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POLICY: Now I’m just messing with her

So Amy Ridenour actually almost did what I asked and went and answered the questions for the free-marketeers I posed in Spot-on. My email has been broken all day and I’m grumpy, so I thought I’d cheer myself up by replying to her replies. This is mostly gratuitous dancing in the end zone on my part. So those of you who believe in the sanctity of erudite debate may want to skip it. The rest of you can join me in the gutter….

My questions from the Spot-on piece (originally titled “How to talk to a free marketeer”) are in red. Her replies in italics. My replies to her in regular text

“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.

Why not? The data—which I referenced in the Spot-on piece—comes from the Annals of Internal Medicine quoting the OECD. That shows that people suffering heart attacks are much more likely to die here than in Iceland, Denmark and Switzerland, and diabetics are much more likely to have their feet amputated than in Canada, Australia and a few other places. Is Amy suggesting that the statisticians in those countries and here are all lying in a massive fraud perpetrated by the Health Care Quality Indicator (HCQI) Project of the OECD? Funny, because that’s the same data source which produces those breast cancer survival rates that so many on the right wax all lyrical about. And if the data is right, why doesn’t America have a case to answer? We’ve heard enough about cancer care from the right!

And BTW the question has two halves but only one premise! To be clear—it’s not logically consistent to say we’re the best at treating disease by only looking at one or two diseases!

“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.

The same answer as a non-answer? Pretty curious. Perhaps health care costs don’t actually cause bankruptcies, or at least not at the 50% rate that Himmelstein and Woolhandler claim. But the 25% number comes from the reworking of the 50% number by Dranove & Millenson, which was in part funded by AHIP. So even they acknowledge that it’s a problem? But Amy “doesn’t accept it”. Can’t argue with that logic, I guess. I mean you literally can’t argue with it!

“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.


So now it’s about the moral right to spend your money the way you want. I have no problem with that. Unfortunately those like Amy occupying the high moral ground don’t seem to care that the little people who have to choose between spending money on doctor visits and drugs or on food or rent—and yes there are some—are likely to not take their drugs or get needed care. She may feel all moral and good about that, but there are direct consequences. The most obvious being that more expensive things need to be done to them later (like the diabetics getting their feet amputated). Which of course the little people don’t pay for (at least not monetarily), but the rest of us do. But I’m glad she sees the moral rather than the practical effect of cost sharing at the point of care.


Another argument, which Matthew Holt presumably knows already, is the theory that folks who are spending their own money will shop around for the lowest prices, thereby adding incentive for health care providers to keep prices competitively low.


And while we’re at it, which country has the highest prices at the point of care for drugs and office visits? And which one has the highest proportion of consumer spending out of pocket on those drugs and office visits? Could it be that it’s the same one? As in this one. And how does that work in Amy’s theoretical model? Maybe she’ll enlighten us.


“Why do you want to raise taxes in order to transfer money from the poor and sick to people who are already richer and healthier than average?”


I don’t. Nor during my working lifetime have I seen many examples of tax increases afflicting primarily the poor and the sick (though perhaps tobacco tax increases could be considered an exception; those of us who opposed those, however, were considered to be puppets of Big Tobacco). My primary health care concerns are these: I oppose a U.S. adoption of a government-run, so-called “single payer” or “universal” health care system because I believe it would lead to needless misery, pain and death. I also am extremely concerned about Medicare’s poor financial prognosis (which I also believe will lead to an ever-worsening standard of care under Medicare). I do not believe that my position on either of these means I “want to raise taxes in order to transfer money from the poor and sick to people who are already richer and healthier than average.”


Now I’m a dumb guy so I’m having trouble following Amy here. It’s good that having criticized me for using the terms “screwed up” and for being “emotional” she remains so coldly analytical while accusing universal health care of causing “needless misery, pain and death.”


But original question was unconcerned with the desires of evil government single-payer bureaucrats to ration pre-natal visits for the first 10 months of pregnancy and the like. Instead it referenced the desires of some on the right to give everyone their own personal account with all the nation’s health care dollars divided up proportionally in it. I simply pointed out that if we do that, then money that previously would be spent on health care would instead remain in the accounts of those who are healthier and wealthier than average. If we were to continue to care for the sick in such a system then someone would have to pay the equivalent that’s now sitting unused in those accounts to cover it. That someone would either be the sick themselves, or the taxpayer or both. In my humble economics, that’s a transfer away from taxpayers (who are presumably of average wealth and health) and from the sick (who are of less than average wealth and health) to those who are healthier and wealthier. Amy may not believe that this is a good idea, but in that case she should refute the personal account concept and join those of us who believe in a social insurance model as being the only effective way to pay for health care. I somehow doubt that’s where she’s at.


