T Nation

Health-Care Policy


Question: What is the best health-care policy we could have.

Assume we are not in a world of unlimited resources, but rather have a finite budget and that medical services are finite.

Note these facts, pointed out my Megan McCardle on her Atlantic blog:


According to a study that even the New Republic's Jon Cohn admitted he thought was probably exaggerated, being uninsured killed 18,000 people a year this decade. Methicillin-resistant Staphylococcus aureus, on the other hand, apparently kills 19,000 a year. ( http://www.nytimes.com/2007/10/16/health/16cnd-infect.html?_r=1&hp&oref=slogin )

The implication being that we could invest our health-care dollars in ways that are much more efficient at producing greater societal health than in universal health insurance.

Per Tyler Cowen, here are some more facts (and an outline for debate):

[i]How to debate health care policy
Tyler Cowen

Health care policy should be debated through micro-facts. Let's consider a few:

  1. American health care outcomes look much better once we adjust for race and other demographic factors, including violence and car crashes. Some groups -- such as Asian-American women -- have remarkably good health care outcomes.

  2. Some of the health care savings of other systems occur through price effects (e.g., doctors are paid an average of $60,000 in France) and do not involve real resource savings.

  3. American's high expenditures, however wasteful they may be, nonetheless drive much of the world's medical innovation. Medical innovation is also a public good to some extent and no the pharmaceutical companies are not simply parasites on the NIH and universities.

  4. America has a different structure of interest groups. and therefore a single payer system in the United States would not operate as does a single payer system in other countries. It would more likely favor the interests of doctors and insurance companies, for a start.

  5. If we take the international health results/expenditures data at face value (and we shouldn't), they imply that greater access to medical care does not itself improve health outcomes. So we should be careful in how we use and cite such results.

  6. Health care outcomes improve with income even under single-payer systems. Our best estimates suggest that this gradient is no steeper in the United States than it is in Canada.

  7. Having health insurance does improve your health care outcomes, but not to an amazing degree. The largest benefits are arguably the alleviation of financial risk, and no I am not meaning to slight that factor.

  8. Pharmaceuticals, unlike many forms of health care, have large and noticeably positive effects on individual health.

  9. The major Democratic health care plans on the table all, one way or another, admit they will spend more money on health care. The fact that other countries spend less therefore does not help predict the change in spending that would result from these plans.

(Sorry for the lack of links, I am on the road, google back to previous MR posts for documentations.)

Now here is how to debate health care policy. Ask a defender of single payer systems (or other possible reforms) how many of these points he or she accepts. Settle on that list, noting that residual disagreements may well remain. Then debate what the list means for what America should do about health care policy today.

Here's how not to debate health care policy. When you hear one point on that list, bring up in response that other countries spend less and produce better health care outcomes and that therefore we should copy the systems of those countries.

But libertarians, I am not letting you off the hook either: Isn't there some form of further government intervention into health care that could help somebody? And if your basic model is that governments steal as much money as they can, and then waste it all, shouldn't we then jump at the chance to institute health care subsidies of this at least partially helpful nature? The alternative is simply that the money gets wasted some other and worse way.[/i]


Answer: One that I can afford to pay for, one that I could choose on my own, and one that is accountable to me alone.


I don't have a total fix for it necessarily, but I got some ideas that can help.
First, we need foreign pharmaceutical competition. We are getting raped because the American pharmaceutical companies have carte blanch to do what ever the fuck they want. The same drugs over seas are a fraction of the cost and the motivation is pure money. Like wise with medical supplies in general.

Second, the FDA has to approve drugs faster.

Third, medical billing needs to be standardized and non-negotiable.

Forth, this is one of the few cases I am in favor of government intervention. The industry needs to be policed and penalties harsh when patients are taken advantage of. Also the insurance companies need similar policing. Things like certain procedures should be covered as mandatory. The insurance company should be held accountable criminally and financially if a patient dies or is permanently damaged because of a refusal to cover.

Fifth, malpractice suites need to be streamlined and capped. Perhaps even create an offshoot of the justice system to deal with strictly those cases. Frivolous cases should be dismissed immediately. Gross negligence should be dealt with as a crime as well as financial compensation.

These are just some thoughts. They are not perfect, but I think it would be step in the right direction. the one thing I am totally against is government care.

That's my $.05 (inflation).


