up their heating bill. We're talking about NOT jacking up everyone else's heating bills because a few get a free ride.
You could make your same statement about food stamps or subsidized housing or any other welfare benefit the poor receive.
Unmotivated humans are going to remain unmotivated humans as long as someone else provides for them. What is difficult to understand about that?
Liberals will help the unmotivated far more if they would simply help the rest of us show the unmotivated that we have confidence in their abilities. Instead, we continue to hear how a segment of the population cannot make it on their own.
Posted by: John Dewey at Oct 19, 2007 2:15:04 PM
John Dewey wrote:
"Liberals will help the unmotivated far more if they would simply help the rest of us show the unmotivated that we have confidence in their abilities. Instead, we continue to hear how a segment of the population cannot make it on their own."
To a certain extent are many poor people saying "all those good things are not worth the effort". Are are many poor people by their actions saying "I am content with very little" or for example saying "I value my money and leasure more than health insurance". Or is it beyond human control are people born to a level of diligence. IMO at least some people are can be motivated externally.
Also a funny thing IHOM is that the biggest motivation to work hard to get into the middleclass for many is not wanting to live in a "bad area", that is an area where poor people live.
Makes me wonder would more police help. Would more police make people more happy to live in a poor area.
Posted by: Floccina at Oct 19, 2007 2:52:24 PM
Floccina,
I've seen it argued that the best economic policy is to flood high crime areas with police because as it stands the citizens there do not even have basic property rights.
Posted by: 8 at Oct 19, 2007 3:15:49 PM
>And if someone wanted to get private insurance on top of the basic universal coverage, they'd be free to do so.
Which is only useful if the public delivery system hasn't decided it needs to strongarm most providers into effectively making a nearly absolute choice between public and private billing.
Posted by: lrC at Oct 19, 2007 3:37:30 PM
"If that is the case why aren't we talking about expanding Medicade to cover all uninsured people, rather than having the government occupy the whole field in a universal health care program?"
There is a widespread misperception that Single Payer always translates to Government Health System. It doesn't have to, and given the current established medical infrastructure in this country probably couldn't. We don't call it Single Provider, we call it Single Payer, and I think most supporters of Universal Coverage would be perfectly happy with a Medicaire for All solution here.
People who point with alarm to this or that aspect of the British or Canadian system are more or less putting up strawmen. You could implement Single Payer in the US tomorrow with almost no disruption, hospitals and doctors by and large already know how to bill Medicare, the savings are in eliminating the for profit insurance companies and perhaps some extra preventive care for the uninsured.
Posted by: Bruce Webb at Oct 19, 2007 4:09:07 PM
Floccina, I've also wondered about why poor people live in high-crime areas. He in Greater Boston, a two-bedroom apartment goes for about $1200/month in high-crime Roxbury and between 1100-1200/month in bucolic Melrose, where I live. Throw in the added bonus of much better schools and less expensive staples at the supermarket, as well as not dodging bullets on a regular basis.
The bottom line is there are people caught up in a cycle of making rotten choices in life, and our welfare state aids and abets this behavior!
Posted by: brutus at Oct 19, 2007 4:10:26 PM
Most of all, the determinants of health are not well understood;
See: Why stupid people die younger and the whole area of Cognitive Epidemiology.
Posted by: Loki on the run at Oct 19, 2007 4:30:53 PM
Yancey,
Pretty much every country in the world with the exception of the US has a single payer system and they spend less per capita and they get results that are as least as good, so it should be possible to implement such a system here. The contrary position - that it wouldn't work in the US - relies on the claim that the US is exceptional which I find unpersuasive.
Posted by: Jeffrey Miller at Oct 19, 2007 4:31:37 PM
"Pretty much every country in the world with the exception of the US has a single payer system and they spend less per capita and they get results that are as least as good, so it should be possible to implement such a system here. "
So then we should find which one spends the least per person and implement a plan that would cap spending at a slightly lower level lower than that.
Honduras, where I once lived, has a system where you can go to a Government hospital for free or a private hospital where you pay full price. Do you consider that a single payer system? If so how much do they spend per person. BTW I once had a procedure done in a hospital in Honduras, I would not do that again, It is a long story but I was tricked into it. Cheers. Perhaps some how beleive stats out of Cuba would like us to duplicate their system as much as possible. They cannot be spending much on healthcare.
