POLICY/POLITICS: The swiftboating of single-payer?

Here’s my FierceHealthcare editorial today

Last year the most viewed article in Health Affairs was an article suggesting that 50% of bankruptcies in America were in some part related to medical costs. The article was written by a group led by two of the intellectual leaders of the single payer movement, Harvard professors David Himmelstein and Steffi Woolhandler. This week their findings were challenged by two Northwestern-affiliated researchers, David Dranove and Michael Millenson, who reviewed their data and claimed that the number was closer to 17%. They also suggested that the not as many of people declaring bankruptcy were as solidly middle class prior to their medical catastrophe as the Harvard group had suggested. Himmelstein et al shot back saying that the Dranove and Millenson had got their math wrong, and that they were lackeys for AHIP the health insurance industry group that sponsored their study — even though it was a peer reviewed article which AHIP funded but didn’t control. Some of their supporters accused Dranove and Millenson of "swift-boating".

Why is this obtuse academic dispute so important? Whatever the facts, and facts are very malleable in our political debates, the role of the middle class in health reform is vital. There is incontrovertible evidence that lower-income Americans have disproportionately higher health costs out of pocket than poorer people in other countries. But 100 years of history shows that politically this doesn’t matter too much. If it becomes accepted that middle-class, middle income Americans are equally vulnerable to financial catastrophe due simply to bad luck with their health, then the political discussion might shift. So this is one of those occasions where, as Keynes said, the scribblings of some (not-yet) defunct economist might actually matter in terms of politics and policy.

UPDATE:  If you haven’t had a chance yet, you can listen to this week’s podcast of my converstation with Millenson on this very topic. 

14 replies »

  1. Sham peer review is mobbing, false accountability, or just plain destruction of a professional career, persona, and indirectly, low cost healthcare. It has gone beyond the education profession in the ivied towers of colleges and universities. It has, like a cancer, metastasized into dentistry. The dental profession has taken a back seat to the medical in more than earned incomes. It has rarely earned a second look by the federal government for false and misleading advertising, excessive and unnecessary procedures, over charging, Medicaid fraud, and destruction of careers through sham peer review. The dental profession has managed to fly unobtrusively below everyone’s radar. Dentistry is the stealth bomber that is aiding and abetting the spiraling healthcare costs that are quickly bankrupting our national treasury. The latest and only expose of sham peer review in dentistry to be published, is “The Maine Conspiracy” by Dr. Aaron and Marie Greenwald. Visit http://www.themaineconspiracy.com

  2. I haven’t read either of these studies, but what’s going on here is clear enough anyway. 🙂
    Let’s assume, for the sake of not having an “argument” that the number is “only” 17%. (More likely it’s all a matter of how you measure and associate health care costs to bankruptcy….I bet almost ALL bankruptcies are in part associated with medical bills or illness of some kind.)
    That alone is a POWERFUL reason to consider single payer.
    There are at least 50 other good reasons.
    Imagine the effect on our economy when people don’t feel trapped in a job they would rather leave; but cling on to just for “the benefits”? Imagine how many minimally productive folks would go out and find work doing something they love if it were not for the fact that they had to have the “benefits?
    Imagine the effect on our economy when we don’t spend hundreds of billions of bucks on all the marketing/administrative costs of hundreds of “competeing” insurance companies?
    Imagine how much less stress and money would be wasted if doctors and patients didn’t have to fight insurance companies tooth and nail for reimbursement?
    Etc etc etc….
    And don’t forget about all the folks whose lives would be saved and/or improved when they got to go to a doctor at the beginning of a problem instead of at the point where it became an ER issue?
    Single payer makes sense in economic AND moral terms! It’s obvious on its face.
    The status quo is corrupt. The fact that it can hire smart credentialed folks to make a “case” for it is not surprising.
    All the hundreds of billions that would be saved by SP saved is money THEY wouldn’t get!
    Look at all the cash being pissed away to minimize the PR effects of the reality of global warming, despite the fact that it is objectively real!
    Hell, the nicotine industry STILL doesn’t buy that it is directly indisputably causative of cancers!
    Himmelstein is right; Bush et al are wrong.
    With a few rare exceptions, the academic establishment is just as corrupted by big money and personal ambition as is the political arena.
    Cut the BS, this is all about keeping a status quo that keeps on generating more billions/trillions of dollars in profits, and human life be damned.

  3. David Himmelstein and Steffi Woolhandler used an undercurrent of angst to promote a study that was flawed. When it came out I thought the conclusions didn’t make sense. However, no one seriously questioned it in the open because they felt the “ends justified the means”. Now, two guys ( Dranove and Millenson) call BS on the study and everyone questions the motives? That’s BS.
    The original study was a propaganda tool. The Dranove and Millenson study debunks it. That it was funded by AHIP, so what? Good research can’t come out AHIP funded programs? The point is, if Dranove and Millenson legitimately shot holes in the original study than trash the orginal study. For those who still want universal health care, the debunking of the original study does little to your arguments. So, call a spade a spade and move on. Those Harvard boys screwed it up royally!

