Harry Reid announced yesterday that the "Public Option" was back in play in the Senate, but his apparent ace in the hole (pardon the awful Nevada gambling puns) was that states could opt out of the public option if they so chose. What wasn't outlined was how states would opt in or out (would it be an executive branch decision? Would opting out or in be a permanent decision or could it be reversed if the state's government later changed hands to elected officials with a mandate for changing the state's status? Could you opt out after you opted in?) but a much more fundamental problem makes me question how this plan is in anyway practicable. First, to dispatch with the obvious, the "opt out" plan is a clear political triangulation, which might not work anyway, meant to satiate progressives who think the public option is the whole point but to give political cover to blue dogs who, if the opt out plan actually made sense might be able to sell it at home as having gotten health-care but having not forced the most heavy handed government regulation on their constituents.

The problem, though, is this thing called the Constitution. Specifically the very first clause of Article 1, Section 8 which gives the Congress power to levy taxes and excises, but which specifies that "all Duties, Imposts and Excises shall be uniform throughout the United States."

I'm not sure that the details of how the plan will be paid for have been laid out in their final form, but the gist is a penalty for those who can afford insurance but don't get it (which Obama argues is not a tax--hard to follow his logic there) but much more importantly a tax of at least 8% on medium to large employers who provide health-care to all their employees and then an alternative tax that will cost presumably approximately the same as paying for employee's health-care for employers who don't. There will also probably be some sort of tax incentives and penalties for small business owners, too, and there might also be other taxes like something of a luxury tax on "Cadillac" health plans that provide too good of coverage and cost too much.

It's hard to understand how states could allow their citizens to opt out of these taxes; I'm no lawyer but it seems like a pretty clear breach of the aforementioned clause of Article 1 Section 8 to not have these taxes not apply uniformly to all the states, whether they've opted out or not. Given that, if the "opt out" option is that your constituents pay exactly the same amount of taxes to fund federal health care as they would whether you've opted in or out, and the only difference is whether those constituents are eligible for Federal largess which is being paid for out of (in theory) the taxes that they're paying anyways, it seems pretty implausible that even the most live-free-or-die, libertarian polity would support its government hamstringing their state relative to all others by sending tax dollars out of the state to subsidize all the other states' ability to offer "free" health-care, and even the most principled, Federalist state government would be able to justify a policy that would be so costly to state residents.

The opt out plan is basically like an offer from one of your friends who has season tickets for a baseball team to let you and some other friends split the cost and then each get a share of the tickets. Except your friend is forcing you to pay for the tickets anyways and the only thing you can opt out of is accepting the tickets once they're bought and paid for. You might not like baseball, but since you were forced to pay anyways the offer of being able to "opt out" of getting what you paid for is not exactly the same as being able to "opt out" of the whole scheme to share season tickets in the first place.

Until I hear somebody explain how a state would not have to pay for the public option even if they opted out, or if they did, what incentive they would have that would help make up for the shortfall from their decision to opt out it seems like a completely unworkable plan. That's not to say the rest of the plan makes sense, but this feature seems particularly egregious in the way that it has not been thought out, and how a lack of detailed consideration of incentives and understanding of economics seem to make this health-care sage an exercise in political farce bound to turn into legislative nightmare.

Labels: ballyhoo, government, health-care, politics

In the debate over health-care, many other countries are held up as models of systems that, while not perfect, don't let anyone fall through the cracks and do a better job at avoiding preventable deaths than the U.S. The implication: keep your massive insurance premiums and plastic surgery and give me an effective, government regulated program.

The other industrialized nations seem to get more bang for their buck; across the entire 25 nations of the EU, according to an EU analysis of health-care spending and effectiveness, a mere 8% of GDP is spent on health as opposed to the US where we spend nearly double that at 15%. They don't give a tabular form of health-care spending as a percentage of GDP but it seems that in the EU15 (i.e., the Western European countries with whom our economies are most comparable) they spend more than the EU average; the text mentions that France and Germany both spend approximately 10% of GDP on health-care. However, one questions their metric on the rate of avoidable deaths when they note that

Spain and Greece, which spend much less on health care than Germany (approximately 8% of GDP), do a much better job of avoiding mortality. Similarly, levels of avoidable mortality do not always refl ect levels of spending in the newer Member States either (Newey et al. 2004).

