Correctly Political: Wealth Care, a Historical Note

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32 Responses

  1. I can’t believe there’s no comments on this yet. This is a really informative piece with lots of stuff I hadn’t been aware of (outside of the heavy concentration of state-level insurance markets). Thanks!Report

    • Avatar North in reply to Mark Thompson says:

      Personally I was so busy reeling from it and looking up some of the links that I was rendered speechless. Well done!Report

    • Avatar Michael Drew in reply to Mark Thompson says:

      I just came over here after asking E.D. specifically about the question of where the interstate restriction is from. I think what might have happened here is that the lead got buried. I remember looking at the title and first few paragraphs of the post and not being able to tell what it was about other than some general ruminations on health care. Then I saw the length and moved on. Wish I hadn’t, because even at that time I was very interested in the question the post goes on to answer. But I think that may have been part of the problem.
      –‘Say what you’re going to say, say it, then say again what you said!’ Just some unsolicited advice in composition someone once gave me.Report

  2. Avatar E.D. Kain says:

    Agreed. Top notch post, with lots of very good information. Besides, it’s always good to see areas where libs and cons can at least ostensibly agree. 50 states with 50 different regulation bodies just doesn’t make sense.Report

    • Avatar Nick in reply to E.D. Kain says:

      I’m with you, E.D. — I’m a strong proponent of a public option, but this seems absolutely convincing to me — especially since it explains why logjams to passing reform are currently centered around Senators with very small constituencies — their health insurance industry is least competitive (how many insurers can there be in Connecticut?) and has the most to lose from a national system.

      I invite you or anyone else to stop by my blog, which is all public option, all the time — just click on my name.Report

  3. Avatar jfxgillis says:



    One thing I hoped to stress is how ancient some of these issues are.

    To get a flavor, here’s TR’s Secretary of Commerce’s report that came out the same week as the letter above.Report

  4. Avatar jfxgillis says:


    Besides, it’s always good to see areas where libs and cons can at least ostensibly agree.

    Funny. TPM has an item up right now on Michelle Bachman and Jim DeMint calling for “states rights” in resisting reform. Like, 1840s style “nullification.”Report

    • Avatar E.D. Kain in reply to jfxgillis says:

      I’ll take consumers rights over states rights in this round. Then again, I’ve never been much of a states rights fanatic. Bachmann is not nearly as frightening as the fact that people take her seriously. Someday she’ll make a great Fox talk show host.Report

    • Funny thing about that – conservatives were hardly up in arms about McCain’s health care proposal last year infringing on states’ rights, even though one of its central features was the elimination of restrictions on the sale of insurance across state lines. Liberals predicted this would create a “race to the bottom,” and have mostly been suggesting that state regulations should be untouched by any reform short of single-payer, but just about every conservative proposal I’ve seen (including DeMint’s own proposal!) has emphasized eliminating restrictions on the sale of interstate insurance.

      So, liberals have mostly been pushing the hard-core federalist stance (although I suspect they’d be in favor of complete federal preemption of state insurance laws if it were on the table), while conservatives have been pushing a more or less anti-federalist stance (although I’m sure they’d be opposed to federal preemption of state insurance laws if it were on the table).Report

      • Avatar greginak in reply to Mark Thompson says:

        I think a “race to the bottom” is a significant risk in eliminating state regs. I think the lib response would be that fed regs would take over and apply everywhere.

        Oh, republicans not abiding by their dearly held principles surprises you? R’s are for state’s rights when it is convenient( see marijuana dereg, etc).Report

        • Avatar Mark Thompson in reply to greginak says:

          I’m obviously less concerned about a race to the bottom – as far as state regulations go, I don’t think the bottom is really all that unregulated. Indeed, one thing that this post shows is that existing state regulations are really set up to protect one or two big insurers within the state, which suggests that they have relatively little to do with actually setting standards of insurancethat have much to do with quality of insurance. But I also don’t think that federal regulations would be terribly strong, in any event – the power of the insurance industry collectively is quite substantial on the federal level, whereas its power on the state level is largely confined to one or two insurers. Thus, on the federal level, anything that raised bars to entry (ie, any regulation whatsoever) would run into opposition from the industry collectively, whereas on the state level, raising bars to entry (under the guise of creating higher standards) is exactly what the primary insurer wants.