I am of course being facious. (smile)
Posted by: Floccina at Oct 19, 2007 5:00:18 PM
Floaccina,
I had Canada and New Zealand and Australia more in mind than
Honduras. I had an interesting talk with some people in Australia last winter about their health care system. They told me that the public hospital were actually way better than the private ones. They also said that when Australia switched to a single payer system (I think in the 1970s) the insurance companies and other interested parties trotted out the same stories we hear in the US about how it would be a disaster. Didn't turn out that way of course, not has it in any other wealthy country.
Posted by: Jeffrey Miller at Oct 19, 2007 5:16:07 PM
Jeffrey Miller speaking of Canada and New Zealand and Australia you know that their systems have not solved the problems in my links below, so the only benefit IMO would be money saving so why not advocate the level of spending of France, 7% of their GDP that would be maybe 5% of our GDP. From what I read the Dutch just set the level at 10% of GDP. Why not set our level at 5% of our GDP. Health may suffer a little but the evidence is that it would suffer very little. I am just throwing out ideas I still have hope that if spending in the USA keeps rising at some point it will get to a breaking point and some entrepreneur (or non profit) will step in with a creative solution to provide really cheap medical care. The book Overtreated implies things were better when not for profits provided for all the hospital and the theme was “the margin pays for the mission”.
http://www.guardian.co.uk/australia/story/0,,1802705,00.html
“The damning figures also show that 70% of the Aboriginal population, who number almost 500,000, die before the age of 65, compared with 20% of non-indigenous Australians. The average life expectancy for Aboriginal men is 59, compared with 77 for non-indigenous males, according to the report by the Australian Institute of Health and Welfare.”
http://www.cbc.ca/story/canada/national/2005/04/11/UNNatives-050411.html
“Life expectancy among the Inuit is 10 years lower than the rest of Canada.”
http://findarticles.com/p/articles/mi_m0PCG/is_2002_Sept/ai_105657385/pg_4
“In New Zealand the difference between Maori and non-Maori life expectancy was 8.1 years for males and 9.0 years for females. The situation in Australia, even allowing for some variability in the reliability of the estimated life expectancies, was dramatically worse, with differences of 21.5 years for males and 20.0 years for females. Indigenous Australians can expect to live only around three-quarters as long as all Australians. Maori, on the other hand, have an expectation of life about 90 per cent of that of non-Maori.”
Posted by: Floccina at Oct 19, 2007 5:51:03 PM
Floccina,
Setting a cap on taxpayer paid for medical expenditures as a fraction of GDP is fine with me.
And I agree (as I'm sure most people do) that a single payer system would not solve all social ills. It just would be a lot cheaper and fairer and less complicated than our current system and would achieve the same health benefits.
Posted by: Jeffrey Miller at Oct 19, 2007 6:49:30 PM
John Dewey's comment should be evaluated in the context of his previously incoherent suggestions. For example, he has asserted that it is good for small business if big business enjoys preferential government subsidy explicitly biased against small business, that is the employee health insurance deduction. The Republican, if not ethereal platonic conservative, mind at work.
Just to throw on some more gasoline, since I'm a leftist, you should know that I think the health care benefit floor ought to extend to something like all those families making less than $100,000. I'm not picky about the exact number but it should definitely apply to a big chunk of the middle class. And this is key, it must not be tied to the employer.
(Full disclosure my household makes more than the hypothetical)
Now off to make some sweet & sour pork according to my Encyclopedia of Chinese Cooking. OJ & tomato sauce from the garden providing the "sweet". Yum.
Posted by: Russell L. Carter at Oct 19, 2007 8:22:16 PM
"we are allowing the unmotivated to escape responsibility for their own welfare."
This (mis)-belief cuts right to the heart of deciding what kind of society you want to live in.
Assume everyone who is poor is lazy and thus 100% responsible for their own misery - do we, as a society, let these people die on the street or do we attempt to help them in some manner?
Do we let people perish because they weren't "motivated" enough? How do you define "enough?"
Posted by: Matt Levin at Oct 19, 2007 8:29:55 PM
Jeffrey, how is a UHC system "fairer" if, as the evidence suggests, income makes more of a difference to health. If we look to results instead of intentions, the UK and Canadian systems are less fair. Why don't those results matter? Why do UHC proponents want to move to a system that is less fair? Why do they hate the poor so much?
Posted by: Thomas at Oct 19, 2007 9:43:42 PM
Do we let people perish because they weren't "motivated" enough? How do you define "enough?"
I think you are defining "people" too broadly.
Posted by: perianwyr at Oct 19, 2007 10:30:56 PM