Not too long ago, there was a post that contained some figures concerning Soc. Sec and and other "safety net" programs. The figures were well laid out, demonstrating just how staggering the spending and mounting debt is for these programs. I believe it was in response to a criticism of how much the US spends on defense, as opposed to socialist programs. Of course, these numbers made it clear that not only do we spend FAR more on such "safety net" programs, but that they are also unsustainable.

Anyways, on to my point. How in the world can anyone propose that the government provide a bigger "safety net?" We can't even afford what we have in place now!


Note that single payer national systems in Britain and Canada do not seem to make health care more egalitarian - i.e., there is still a strong association between health and income.

See this paper:



This paper reexamines differences found between income gradients in American and English children's health, in results originally published by Case, Lubotsky and Paxson (2002) for the US, and by Currie, Shields and Wheatley Price (2007) for England. We find that, when the English sample is expanded by adding three years of data, and is compared to American data from the same time period, the income gradient in children's health increases with age by the same amount in the two countries. In addition, we find that Currie, Shields and Wheatley Price's measures of chronic conditions from the Health Survey of England were incorrectly coded. Using correctly coded data, we find that the effects of chronic conditions on health status are larger in the English sample than in the American sample, and that 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.

And this paper:


Does Canada's publicly funded, single payer health care system deliver better health outcomes and distribute health resources more equitably than the multi-payer heavily private U.S. system? We show that the efficacy of health care systems cannot be usefully evaluated by comparisons of infant mortality and life expectancy. We analyze several alternative measures of health status using JCUSH (The Joint Canada/U.S. Survey of Health) and other surveys. We find a somewhat higher incidence of chronic health conditions in the U.S. than in Canada but somewhat greater U.S. access to treatment for these conditions. Moreover, a significantly higher percentage of U.S. women and men are screened for major forms of cancer. Although health status, measured in various ways is similar in both countries, mortality/incidence ratios for various cancers tend to be higher in Canada. The need to ration resources in Canada, where care is delivered "free", ultimately leads to long waits. In the U.S., costs are more often a source of unmet needs. We also find that Canada has no more abolished the tendency for health status to improve with income than have other countries. Indeed, the health-income gradient is slightly steeper in Canada than it is in the U.S.


Many people in Britain are quite dissatisfied with the national health care system:

[i]Record numbers go abroad for health treatment with 70,000 escaping NHS
Last updated at 09:47am on 28th October 2007

Record numbers of Britons are travelling abroad for medical treatment to escape the NHS - with 70,000 patients expected to fly out this year.

And by the end of the decade 200,000 "health tourists" will fly as far as Malaysa and South Africa for major surgery to avoid long waiting lists and the rising threat of superbugs, according to a new report.

The first survey of Britons opting for treatment overseas shows that fears of hospital infections and frustration of often waiting months for operations are fuelling the increasing trend.

Patients needing major heart surgery, hip operations and cataracts are using the internet to book operations to be carried out thousands of miles away.

India is the most popular destination for surgery, followed by Hungary, Turkey, Germany, Malaysia, Poland and Spain. But dozens more countries are attracting health tourists.

Research by the Treatment Abroad website shows that Britons have travelled to 112 foreign hospitals, based in 48 countries, to find safe, affordable treatment.

Almost all of those who had received treatment abroad said they would do the same again, with patients pointing out that some hospitals in India had screening policies for the superbug MRSA that have yet to be introduced in this country.

Andrew Lansley, the shadow health secretary, said the figures were a "terrible indictment" of government policies that were undermining the efforts of NHS staff to provide quality services.

The findings come amid further revelations about the Government's mishandling of NHS policies, and ahead of official statistics that will embarrass ministers.

On Wednesday, figures are expected to show rising numbers of hospital infections. Cases of the superbug Clostridium difficile, which have risen five-fold in the past decade, are expected to increase beyond the 55,000 cases reported last year.

On the same day, statistics will show that vast sums have been spent on pay, with GPs' earnings rising by more than 50 per cent in three years to an average of more than £110,000.

New research shows that growing NHS bureaucracy has left nurses with little time to see patients �?? most spending long periods dealing with paperwork.

Katherine Murphy, of the Patients' Association, said the health tourism figures reflected shrinking public faith in the Government's handling of the NHS.

"The confidence that the public has in NHS hospitals has been shattered by the growth of hospital infections and this Government's failure to make a real commitment to tackling it," she told The Sunday Telegraph.

"People are simply frightened of going to NHS hospitals, so I am not surprised the numbers going abroad are increasing so rapidly.

"My fear is that most people can't afford to have private treatment �?? whether in this country or abroad."

