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POLICY: Eric Novack responds

Here is a fundamental problem with the debate that Matthew is having with Amy Ridenour and David Hogberg: Matthew (and single payer advocates generally) focuses his attacks on the general ‘injustice’ that might exist in the healthcare system. In the face of such injustice, the theory goes, the government must step in to ‘even out’ the system (another way of saying that the ‘risk pool’ for unhappiness ought to be as big as possible—or, put another way, misery loves company).

“Free marketeers” (presumably an effort on Matthew’s part to turn those who believe that less government intervention actually is good for economies—for which the evidence is incontrovertible—into a pejorative) are generally no more happy with the current system than ‘healthcare-by-lobbyist’ activists (my own pejorative for bureaucrat run healthcare). However, people who believe in markets want to introduce free market reforms, recognizing that this process must be incremental.

Put another way—single-payer advocates speak in broad generalities of fairness and justice and risk pools—which sounds great to the public, but is short on actual policy implementation. Limited government advocates have, thus far, been focused on actual concrete steps to improve the system.

Which is easier to criticize? Of course you can attack an HSA more easily than an ‘everybody in/ nobody out’ risk pool.

To learn about the details of single-payer advocates, you actually need to read the legislation they are promoting. Here’s the basics: unelected bureaucrats are given complete control over budgets that
far exceed individual state spending (i.e. in Arizona, the single-payer plan would give a 9 member unelected group complete control over a budget ($30 billion) nearly 3 times the size of the entire state budget (about $11 billion)). It is not ‘socialized medicine’ because doctors and nurses and therapists and hospitals are not
employed or owned by the government—but government is the only legal purchaser of any services. Patients are explicitly banned from paying, with their own money, for any treatment, test or service, that has not been authorized by the faceless bureaucracy. In other words, it is Medicaid for all. Funding mechanisms for the single payer scheme are sketchy, at best (and given the recent failure in Illinois,the difficulties in Mass and Maine—single payer advocates need to keep it that way).

So, at the risk of putting my nose into Matthew’s post, let’s look at Matthew’s questions and Amy Ridenour’s responses:

“Why are you so happy to have a health care system that kills so many more people who have heart attacks, and amputates the feet of so many more diabetics?”

I don’t accept either of the two premises of the question.

I do not speak for Ms. Ridenour, but the premise of your question is that a single-payer, universal scheme in the USA would magically solve disparities in these statistics. Correct us if you disagree, Matthew.

“Ask the free marketeers to explain why they feel comfortable with a financing system that causes at least 25% of all the nation’s bankruptcies.”

Same answer as above.

At least, Matthew, you are not buying completely into the propaganda from PNHP authors Himmelstein and Woolhandler. A more complete critique of the failings of the original study are available from George Mason law professor Todd Zywicki, but the fundamental flaw is not the 50% number, but the fact that there is no ‘control group’. That is to say, the authors make no attempt to provide context as to other sources of debt, or the rates of households that have the conditions described in the paper, but DO NOT file for bankruptcy. Again, your premise is false and cannot be proven.

“Why [do free marketeers] espouse even greater cost sharing even though it’s been shown yet again this week that increased payment at the point of care reduces people’s likelihood of following their
doctor’s advice?

One argument for “letting” people control more of their own health care spending is that the people who earned the dollars have the highest moral right to decide how they are spent.

Here, single payer advocates like to have it both ways. On the one hand they speak of inability to get care, while simultaneously decrying that up to 50% of care is unnecessary. Which is it? Or is it both? And, again, how is it that an unelected bureaucracy, given complete authority over what care you can choose to purchase with your own money, do a better job of both MAKING people take the doctor’s advice, while simultaneously preventing the 50% of care they think is uneeded? Again, single payer advocates have no answer for this other than a ‘panel of experts’ that will be immune from criticism from individuals, but highly susceptible to the money and efforts of aggressive lobbyists.

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MattDavid HogbergVijay Goel, M.D.Tom LeithLaura Marshall Recent comment authors
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Matt
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Matt

It’s interesting to see Eric advocate against a massive government intervention in something that he believes that while, flawed, still largely works. Yet at the same time, he would impose “health courts” upon the patients. Innumerable “faceless bureacrats” will be necessary to administer those, and it will be ridiculously expensive. In advocating for them, he even says that they will help increase the amount of care patients recieve, yet he claims that much of the care, in the form of “defensive medicine”, is unnecessary.
What is the distinction, I wonder?