Whoa. So the German model of state-regulated organization of people into what are essentially health-care co-ops that get treatment from for-profit providers, is inferior to the public option model of Spain, a public insurance scheme in which most Spaniards take part? Or that the newer members (i.e. countries in Southern and Eastern Europe) are better too? Not to slander places like Spain and Greece and Slovakia (from where some of my ancestors trace their roots) but would you rather have the health-care accessible in Spain and Greece and the newer members of the E.U. than that, not of the U.S., but of Germany or France? Greece and Slovakia and Spain simply don't have the GDP and general level of technological advancement that make me confident that this metric is accurate.

But let's take the into account some other issues. One issue conservatives in opposition to the current legislation proposals bring up over and over is tort reform. One they do not is intellectual property. I have not heard once mentioned that one of the few sectors of the global economy where free trade has not been on the march as we've globalized the economy is pharmaceuticals. I heard some people ask at the health-care town halls why the U.S. government doesn't use its considerable bargaining power to get us the cheap drugs they have access to in Canada. The short answer is that if we paid the same as Canada for drugs there would be a lot less money for drug R&D. As a research scientist I'll tell you the way that funding is doled out by the Federal government via the NIH, sometimes the National Endowment for the Sciences and private foundations while meritocratic and not bad attempt at reaching an optimal distribution of limited public and charitable resources looks, in scale, like absolutely small potatoes next to what even a pilot program co-development contract with a big Pharma company looks like. Furthermore, even though an academic who, say, discovers a drug does not actually own the intellectual property rights to his discovery (generally the University or other research institution that employs him does) but if that drug goes on to be profitable, even though the revenue for the institution is only a royalty paid to license the drug, and then somewhere generally around 50-75% of the net revenue to the institution goes to the department, further research funding, etc, so a small fraction of a small fraction ends up with the inventor, that can still be enough to make that guy a millionaire many times over. (Note: this is an exceedingly rare consequence of becoming an academic scientist.)

At any rate, Big Pharma has that money to offer scientists with potential drugs to develop and the money to pay for licensing of basic science (they do their own proprietary, non-published R&D too) and also do things like have some of the most impressive biomedical journal libraries I've ever seen because they make a lot of money, it's true. They make most of their money in the United States market because a) it's a huge market and b) consumers or their insurers pay a lot more than people in other countries. In other countries, first of all, patent law differs and any disclosure of things like the molecular formula of a drug before an international patent is filed renders it public domain, whereas in the U.S. a placeholder can give drugs that were not developed in house at big Pharma R&D labs about a year of protection between say, publication or presentation at a conference and patenting. This is a small part of the problem, but it puts some drugs into the public domain in other countries that are profitable in the U.S. More importantly, other countries with nationalized health systems can basically make the pharmaceutical companies a pretty difficult to refuse offer (although not impossible; sometimes the most modern drugs for treating, say, a relatively rare cancer are not available in places like the UK because reasons of cost dictate that the national health-care system doesn't buy the drug) But generally, the offer is something like this: give us your drug at a price that is far below what it is in the U.S. but is still going to make you a profit in the sense that now that you've got the ability to mass produce the drug, the cost to make a pill is far less than the price on offer, or don't sell your drug in our country and reap no money at all. Let's see... the choice, after you've already done the R&D and built the factories is between: large volume of sales that generate far more revenue than they do expenditures on things like labor and materials, or have invested all that money in R&D and manufacturing and don't sell it to a huge swath of the world... Of course, that "profit" that the companies make when you look solely at the cost of making a pill versus how much the pill is sold for is not enough to both fund R&D and actually create real, net profits for the company which has to do lots of expensive R&D before it has a pill to offer,. Generally the difference is made up when companies recoup their less profitable sales with higher prices on U.S. consumers, who fortunately for big Pharma and foreigners but sadly for Americans, live in a country that does not engage in government price controls of pharmaceuticals (yet, anyways.)

We hear often asked "Why can't Americans pay what Canadians do for prescription drugs?" I think a better question is: Why can't the Canadians, the British, the Germans, the French, etc., pay as much in the future as Americans, which would be less than we pay now, but more than they do. Am I being unfair? Am I claiming that the Europeans are basically cherry-picking of expenditures made by the U.S. to sustain health care programs for a lower cost than they could if the U.S. didn't do what it does? Basically, yes. Let's take a look at, say, military expenditures. They slice a full fifth of the pie (20%) of the U.S. government's expenditures and the U.S. military frankly provides protection (sometimes literally, as in Germany and Japan and South Korea) and figuratively by providing a military option to deal with any rogue states who engage in aggressive acts for many countries whose health-care systems we can attempt to emulate like Germany, the UK, Canada and Taiwan. Taiwan is an exception to the following statement, but it certainly spends less on defense than it would if the U.S. didn't keep carrier groups in the western Pacific. With that exception, expenditures in the European and other industrialized countries by the government must be topped by the UK, which at 6.6%, spends almost exactly one third as much of its government expenditures as the U.S. spends about 4.5% of its GDP on its military; Germany spends a good bit less than a third of that at 1.3%. If we were in the opposite position and the EU spent so much on keeping the peace via military spending that we could go from 4.5% of GDP on defense to 1.3% and shifted that peace dividend to paying for health-care we'd basically have the disposable income of a country that spent a shade under 12% of its GDP on health-care, comparable to the 10% Germany spends.