          All of which is to say, I really don’t see much practical difference between the “race to the bottom” and federalization, except that the industry as it currently exists wouldn’t be terribly happy with either since they would both force insurers to compete with each other directly. That said, I’d probably marginally prefer federalization over the “race to the bottom” because the “race to the bottom” would likely result in some form of preferential treatment for whichever insurer already has the strongest ties to that “bottom.”Report

  5. Avatar Chris Dierkes says:

    man that was a fantastic post.

    I have this very strange love/hate thing with David Frum. I think his domestic policy is really stellar and his foreign policy take is for the f’in birds. Weird.Report

  6. Avatar Glen Raphael says:

    It still seems to me the elephant in the room is the fact that there’s essentially no relationship on the margin between amount spent on health care and health outcomes. People assume there *ought* to be one, but there isn’t. Spending more on “health care” doesn’t buy more health, it just buys more reassurance that somebody “cares” about your health, which is a luxury good we can afford more of in the US. Sure, we could reduce the costs per procedure, but the real problem is that more procedures don’t produce more health. To the degree that health care is really about signalling, trying to reduce costs is beside the point. It’s like trying to reduce the extravagance of prom parties by controlling the cost of limos – the kids and their parents will just spend more on something else to compensate.

    Robin Hanson says we should just cut medicine in half by any means available; I think he’s got a point.Report

    • Avatar jfxgillis in reply to Glen Raphael says:


      That’s because thinking of health care at the “margin” is a phenomenally stupid concept. At what marginal cost do you stop spending dollars to save your child from dying of cancer?

      Oh. I’ll spend $750,000 for a cure but at $755,000 …. eh … go ahead and die, kid, Mommy doesn’t love you THAT much.Report

      • Avatar Glen Raphael in reply to jfxgillis says:

        Too much medicine kills, just as certain as too little. Medical errors kill about 100,000 people per year in the US. One implication of this fact is that when insurors refuse coverage for an “experimental” treatment, there’s a good chance they’re doing you a favor. One of my favorite tidbits from Robin’s article – which you really ought to read – was this:
        Regions that paid more to have patients stay in intensive care rooms for one more day during their last six months of life were estimated, at a 2% significance level, to make patients live roughly forty fewer days, even after controlling for: individual age, gender, and race; zipcode urbanity, education, poverty, income, disability, and marital and employment status; and hospital-area illness rates.Report

        • Avatar Nick in reply to Glen Raphael says:

          Hi, Glen.

          Longevity is not health. Also, the fact that the article changes its definition of health (occasionally using a ‘general health index’, sometimes using longevity) according to the study it’s citing, but always makes sure to trumpet the level of significance, is a classic example of the multiple comparisons error (here). In layman’s terms, that’s cherrypicking — if you have fifty separate definitions of health (and we do), any one trial will likely show a negative impact at a 2% significance level.

          Long story short, you cut your healthcare in half, and let me know how it goes.Report

          • Avatar Glen Raphael in reply to Nick says:

            The Rand experiment used a “general health index” because to use longevity as the metric in a controlled experiment you have to run the experiment long enough for a significant number of your subjects to die and follow them until they do. Which takes a long time. It’s not cherrypicking to use the best data you’ve got so far, which each of those studies Hanson mentions individually do. I advocate that we run a bigger, longer Rand Experiment to find out if the earlier findings still hold; I suspect that they do. I do, in fact, follow Hanson’s advice, which basically is: don’t get any health care you wouldn’t be willing to pay for yourself out-of-pocket and treat your doctor like you would treat your auto mechanic – skeptically when it comes to accepting expensive treatment suggestions. (He also advises you avoid the latest new treatments or drugs in favor of older, more established ones wherever possible.)

            In the Rand study, the people who paid for their care from dollar one used less care, missed fewer days from work, and were slightly *healthier* on a variety of metrics than those whose care was more subsidized. They didn’t just look at the sum but also looked at all the individual categories to determine this; the judgment criteria were specified in advance of the experiment and the judgment was double-blinded.

            It would actually be tricky for me to cut my healthcare in half since I already see a doctor less than once a year. 🙂Report

            • Avatar Nick in reply to Glen Raphael says:

              Your last line kind of crystallizes the whole point. It would be tricky, wouldn’t it? That one last doctor’s visit, the one you consider absolutely necessary, is a doozy.