So there you have it. All my questions completely answered to the satisfaction of anyone who doesn’t care about logic, health services research, or reality. The rest of you may be awaiting her man Hoggy’s shot at it coming soon.


And for those of you who really can’t figure out what “rent-a-quote” means, look at this obituary.

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8 replies »

  1. Barry – I think that it’s rather obvious that Mr. Holt does not intend to defend his assertions concerning diabetic amputations – but would rather brand anything counter to his argument as “rubbish”. His justification is merely because he says so.

  2. Matthew,
    I’m interested in your reaction to this graphic from Ezra Klein’s blog showing the percentage of the population over 15 years old in various countries with a Body Mass Index (BMI) greater than 30. The U.S. is in a class by itself here while the other English speaking countries have higher rates of obesity than other countries in Europe and Asia.
    I believe that the very high U.S. obesity rate (and associated diabetes) has a lot more to do with lifestyle, diet, culture, and poverty rates than the healthcare system or the percentage of the population that lacks health insurance. The U.S. also has much higher rates of heart disease for the same reasons with at least some of it connected with diabetes. On the other hand, the U.S. now has the second lowest percentage of the population who smoke (after Canada) which I attribute to the steep increase in cigarette taxes implemented in recent years. I think that is an example of both good tax policy and good health policy.
    Both diabetes and heart disease can go undetected for years until a major event like a diabetic coma or heart attack occurs. I recall having surgery in an NYC academic medical center in 2004. My roommate was a young guy in his 20’s who qualified for Medicaid. He went into a diabetic coma and had to have his foot amputated. He never presented himself to a healthcare provider until it was too late even though he had insurance and NYC has plenty of good hospitals that serve the poor. I wonder to what extent these adverse outcomes among people with diabetes and heart disease relate to this issue of waiting until it’s too late to seek care. This could be another instance where poverty and ignorance are more important factors than anything to do with the healthcare system.
    With respect to cancer of all types combined, there seems to be much less difference in the number of cases per 100,000 population from country to country. Except for lung cancer, diet, lifestyle and culture appear to be less important factors, though preventive care plays an important role in catching at least some types of cancer early when it is much easier to treat.
    Bottom line: I think you may be attributing too much of the difference in diabetes and heart disease related outcomes among countries to differences in the healthcare system and not enough to diet, lifestyle, culture, and poverty rates.

  3. That’s right Mr. Holt. You refuse to address the point without resort to ad hominem attacks. Are you saying that the health care system plays as big a role in diabetes outcomes as it does for cancer outcomes? Are you kidding? And you’re worried about my credibility?
    Your rubbish about free marketers needing to defend diabetic amputations is just demagogic bombast.

  4. That’s right Mr Browning. The holocaust and the Waltons paying less tax so that average taxpayers can pay more are morally the same because they both happened to minorities of the population.
    And you expect anyone to take you seriously? I’m sure not, but I’m slowly beginning to enjoy the laugh you’re starting to bring. Which is an improvement anyway.
    For your homework you can explain how your cancer care logic (which anyway is largely BS depending on how you count it too) is different than heart attack survival rates.

  5. What a load of horseshit. You never attempted to respond to my major points:
    1. Culture can and does affect outcomes. However, to assume that it does so in a linear fashion across all diseases would be a mistake. Diabetes management is nothing like getting cancer treatment – it depends on personal initiative, discipline, self-esteem, a non-fatalistic view of life, etc. We have certain subgroups in great abundance in our society that are quite deficient in these areas.
    2. Your assertion that if the number of victims of an injustice is a small percentage – then it is somehow justified is a deeply immoral position.
    What’s your problem with honest debate?