The military situation is a non-sequitur, you might argue, we chose to be the global policeman or at the very least chose to invade Iraq, and at any rate we were the ones who demilitarized Germany and Japan and attempted to avoid military build-ups in other industrialized countries in the first place. True enough. A more direct issue of cherry-picking is the fact that as alluded to before in terms of prescription pharmaceuticals, all sorts of biomedical innovation takes place disproportionately in the U.S., where we spend more money per capita on R&D, driven by our more profit-driven health-care system, and the rest of the world reaps the benefits as medical devices, techniques, and basic knowledge generated in the U.S. become available for use in countries that have eliminated a powerful incentive to innovate from their health-care systems.

First of all, looking at research across a wide panel of biomedical research categories, using a metric of average impact of the research done in a field in a country (specifically "transferred Normalized Mean Citation Rate"--the world mean is 0 as will become obvious), the U.S. out competes every country in the world, with a mean of .155, versus a respectable .118 in the UK, but of the 6 large, industrialized countries in the study (the US, UK, Germany, France, Italy and Japan) the next highest value is Germany at .026, followed by France at .012, Italy at -0.052 and Japan at -0.111. That America's research would generally have an impact that much greater than Germany, original home of Merck (now an American company, natch) and once the land whose language was the lingua franca of science says quite a bit about their innovation. This measure in the field of Clinical Medicine is even more striking, with only the UK being competitive with the U.S., with the U.S. 0.165 and the UK at 0.093; Germany, France and Japan, all considered model health systems? They respectively come in at -0.029, -0.07, -0.10. Worse than the global average of scientific papers written.

OK, well, that's a metric about how good countries are at writing papers. What about the whole kit and caboodle of biomedical research. Glad you asked. Two countries in Europe outspend us on R&D as a percentage of GDP: Sweden and Finland. They spend 4% and 3%, admirably, compared to the U.S.'s 2.7%. The only model system frequently mentioned that comes close the U.S. is Germany at 2.4%, but as shown above, their bang for their buck is questionable. The study from which I'm quoting these new figures found something similar to Hu and Russeau, which is that per billion dollars of R&D dollars spent Germany generates 1200 and change citiations, compared to over 2600 for the U.S. Research spending in the original 15 EU countries (essentially Western Europe plus Greece) is 1.9% of GDP throughout the region compared to America's 2.7%, with generally less productive research, with 2665 citations per billion dollars spent in the U.S. versus 1723 for the EU-15.

This doesn't explain all the discrepancies but it points to the sources of some of them. We spend more on R&D because the market demands it as opposed to the state mandating how much we get. We get more bang for the buck because, heavily regulated though it is, U.S. research Universities and hospitals still are under more consumer pressure than their European counterparts to innovate. We pay more than we should because of a trade status quo where Pharmaceutical companies make up for nationalized price controls in the rest of the world by making up the difference by tapping the U.S. consumer. In other countries more regulated economic systems provide for less disincentive to becoming a doctor relative to the drop in pay (doctors in Germany and Japan make about half of what their counterparts in the U.S. do) because there is less income inequality. Regardless of how you feel about income inequality, it seems axiomatic that in a country with greater income inequality implementing cost controls to reduce the percentage of GDP spent on health-care by lowering doctors salaries will, ceteris parabis, mean more people dissuaded from becoming a doctor than in a country where more lucrative options are less plentiful and less profitable.