Low prices in India, where flights, hotels and a heart bypass cost less than half the price charged by British private hospitals, explain its top ranking in the survey by Treatment Abroad, a British website providing information on hospitals overseas.

Hungary's popularity rests on a boom in dentistry, thanks to a shortage of NHS dentists in Britain.

The British Medical Association advised people to be careful when considering treatment abroad, highlighting the dangers of flying soon after surgery, which can cause complications.

A spokesman said: "Travelling can place a great deal of stress on the body. Patients travelling abroad for surgery should consider their fitness to fly and get an understanding of an appropriate convalescence period before attempting to return home."

A Department of Health official said the number of patients seeking treatment abroad was a tiny fraction of the 13 million treated on the NHS each year.

Waiting times had fallen. Almost half of patients were treated within 18 weeks of seeing a GP. Most people who had hospital care did not contract infections. [/i]


socialized medicine = pure shit

at most there should be some kind of national health care insurace for low-income people, like what obama is proposing


Aren't you contradicting yourself with those two statements?

My question is when did health insurance become a right?


In a hurry: I really like the idea of extended Health Savings Accounts (coupled with natural tax breaks for them) and coverage for catastrophic events.

But also, a topic for consideration: making the threshold to sue a doctor for malpractice recklessness instead of negligence? This was suggested to me by, of all people, all med-mal lawyer.



socialized medicine?

why would a cheaper system with better results be horseshit?


I agree.

But I also think it's institutionalized recklessness to require residents to work 36, 40 or 48 hour shifts. Particularly surgical residents or residents prescribing or administering medication. And this is my opinion as, of all things, a corporate lawyer who hates lawsuits... =-)


Please refer to the 2nd-to-last paragraph of the initial post.


Nevermind nobody on the left actually wants to emulate UK's system...
But, yes brits participate in a medical tourism industry fueled by by the huge amount of americans escaping the high costs of US healthcare.

"Many Americans in Need of Coverage
More than 45 million Americans lack health insurance, and that number continues to grow. According to the Kaiser Family Foundation, between the years 2000 and 2004 the number of uninsured Americans increased by 6 million.

Mahoney believes that by looking at options outside the American health care system those who lack adequate insurance can get medical care at significantly lower prices. Often referred to as medical tourism, seeking medical care outside the United States is an idea that is taking off at new levels.

More and more Americans are looking across the border and overseas to get their medicine. Jeff Schult, author of "Beauty from Afar," a guide to medical tourism, estimates that more than 100,000 Americans a year travel beyond the boarder for cosmetic procedures alone.

In 2005, for example, Bumrungrad Hospital in Thailand served more than 50,000 American patients, a 30 percent increase from the previous year. Thailand is just one of the countries where foreign patients have flocked. India, Brazil, Costa Rica and Mexico all market themselves as medical destinations, according to Schult."


So yeah we both suck, but they're 40% of the cost.


didn't realize tyler controlled the debate here.


How much of that was from immigration, legal and illegal?

Here's something on the # of uninsured: http://www.reason.com/blog/show/122737.html




He doesn't - but perhaps you could play nicely and go with the premise? How do you assess points 1-9?


Cheaper like France is cheaper?

[i]French health care

Many people ( http://ezraklein.typepad.com/blog/2007/03/arguing_health_.html ) (Jon Chait also http://www.ajph.org/cgi/reprint/93/1/31.pdf ) argue that France has the best health care system in the world.

As of 2003, the average income of a French physician was estimated at $55,000; in the U.S. the comparable number was $194,000.

A visit to a GP's office (half of the doctors in France are GPs) had a reimbursement capped at 20 Euros, again circa 2003. It is not hard to pay ten times that amount in the U.S.

Did I mention that health care is a labor-intensive industry? ( http://www.google.com/search?hl=en&q=health+care+labor-intensive+industry&btnG=Search )

This is the major reason why French health care is cheaper than U.S. health care. France also spends less per unit on other inputs, such as prescription drugs.

Note that France still spends more than all or most other European systems, namely about 11 percent of gdp.

When comparing health care outcomes, France only does slightly better than many Mediterranean countries with obviously non-enviable health care systems. It is not obvious that France does better on health care outcomes than Japan, again a country with non-enviable health care institutions. In other words, France spends lots of money making people feel good about their health care processes, with only very marginal measured health care results. The United States also spends money on customer comfort, albeit in a more expensive and less egalitarian way.