  6. Barry. Not sure that there aren’t lots of immigrants trying to get into those countries. Plenty of politicians there seem to think they’re being over-run by immigration! I’d also agree about the payroll tax aspect. But the fact is that for MOST American jobs health care costs ARE a payroll “tax”, which vastly exceeds the per worker “tax” or health care taxes in the rest of the world because the underlying costs of the system are so much higher. So I don’t think your point is logical–unless we really were to fund health care for the poor here by a bigger payroll tax on low income jobs. Surprisingly enough it’s not low income jobs that I think should be taxed more heavily!
    As for Mr Browning–well let’s give him credit for at least trying to make an argument. One of the first times I’ve seen it.
    He accuses me of being “illogical” but of course he starts talking about cancer care as being “medical” while diabetes care, heart attack survival et al is not connected with medical care but due only to culture. That’s rubbish. All medical care is affected by culture. My point is simply that if you’re going to criticize foreign health care systems you have to be prepared to accept the same criticism back–and of course justify the much higher costs and the inequity with which they’re shared out here. And he can’t.
    Otherwise my crime is apparently supporting Michael Moore (who I directly criticized for shoddy research last week), not criticizing Ezra Klein (whom I have criticized about user fees, and who is not the socialist collectivist that Mr Browning fears he is) and not decrying an article by Kristoff that I haven’t even read yet! That’s the very best you can come up with Mr Browning? Go back and read my Oh Canada article. You’ll see that I am genuinely fair and balanced on the problems of both the US and Canadian system. Something you have never been.
    And as for the “passing on wealth” BS argument that he brings up, if Mr Browning hadn’t noticed, the Republicans abolished the estate tax while increasing overall Federal spending. Unless Mr Browning has abolished the laws of economics (which he may be trying to do) that spending has to be paid for by someone either now or in the future. If less will be paid by the billionaires no longer paying estate taxes then more will have to be paid by the rest of us. Count me as one not being delighted that the Walton kids get to keep more money so that me and my kids will pay more. I assume Mr Browning’s likening the persecution of the minorities who (currently do not) pay estate taxes to Nazi Germany is a joke. At least I hope so. If not he’s even stranger than I thought.

  7. I have pointed out before that infant mortality varies considerably even within the United States though the definition of a live birth is the same nationwide. The differences appear to have very little to do with the percentage of people who are uninsured or whether or not pregnant women have adequate access to prenatal care. The factor most highly correlated to high infant mortality appears to be poverty.
    I don’t have data that compares the percentage of the population in different countries with incomes below what the U.S. would call the Federal Poverty Level (FPL). I suspect, however, that illegal immigration is a more significant factor for the U.S. than elsewhere. Lots of people want to come to the U.S. in search of a better life than they have (and can expect to have in the future) in their home country. We have millions of people who work in low wage industries like restaurants, retail stores, hotels, and as landscapers and housekeepers, etc. The nature of many of these businesses and the wages they can afford to pay often preclude offering health insurance. On the other hand, if health insurance were taxpayer funded via, say, a 15% payroll tax on the first $100K of income, many of these entry level jobs might either disappear or never be created in the first place. One of the historical strengths of the U.S. is our diversity and our ability to assimilate people of different cultures. A byproduct of that history is that we probably have more people living in poverty at any given time than other countries do. Most of the European countries, while they might offer what some view as a more complete social safety net, are much more homogeneous cultures and less welcoming to immigrants. Why aren’t more people in search of a better life trying to get into France, Germany, Great Britain, Canada and Japan where health insurance is universal and supposedly better?

  8. I wish I had time today to unravel Mr. Holt’s illogical diatribes – however, I’ve only time to ask a couple of questions and perhaps make a point.
    1. Mr. Holt reserves alot of venom for the right who cherry pick from the data. Curiously, why does he occasionally link (approvingly) to master cherry-pickers and liars like Ezra Klein and others? Mr. Klein likes to downplay Canadian wait times by focusing only on waits for surgery while ignoring the long waits to see a specialist and to get diagnostic tests. Mr. Holt also approvingly writes of Michael Moore’s upcoming propaganda in which he makes the dubous claim that Canadians’ longer life expectancy is due to their form of health care financing. Why the double-standard, Mr. Holt?
    2. I agree with Mr. Holt that cultural factors probably play the dominant role in outcomes. However, why should we assume the the impact is linear? Doesn’t it make sense that diabetes management is more impacted by cultural habits than cancer treatment outcomes. In the UK, 40% of British cancer patients die without having ever seen an oncologist. I wouldn’t necessarily discount the impact of a horrible socialized system on cancer outcomes as Mr. Holt does.
    By the way, the ever-clueless Nicholas Kristoff has a particularly ignorant health care piece on the NY Times op-ed page today that makes the ludicrous claim that US infant mortality (and maternal mortality) rates are linked to the quality of our health care system. Mr. Holt never seems to criticize these columns (and there are lots like this on the left)
    3. Finally, an observation: Mr. Holt’s linkage of the debate about estate taxes is revealing. For the same reasons that he feels that a person should not be able to use their wealth to acheive better health outcomes, he feels a person should not be able to pass on their wealth to their children. His logic is a bit curious though. He reasons that since the number of victims of this injustice are a small minority – then, the action is moral and justified. No surprise there. Care to make any more comparisons with a certain German regime, Mr. Holt?

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