Health-care must be reformed. No one disputes this. But I question whether it's fair to argue, by implication alone, that the reason the U.S. spends so much more on health-care as a percentage of GDP is merely that we are lining insurance company CEO's wallets with profits. A number of structural factors mean that we spend more on research, are more productive in that research and therefore drive medical innovation in the rest of the world, and the cost of that innovation is therefore born disproportionately by the U.S. Similarly with prescription drugs, a trade regime that allows for price controls around the world leaves the U.S. consumer in a position where they pick up the slack for the a world of patients who are free riders. Simple structural differences in the countries like what a young person looking to make a career's options are, and the financial reward they will receive in relation to the amount of work they will do if they enter a health-care profession versus another profession all make U.S. health-care more expensive. We could nationalize health-care and control costs; in this country, though, doctor shortages of the type seen in Canada and Germany and Japan where their economic structures and socioeconomic and demographic pictures are more egalitarian and homogeneous than ours, would probably arise, and probably be worse than in those countries. In other words, before you say that big, industrialized countries aren't in financial ruin because they have more highly regulated health-care structures (and they spend less money, too) jumping to the conclusion that if we adopted the same structure that we could afford it (and the corollary that we'd actually save money) is far from obvious to me. I'd like to see these questions addressed before analogies to systems in other countries that differ in so many ways from our own are tossed about.

Labels: ballyhoo, economics, health-care

It's often accused that us anti-big-government, little-L libertarian, classical liberal, currently anti-Democratic types are little more than stubborn, contrarian obstructionists with no new ideas to bring to the table regarding how to solve the nation's problems. And to some extent that's true; personally I would rather not see any new spending on health-care until the ratio of debt to GDP stops being in unprecedented territory. According to the CBO's most recent projection of what will happen as Fiscal Year 2009 draws to a close on October 1 and the President's 2010 budget goes into effect, we will have a public holdings of government debts equal to 56.7 percent; to understand why this is in uncharted waters in post-Depression, post-WWII history, the last time public debt as a percentage of GDP was this high was as the country paid off its massive war-time debts (buy T-bills, remember?) during the prosperous 1950s, in 1955, if you believe the data in historical table 7.1.

Some frightening things to notice here... I don't know precisely when the aforementioned compilation of historical economic statistics was compiled, and the different tables could have been made at different times, but you'll notice it wasn't released, in total, until some time in 2008, and that the table for public debt only includes more or less status-quo-ante projected data for 2008 as well 2009 which indicates to me that before this table was compiled before the crash. Of course, the folly of projecting only the middle of road estimate becomes obvious here--projected public debt holdings as a percentage of GDP were estimated to top out in fiscal year 2009 (i.e. 10/1/2008 - 9/30/2009) at 39% and then start dropping next year. The real data as shown in table 1.1 of the newest CBO projections are 56.7% for 2009 and 64.9% for 2010, which are probably underestimates since while revised downward from the last budget projection the CBO is still using rosy GDP projections, such as a gain of 2.4% for next year.

See why us obstructionist, "Dr. No" types worry about completely overhauling, in toto, 16% of GDP and making much of it liable to be paid for by the government, before even hearing about the specific plan? Public debt to GDP is a proxy of debt to income, equivalent to something like your the ratio between your after-tax income versus your total debt, and I don't know many folks earning $50k a year who'd be comfortable holding roughly $30k in debt, which is where we're heading, and beyond, as a country, without even accounting for the cost of whole-cloth health-care reform. It's scary that the last time the percentage of GDP accounted for by public debt, in 1955, it was during a time of sustained economic expansion, with that number shrinking dramatically each year after we had financed, on credit, a very expensive and necessary endeavor, World War II. The number had topped out at 120% and yet a decade after the war was over we had paid down that debt and grown our economy at such a rate that we wouldn't hit the same level of debt again until the worst recession since the Great Depression combined with the most spendthrift peacetime Administration since--well, ever. Technically, we are at war, but if you look at a breakdown of the budget and what has added to the debt, the total costs thus far of both the wars in Iraq and Afghanistan are roughly the size of the stimulus allocation, and it is costly domestic programs to both try to jump-start the economy--defensible in principle--and to for some reason enact costly new reform programs at a time of fiscal crisis that has caused this budgetary instability.

Perhaps it's time to rein in the spending when the Congressional Budget Office notes, buried in a footnote which belies the the insane warning-bell, blinking red light, the submarine hull is about to be breached alarm blaring that should be set off in every citizen's mind when they read things like this (see note 4):

Increased deficits and the attendant increases in interest payments must be offset by policy changes at some point or interest costs would compound relative to output over time, driving the debt-to-output ratio ever higher (under the assumption, which CBO’s findings incorporate, that the rate of interest on government debt is higher than the rate of economic growth).

