Asymmetrical Information

I suspect most people only engage the health care debate when their health is in jeopardy.

Jane,

If you have to look at the median or the mean and not the tails (and I agree), then why are anti-national health care types forever trotting out examples from the Canadian health care system?

I know you read Kevin Drum. You know he thinks the French health care system is quite good, and he has provided numerous links to the statistics that back him up.

I live in Germany and the German health care system, in my humble experience, seems to offer first-class care with minimal problems. I understand that my data point does not constitute an argument, but the German system sure seems a lot better than the Canadian system from what I read.

So why the infatuation with the Canadian system? Could it be it's a tail rather than a mean or a median?

Cheers,

Dear Megan/Jane - Could you please give the titles of the authorities you upon in your debate with Chait? Thank you.

David

So why the infatuation with the Canadian system? Could it be it's a tail rather than a mean or a median?

Probably. The problem, IMO, is that the least level of language and cultural barrier is found between Great Britain and its heritage -- Australia, Canada (except for Quebec), and the US. Of the three examples closest to the US, Australia is too far away to notice, and Canada and Great Britain have two of the worst-designed social healthcare systems in the western world in that they attempt to be everything to everyone with no accounting for moral hazard etc., resulting in lines and rationing.

Also, left-leaning Canadians tend to be the most vocal voices of criticism against the US healthcare system, again probably due to proximity, so their system is naturally one of the most-scrutinized by US advocates and critics of a social system here.

Many of the continental European systems do provide a minimum standard of socialized healthcare but also implement structured copayments or other moral hazard mitigation mechanisms, and these systems are often amenable to peaceful coexistence with private healthcare markets. If the US is ever going to clean up the mess that is Medicaid, Medicare, VA, etc., and maybe even offer some sort of more generalized social healthcare system in the process, IMO it should be looking more toward Sweden, Germany, France, et al and less toward Canada or the UK.

The topic is immune to reasoned debate. When it comes to access to technology that'll help a person avoid the ol' dirt nap, or live a life without hideous pain or disability, demand is infinite, as long as we ignore the "...able to pay" aspect of demand. Thus, health care delivery debates, at their core, are about who will be told,"Nope, you can't have that, and no, it doesn't matter if you are going to die or suffer without it." This is not a topic people approach with cool rationality.

It doesn't help that the segment of the U.S. population most likely to need intensive health care goods and services is the segment which has been trained for forty years that rationing is mostly for other people. Any dramatic change will entail informing this group that this is no longer going to be the case, which makes dramatic change pretty difficult to achieve, given that this is the same group whose votes are most highly sought, given their level of voter turnout.

I think Jane’s basic point is that the plural of “anecdote” is not “data” and that attempts to characterize the debate based on cherry picking examples to fit one’s argument is misleading at best. That’s not just true for health care, it’s true for pretty much every complex topic and we ought to be wary of those who rely on this to make their arguments.

You are very good at these. Also, it is odd for Chait to say that my column never mentions overhead costs being directed at "denial of care." The whole column is about that. The counterintuitive point is that denying care to some people makes insurance companies willing to finance care for many, many others. He also repeatedly conflates health care outcomes with health care inputs, as I believe you called him on at least once.

It's a somewhat simplistic figure, and has to be adjusted for demographic and socioeconomic differences, but comparisons of life expectancy between nations are at least somewhat useful. America's vastly higher levels of per-person health care spending than any comparable nations clearly have not translated into longer life expectancies.
Again, that's not the full story, but it should not be ignored.

Oh gosh, life expectancy at birth isn't even a quarter or half of the story. Factor in homicide and auto fatality rates, how premature birth fatalities are recorded, and most importantly, the rate by which the citizenry sits around and eats potato chips, making climbing the stairs to bed a breath-shortening experience, and you might begin get some sense of it. The segment of the population which receives the largest percentage of health care spending in the U.S., middle class retirees, does quite well compared to similar groups in other industrialized nations, in terms of life expectancy, before even accounting for the fact that in the U.S. such a person is more likely to bet fat and sedentary.

There is no better place on earth to be a fat, 75 year old diabetic with a heart condition and arthritic hips than the United States.

Will Allen:
America may have higher obesity rates than most other developed countries (though they're catching up), but we also have lower smoking rates. These things may cancel each other out.

It's a somewhat simplistic figure, and has to be adjusted for demographic and socioeconomic differences, but comparisons of life expectancy between nations are at least somewhat useful.

No they’re really not. Individual life expectancy is driven by so many factors that have little if anything to do with health care (unless there just isn’t any available) such as lifestyle, diet, exercise, smoking, etc. that it’s a misleading comparison at best.

Inability to a achieve and maintain a high metabolic rate is the best predictor of death, according to a study done at Stanford, much more so than smoking per se. Of course, three packs a day will often hamper the ability to get the ol' heart pumpin', so it doesn't mean smoking is without impact. I don't know if anyone has done a study across indutrialized countries regarding metabolic capability.

I can't remember where to find it, but I've read in a couple of places that the elderly really do quite well in the U.S. compared to other countries, in terms of life expectancy. Of course, the U.S. spends a lot more on the elderly than everyrwhere else.

What I was trying to say, as I posted in the comments, is that you have to look at the median or the mean, not the tails.