It is easy to argue that the French system is better than that of the United States. But a defender of the French system must, in reality, fight "a war on two fronts," to paraphrase Derek Parfit. The French system does not, by the standards which have been erected in the debate, appear noticeably better than many other cheaper systems around the world. ( http://www.infoplease.com/ipa/A0004393.html ) It does spend more money producing "customer satisfaction" and papering over some of the obvious inhumanities of the cheaper systems. That's why it is easy to hold up as a model.

The disconnect arises because single-payer defenders wish to use international data to compare health care systems -- France > U.S. -- while pushing under the table the more radical (apparent) implications of that data, namely that France is spending far too much as well.

If we are going to be umm...transitive here, let's have the debate where it belongs: expensive health care with marginal impact on measured health outcomes vs. saving lots of money and giving people much less in the way of health care services. I do think there is a good case for the latter ( http://www.marginalrevolution.com/marginalrevolution/2007/03/from_mr_comment.html ), though looking toward the future I would myself prefer the former.

I might add I do favor taking action to lower doctors' wages in the United States. Letting in a greater number of qualified foreign doctors is step number one. But if we're going to criticize the U.S. system for its costliness, let's put the blame where it belongs.[/i]


Just what I want, the DMV running our health care.

When the hell does our government ever get anything right? I thought people were complaining about how the VA was treating their patients. And now people propose this same government take charge of all heath care.

Yes I know this wasn't the intent of the start of this post, but this is where people are foolishly going.

But think of it like this. The government does such a great job of managing its own budget, with that wonderful 9 trillion in debt. (Or 58 trillion if you include all of social security, not just the assets.) With a history like this, why would anyone ever expect the government to actually have some competence controlling health care costs?

This is like cashing out your 401K, and giving the money to a crack addict to manage.

To correct our medical care, those health savings accounts will help a lot. It turns health care back into a market.

Actually the best thing to do is get the health care industry to be more of a market. Wal-Mart made big news by putting out those $4 generics. I heard investment talk shows saying this was a big change to the market, and in one fell swoop, they took out the big margins in medicine.

I do think our government should consolidate the research acceptable to approve drugs to match other governments. Just so that a drug that has gone through tons of testing does not need to go through it all again just to be approved here, or in the other country.

One thing that annoys me are the drug companies that pay other companies not to produce medicine that qualifies for generic status. I have actually thought that if I someday was wealthy enough, I would start a non-profit company that specifically produces generics, and refuses all bribes.

Maybe a lower level part of the FDA could be developed that would allow supplements to make claims that are substantiated by research into the exact supplement being sold.

Some protection for doctors is in order. Class action lawsuits, otherwise knows as criminal lawyers using the legal system to steal money, should have significant restrictions in place. I have actually been the beneficiary of some of these lawsuits. (Got a coupon from a computer manufacturer that is no longer in business. And some money from a previous insurance company that I have to admit pissed me off, so I didn't have too much remorse for them.)

I used to just throw away the notices about these lawsuits, but now realize I should respond, and opt out of these things. (Strange how you do not have to give them permission to be your lawyer, and take legal action on your behalf. Hey, maybe there could be a class action lawsuit about that.)

I only recently found that the when the number of people uninsured in America is listed, 40 million, that over a third of them are actually illegal aliens. And the fact that illegal aliens are taxing the system, it should be of no surprise that those costs are passed on. Kind of like how the cost of shoplifting is included in the price of everything I buy.

Here is an idea. Dump any government care, and have them contract out health insurance policies. Anyone can get those policies, but has to pay for them. If a person wants, or needs the government to cover their health insurance, if they are able bodied, they actually work for the government to earn that insurance.

This is actually an idea I have had about all welfare. You want government assistance, you simply work for it. I am sure there are plenty of things the government needs done. People simply choose out of a list of those things, and only work to the point that they get their benefits.

The benefit is that the government gets more work for all the money they give out, there is no qualifying, so fraud is dramatically reduced.

One of the problems with welfare is that at some point attempting to get off welfare is more like punishment. If you work, you get less benefits, and the benefits are sometimes worth more then the work, so what is the point of working?


The VA in general has a great care to cost ratio, I think you're confused about problems at a particular hospital.

Also every politician seems pleased as punch with their health care (obviously)
If its good enough for the President and Rudy's prostate, it's good enough for me.


VA or just regular DOD care. It all sucks. I'm still busted up and can't get the bastards to fix me. They didn't fix me while I was in, they won't try to fix me now that I'm out, and they'll fuck it up again when I go back in.