So before we even get to health-care, think about that: increased deficits must be offset by policy changes at some point or the debt-to-output ratio will grow ever higher, which is essentially walking off into certain economic and national annihilation: if we are no longer a serious creditor, not only will the value of the dollar and all dollar-denominated savings plummet, but the very country itself could find itself without the money to operate; if at some point there's no interest rate at which someone with enough cash to finance our annual deficit will take a risk on us as a debtor since we've proven so fiscally irresponsible--and just imagine how fun watching interest rates rocket up in a matters of weeks would be--then what's the Administration's plan for paying for essential government services? Do you stop paying soldiers or do you stop paying out Medicare and Social Security pensioners? In other words, we've got to make sure that we don't buy something we can't afford and thereby lose what we've got.

But beyond the fact that adding to deficit spending at the moment seems absolutely insane and reckless beyond belief, let's talk about health-care reform. Obama talks about how the system is "broken," but most people are happy with their current care, and those who aren't are not denied care, even for a sore throat, if they walk into an Emergency Department at a hospital and not their GP's office. Is that a good thing? No, it is not; it is a problem. Is there any country in the world that does not have problems with it's health-care systems? No, there is not. Canada and Britain, the two most fully socialized, single-payer systems with which Americans seem to be remotely familiar, have long waiting lists for "elective" procedures like knee replacement or drug treatment, which as at least one woman in a video I saw needed both after gradually getting addicted to painkillers while spending 16 months waiting for them to replace her bum knee with essentially no padding left in the joint. In other countries, other problems exist; in Germany doctors unions--in a country already much more used to income equality and unionization--are complaining that their wages are too low, which they almost certainly are, since a main feature that makes Germany's public health-care system more financially sustainable is capping doctors' pay. In an increasingly globalized economy where many brilliant people are currently drawn to America, would you like to shut off that flow and have your quadruple bypass done by somebody who wouldn't be a doctor except he got into med school because his more competent peers decided either not to come to this country in the first place or not to go to med school and instead went to work at Goldman Sachs? In Japan doctors don't get paid as much as here, but there's less anger about it than in Germany; they are, after all, almost all in private practice. However, since the government mandates how much they can charge for any procedure--based on patients' ability to pay, not how much it costs the doctor to discharge the service--almost all of these clinics are in the red. Government bailout, anyone? And then my favorite foreign health-care problem comes from Taiwan, where a rapidly industrializing Asian Tiger economy developed its health-care system essentially from scratch in the mid 1980s under the guidance of the leftist-academic public health scholars who probably believe the same things and in some cases are probably the same people who had a role in crafting the ideas behind the goals embodied in the current Obamacare plan(s): in Taiwan, health-care is "free," doctors are government-paid, but instead of rationing care (directly limiting the supply of health-care) or capping procedure prices or doctor compensation (indirectly limiting the supply of health-care) they have gone after the demand side of the equation. How can you make people demand less health-care, you ask? Well, if you go to see the doctor an inordinate amount of times in Taiwan you, no joke, get summoned to talk to a government bureaucrat about why you're consuming so many limited resources and to tell you not to go to the doctor unless it's absolutely necessary. Of course when it is absolutely necessary, and if there aren't enough surgeons, say, then things like elective surgeries are rationed.

So here the problem is, in contrast to the rest of the industrialized world, not that there's not enough health-care, but that its quality is unevenly distributed. The wealthiest can get every life-prolonging preventive measure they can afford, paying for full body scans to look for cancer, just in case. People with good jobs that provide either very good or not-so-good health-care plans at least can get things like colonoscopies. The young often don't have insurance, but many of these people either are poor enough to qualify for Medicaid, or have enough discretionary income to afford private insurance (which for a young, healthy person is relatively dirt-cheap, at least if they live in a state without community-rating.) Those with pre-existing conditions often can't find an insurer who will take them at anything less than an astronomical cost, since the likelihood of having to pay for expensive doctors visits is essentially 100% for the insurer. And of course, those who are both poor and unable to navigate the bureaucracy and sign up for Medicaid wind up using the Emergency Room as their GP, a situation that is bad for everyone, as Emergency nurses shouldn't be wasting time on triage of non-emergent patients and ER docs shouldn't have to treat strep throat.