              And I’m not criticizing the use of a general health index — I’m criticizing use of a general health index sometimes, and longevity (as in the part you quote above) sometimes, and patient satisfaction sometimes, the reason that your Cato article leads off with: “Note that a muddled appearance of differing studies showing differing effects is to be expected. After all, even if medicine has little effect, random statistical error and biases toward presenting and publishing expected results will ensure that many published studies suggest positive medical benefits.”

              Which is basically for him to say, well, it’s going to look like I’m wrong because the studies are going to look bad because I’m so right. Pay no attention to the man behind the curtain.

              And all told, I’m very much in favor of people limiting their own health care use — I’m not at the doctor’s so much myself — but I’m very much not in favor of the rich saying that the poor, who can’t afford doctors and don’t have the opportunity to get care, are probably better off without it.Report

              • Avatar Glen Raphael in reply to Nick says:

                Which is basically for him to say, well, it’s going to look like I’m wrong because the studies are going to look bad because I’m so right.

                Nonsense. He’s just giving one possible reason (of several) why the big aggregate studies – which all do support his view and do make it look like he’s right – can be reconciled with smaller individual studies that might initially seem to suggest otherwise.

                I’m very much not in favor of the rich saying that the poor, who can’t afford doctors and don’t have the opportunity to get care, are probably better off without it.

                But what if it’s true? The relevant quote from the Hanson essay regarding the Rand study: “At a 7% significance level they found that poor people in the top 80% of initial health ended up with a 3% lower general health index under free medicine than under full-priced medicine.”Report

              • Avatar Nick in reply to Glen Raphael says:

                Ok, we can get into the line by line, fine.

                “The first study known to me was by Auster, Leveson, & Sarachek, Journal of Human Resources, in 1969 . It found that variations across the 50 U.S. states of 1960 age-sex-adjusted death rates were significantly predicted by variations in income, education, fractions of white collar and female workers, and the existence of a local medical school, but not by variations in medical spending, urbanization, and alcohol and cigarette consumption.”

                How is the existence of a local medical school not an indication of medical spending? Can medical schools be built without spending? How may I acquire one of these free medical schools? Also, to point out, death rates is a /third/ (there are more) method by which Hanson is measuring health outcomes (it is distinct from longevity, as well as general health).

                And I can’t answer your question about ‘what if it’s true’, because the quote you give has the highest error rate I’ve ever seen in a straight-faced piece of medical research, and is also totally incoherent, since poor people who can pay for full-priced care are not poor, or are being given care, which makes it functionally free care — basically, the survey seems to prove that full-price care is better than free care, which I’m sure is the case. Additionally, it is completely irrational to limit the study to those in the top 80% of initial health — it basically ensures that the positive effects of health care will disappear.

                It’s an interesting, counterintuitive argument, and I’ve got a lot of sympathy for thinking outside the box, but it’s wrong. Factually wrong in its original form, and morally wrong as a justification for denying health care to those in need.Report

  7. Avatar Jaybird says:

    Surely we can all agree that so long as Wickard v. Filburn is precedent, it supercedes Paul v. Virginia, no?Report

  8. Avatar Henry GrosJean says:

    I question the WHO ranking us 37th. Admittedly we have problems, but they rank us lower for a number of reasons: Health Savings Accounts rank against us as they have more out of pocket costs, outside of the U.S. other countries consistently don’t bring baby’s who have known birth defects to full term (are aborted) but do not count these in their mortality tables, plus pre-mature baby’s are not kept alive like in the U.S.. And, if anyone bothers to look at health care spending in countries with even quasi-socialistic health care spending is controlled by rationing. There is no other way to control it. And, I have no problem with rationing as it’s done already. I just think the reform crowd needs to call it what it is and not mask it in rhetoric.Report

    • Henry:

      I specifically allowed that point and, you’ll note, didn’t even link to the primary source which, you’ll also note, I tend to do when I think it’s important.

      I think the Commonwealth Fund rankings are much more significant, both because it’s more apples-to-apples and because I think their metrics are superior to the WHO’s–in part for reasons like the ones you listed.Report