That's what Yglesias was complaining about. A system that immediately killed 49% of the people but let 51% of the people live forever (like, if they legalized a social democracy variant of Nosferatu vampirism or something) would maximize the median and the mean, but it's still obviously a terrible system.

I think what Matt is getting at, which presumably anyone with any vaguely utilitarian notion at all will agree with, is that it matters how fat the bottom tail is.

Uh...

If you only look at the median and the mean, there's no reason to even give the "health care crisis" in the US any thought, or make any arguments.

As a first generation son of Austrian immigrants, I won't be easily convinced that their system works, so in the interest of full disclosure, I will say that I support MORE market forces in medicine, not less. Insurance should be insurance, not a money-laundering mechanism whereby routine medical services can be sheltered from taxes, for example, IMO. Insurance typically is a way to minimized catastrophic risk, with built-in mechanisms to avoid moral hazard. Health insurance would look like this, if it were to work. See Arnold Kling for more; I'm not a professional economist and he's written plenty anyway.

That said, the famous Average American gets wonderful medicine. If Megan didn't believe this, she wouldn't support the idea of tax-funded "insurance" combined with an unchanged private medical system. Few seem to want fundamental change in the way we get our medical care; many want a change in how it's financed.

So, if you ignore the outliers and pay attention to the median and mean, you've "solved" the problem. Ignore the relatively small number of people who "fall through the cracks" in our current system, just as you want to ignore the people who "fall through the cracks" in Canada, Europe, or wherever, and you've taken care of the problem on paper.

I'm the first to decry the emotional anecdote as an argument for massive policy change that impacts all of us, especially when it may impact most of us negatively. However, in this case, the median and mean offer only limited information. Alarmist headlines claim that 45 million Americans are uninsured -- not that they get no medical care if they need it. That's 15 whopping percent, even if you accept that they get no medical care, which is not true anyway. The mean and median are doing just fine.

Where does that leave us?

I don't think that it leaves us anywhere that will satisfy anyone involved in the discussion. And those near the mean or median are NOT involved in the discussion, because they're doing fine with things as-is.

So, we're back to square one, I'm afraid.

Simply abolishing Medicaid would, after all, have no real impact on the typical middle-class, middle-aged American and would leave room for him to pay lower taxes.

A better idea would be to means-test Medicare (or just abolish it and let the elderly poor qualify for Medicaid) which is the greater problem in the long-term. This would enable us to continue providing some sort of “safety net” for the elderly (which is how Medicare was originally sold) without forcing taxpayers to subsidize wealthy and middle income elderly who can afford their own health care.

You can always find someone in any system who has slipped through the cracks; this is not a particularly good guide to [education, welfare, gun rights, Iraq] policy.

I think most of our political debates are about the margins; I just wish that everyone would acknowledge that fact and confine their "solutions" to those same margins that are actually the problem.

In the Blogginghead.tv conversation with Jonathan Chait, Jane Galt mentioned a "McKinsley" (?) study that compared the longevity of patients after they had a diagnosis and found that patients treated in the US had a longer longevity (or some other better outcome) than patients treated in other countries. Does anyone know the citation for this study? Thanks a lot!

Nevermind, see this Marginal Revolutions blog entry to see the study (or studies) Jane Galt was talking about:

http://www.marginalrevolution.com/marginalrevolution/2004/04/where_is_health.html

(Jane was referring to an article(s) in the McKinsey Quarterly, a journal produced by the McKinsey consulting company)

Jane,
I'm a part time PCP and part time derm doctor.I don't take medicaid-but do a lot of free work.Both in my office and at a free clinic.
My thoughts:Americans want magic.They want it free and with no effort.I don't know the origin of this,but there is no solution until the mind set changes.Incidentally,from an undergrad class on medical ethics;the largest discrepancy in life span is between Utah and Nevada.It's 17 years.

Jane,
I'm a part time PCP and part time derm doctor.I don't take medicaid-but do a lot of free work.Both in my office and at a free clinic.
My thoughts:Americans want magic.They want it free and with no effort.I don't know the origin of this,but there is no solution until the mind set changes.Incidentally,from an undergrad class on medical ethics;the largest discrepancy in life span is between Utah and Nevada.It's 17 years.

Incidentally,from an undergrad class on medical ethics;the largest discrepancy in life span is between Utah and Nevada.It's 17 years.

I guess the lesson from is that instead of trying to create a national health care system, it would be cheaper to have everyone convert to Mormonism. ;)

It would be more accurate, surely to, say (as I suspect, from your other pronouncements, you meant) that in judging the worthiness of a policy you have to estimate its overall UTILITARIAN value, and therefore its UTILITARIAN value to the average recipient. This allows you to fully take into account the fact that poor people need an additional amount of economic health-care assistance a lot more than nonpoor people need that same additional amount of health-care assistance, even if it's impossible to ever precisely quantify this difference in utility. In short, because of clumsiness in your phraasing, Yglesias thought you guilty of a degree of callousness that you do not, thank God, really possess.

As for Utah: well, you know, Mormons aren't supposed to smoke or drink. That's probably enough to explain the difference right there, but it's, er, rather irrelevant to the health-care debate.

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