David Hogberg
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Laura,
Some thoughts on your comment about choices here.
Best,
Dave

Vijay Goel, M.D.
Guest

This post makes some great points regarding the “top-down” justifications coming from single payer advocates and the “bottom-up” solutions coming from the free-market camp. I think this highlights some principles in examining proposals coming from single payer and free market camps: 1) Single payer proposals are only as good as their approach to regulating care and obtaining funding. Where principles may make for great rhetoric, funding and administrative approaches will determine their success. Historically, single payers have taken the approach of top-down management commoditizing and regulating many of the actions of providers. This in turn has created rationing of care… Read more »

Tom Leith
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Tom Leith

> single-payer advocates speak in broad generalities > of fairness and justice And lassiez-faire liberals do likewise. The crux of the whole discussion is a conflict of vision concerning justice. > [single-payer advocates are] short on actual policy > implementation. I agree fully that in the face of great opposition single-payer policy implementation efforts have been largely ineffective. Thus far. But patient advocates and payers have been effective in getting lassiez-faire liberals on the provider side, the financing side, and the drug & device manufacturer side to make some very minor improvements in order to stave-off further attack. This counts… Read more »

Laura Marshall
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Laura Marshall

One problem I have with folks who espouse a “free market” for healthcare is that the customers in such a market don’t really have a choice about making a purchase. First, because if one is ill, one has only two choices when it comes to purchasing a healthcare “product;” getting it and surviving (or feeling better), or not getting it and having what measurement folks call an adverse outcome. Second, the idea that a “customer” could actually choose between doctors, or hospitals, or nursing homes with good comparison information is still disingenous; the data available to the public are rare… Read more »

James
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James

I just want to add one last thing about the argument for a single payer at least universal healthcare. Aside from a moral argument for the right to healthcare, there is of course the economic argument. In the recent report issued by the CWFund on international comparisons of healthsystem performance, it study ranked the US dead last out of six industrialized nations (the UK, Germany, New Zealand, Australia, and Canada). Germany was ranked 1st. Most tellingly, the US spends 16% of GDP on healthcare or about a little over $6,000 per capita. Compare that to Germany’s a little over $3,000… Read more »

Matthew Holt
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Eric. My piece is not saying that single insurance pools would solve all the ills of medical care inefficiency or inequity. Although they’d go further than our current non-system My point is simply that defenders of the current status quo are claiming that care is worse in other countries. Yet in many instances/disease states it’s clearly better. You and I are sensible chaps and we realize that the payment/financing system doesn’t cause all of these differences. But your colleagues on the free-marketeer/booty capitalist side of the house (as opposed to managed market types like me) HAVE been arguing loudly that… Read more »

James
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James

The is a definitive and fundamental difference between healthcare and other consumer goods such as cable tv, a cell phone, and restaurants, namely they are not necessary to your physical well being. You’re not going to die or suffer if you can’t watch tv. As for the providers that are forced to provide care through EMTALA regulations, yes they are very concerned about reimbursement, some of which is largely given through their tax-exemptions (the large majority of hospitals are non-profit). I think that providers and physicians are probably largely supportive of single payer or more likely universal healthcare since no… Read more »

Eric Novack
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James- in your last paragraph, you conveniently leave out the providers of healthcare, who are forced to provide urgent care with only the hope of any reimbursement. But the key questions are: ‘who’ should be in charge of the ‘rationing’ you believe is necessary? Who should make the everyday financial decisions for the ’45 million Americans who need to be protected from financial ruin’? Should those people be forced to not have cable tv? a cell phone? go out to eat? As I mentioned, the real ‘risk pool’ single payer advocates want to increase, is the pool of people dissatisfied… Read more »

James
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James

I think its rather unfair to lump Mass and Maine together. Admittedly, Maine is having some significant problems as pointed out by the recent NYTimes piece on it, namely, that Maine never issued an individual mandate and asked hospitals to voluntarily limit their margins and price increases to 3%. Voluntary sacrifice is never going to work. The health reform in Mass. is showing much more promising signs, which is a large reason many states, like CA, is looking to copy elements of the reform model. The entire aim of single payer is to create a more equitable (and this should… Read more »