  4. Eric,
    That is because FOX has not seized onto healthcare issues just yet. They are busy defending today’s agenda.
    Once there is a credible threat of real change to single-payor happening they will be all over this. Imagine how would Bill O’Reilly frame the issue!
    That would be a media circus to watch. Remember the campaign against Hillarycare?

  5. Where was the intellectual outrage when the initial study was published? That the authors of the initial study are avowed opponents of the current healthcare system and, not surprisingly, produced a study that maligned the current system should surprise nobody.
    The problem is not that the intial study was very flawed or that AHIP funded the subsequent study; rather it is that the popular media did not publish this study but put Himmelstein’s article on the front page.

  6. Look, if Dranove and Millenson were so concerned about the study then how come they didn’t rush to publish a letter criticizing the study before taking AHIP’s money. They didn’t care until AHIP waved dollars in their face. As he says in his podcast, “I’d be happy to beat up anyone.” He was even happier that he got paid for it.

  7. To imagine that David Dranove and Michael Millenson did not know who their patrons were is just BS. What happened is that AHIP knew the result they wanted. They HAD ALREADY RUN THE NUMBERS. Dranove’s and Millenson’s article is not rocket science and the problems with the original study are not unknown. In fact, the original study was poorly done and did border on advocacy. How the original article got published without more changes (or at least caveats) is probably a story in itself. What Dranove and Millenson did was take money so that they could slap their reputation on facts that AHIP already knew, but knew if presented by anyone other than respected academics would be dismissed out-of-hand. I have no problem in imagining that Dranove and Millenson resented the publicity that David Himmelstein and Steffi Woolhandler got for a poor study and enjoyed deflating them. The fact that they were political tools for AHIP in the process did not come into their consideration, but that’s exactly what was happening.
    One of my favorite sayings, “just because you’re paranoid doesn’t mean they’re not out to get you” applies. Just because Dranove and Millenson debunk a poor study with facts doesn’t mean that their attack wasn’t blatantly about AHIP’s politics (and not facts).

  8. No, not science and mathematics. But social sciences tend to get entwined with politics – BIG time. People who fund this type of research tend to have an agenda.
    Spike is correct that flawed reasoning gets exposed, eventually. But neither flawed reasoning nor mechanisms to get it smoked out is the monopoly of academia.
    My point was that “ideological warfare” spills out into academia too. We cannot presume something valid, just because there is a “study”.
    What if Millenson, Dranove or anyone else did not bother to rebut? Would you take the original study at face value?

  9. Academia is only BS when it disagrees with your point of view. Spike is right. academia does have a systematic way of constantly putting theories to the test. Or else you are suggesting that science and mathematics are simply “ideological warfare”?

  10. I would deny that because adademia does have a systematic way of ensuring that poor studies are revealed for what they are. The fact that Millenson and Dranove could rebut the “50%” number so effectively shows that facts do still matter in academia. That’s my take on it, anyway.

  11. It’s amazing to me when academic research falls prey to political strategery. Is it really so uncommon in the academic world that researchers test the theories put forward by other researchers? I thought it was these empirical test that made academia sort of immune to quacks, crack pots, and voodoo reasoning.
    So a couple of liberal leaning, elitist Harvard professors get their panties in all in a bunch because someone (some punks from Northwestern even) questioned them?! It no longer becomes a question of the quality of research but an issue of motive and political gain. Its absurd!

  12. Yeah, IMHO David/Steffi made a mistake by coming after their motives, rather than just attacking them on their “misuse” of the data (which even as a sympathiser I think they stretched to bending point in the original article, by including things like gambling debts as medically related). Millenson at least (I don’t know Dranove) is a solid Democrat moderate, albeit one who enjoys deflating sacred cows and pointing out the obivous — that single payer is not a political winner as yet — than one who’s dirven by the search for a political solution.
    Saying that just because it was AHIP’s money, they were biased, opens David/Steffi to the charge of not disclosing their political/ideolgical biases when they publish data (not that we don’t all know what they are). After all they all go through the same peer review and AHIP had no say in the research or the process….and might have been happier if the result was under 10%!
    I think that there is an avenue for leftist reformers suggesting that the middle class might join the other half of Edwards “2 Americas” using current data on employemnt sponsored health insurance and out of pocket costs alone. It’s happening to many more people than it used to, and survey data for decades have shown that high out of pocket costs leads to high dissasitfactoin with the system. That’s going to be AHIP’s achilles heel

  13. Quoting Dranove and Millenson:
    “We admit to being unprepared for the political attack-dog tone that dominates [the Himmelstein et al.] response…Perhaps Himmelstein and colleagues are simply taking out on us their frustration that middle-class American voters have ignored their decades-old advocacy of a Canadian-style health system…
    We agree with Himmelstein and colleagues that too many vulnerable Americans are financially devastated by the cost of illness. They seem to regard with a sense of outrage our objective examination of the methods they use to establish just how many such individuals there are. We, in contrast, continue to believe that passion to right a wrong does not justify abandoning dispassionate analysis of the best way to do so.”
    That’s good stuff, in my humble opinion.
    Trapier K. Michael