But the American people have lived with this system for years, decades, even. Why is it essential to overhaul it--other than for political reasons--in one fell swoop? Why can't we attack the problems incrementally? There are several main problems that could be addressed one by one, and we could see the results of the fixes as we try to navigate towards a health-care landscape where a country as wealthy as the U.S. is able to provide a minimum level of care for those who cannot afford it themselves. First, a huge cost-cutting measure we could try would be tort reform; malpractice awards could be capped, the incentive structure for attorneys to win massive settlements could be changed, or the burden of proof in malpractice cases could be made higher; any of these reforms seems like it would be likely to cause the number of successful, massively expensive lawsuits to drop. This would be a double-win, since it would directly lower the rates that doctors pay for malpractice insurance--which gets passed along to the consumer, which of course gets passed along to his insurer-- but it would also limit the practicing of "defensive medicine," where expensive tests are ordered not because they are really necessary, but because they provide cover if something goes wrong and a malpractice suit gets filed.

Second, we could go about reforming insurance so that it acts more like other forms of insurance. Think about how absurd it would be if car insurance or homeowner's insurance worked like health "insurance." If you had to get a new tire because you hit a pothole, instead of just paying for the tire, you'd pay a $10 copay and file a claim with your insurance company. Also consider if you could sue the mechanic if your car had a problem regarding its wheels or tires later. Think about the incentives that would create; the mechanic would not only replace the tires, but check your alignment; if he found that your wheels were misaligned and needed to be re-aligned, would you have had any incentive to question whether his price for checking your alignment and then aligning the wheels was competitive with other mechanics, let alone a reasonable price relative to the time and materials he needed to use to perform the service?

The majority of Americans are healthy. Think about what would happen if Americans, instead of having their health-insurance paid for by their boss and getting a smaller take-home paycheck, if--like for car insurance or homeowners' insurance--they simply paid for it with the money that businesses could add to their salaries if they didn't have to buy insurance packages. Like car drivers, it might be necessary to compel people to buy insurance both to pool risks and to avoid free riders, but that would cost much less than providing a government umbrella over the whole system. Imagine, too, if, unless you got some very expensive illness or injury that required many, expensive treatments or hospital stays or surgeries, you paid out of pocket for your annual physical or appointment with the dermatologist to check out and cut off a mole. You'd be much more cognizant of what services you were consuming, what they cost, and would have a vested interest in getting efficient, quality medical care that wasn't full of charges consisting of needless tests and outrageously high overhead due to things like exorbitant malpractice awards and outright medical insurance fraud. This would serve to drive prices down, as doctors who could provide a checkup for less money and still turn a profit would see more patients come through their doors, and there would be a political constituency to fight the trial-lawyers persistent ability to lobby congress to prevent any sort of tort reform.

Health-care insurance would therefore become dis-attached from one's employer, would cost less as prices were driven down and claims for all but catastrophic care were eliminated. Once you let the free market bring some more sense to the incentive structure for determining which services are provided and how much they cost, you could then use government subsidies in a much more targeted fashion to help equalize access to coverage; if you could successfully drive down costs, subsidizing the purchase of an insurance plan or reimbursing people for primary care, especially preventive care, for the lower class and lower middle class would both require much less money, it'd be much simpler. Consider food-stamps or now EBT cards; neither are free of problems; both are vulnerable to fraud. But what do you think is the more cost effective way of subsidizing food for the poor? Giving someone a card that they can give as payment to privately run supermarkets and trying police fraud in that system or creating an entire government bureaucracy to set up "free" supermarkets where the poor could "shop" and then have the government look at how much they bought, how much of their subsidy is left, etc.? Think about the overhead that it would take to create an entire shadow system of government run supermarkets that only serviced the poor and weren't open to other individuals to come in and try to pay for things with cash. With health insurance there's no prominent public building like a bizarro supermarket where everything's free but only the poor can shop there, but the institutions of Medicaid and Medicare, and possibly the "public option," all are real analogues to the imaginary bizarro supermarket. There's nothing wrong with the wealthiest country in the world subsidizing the health-care of its poorest citizens; it's down-right noble and a good idea. But I quarrel with the idea both that this is some fundamental human right--just exactly, how much money does your "right to health-care" entitle you to have spent on your behalf--or more importantly that massive, whole-cloth government reform is the only way to attack the problem of unequal access to care.

Those who are lobbying for the defeat of Obamacare do not necessarily hate the idea of reform, but the idea of attacking this with a one-off, whole-shooting-match reform of our entire health-care system is both not a good way to get better results for Americans regarding health-care, and it's not something we can in any way, shape or form afford to pay for right now.




Unless you're willing to go the route which Canada went and pass a law--until it was recently struck down as Unconstitutional--which bans people from buying health-care outside of the government system (thus thriving clinics in places like Buffalo and Seattle, which are close to wealthy Canadian population centers) then you're always going to have a problem of disparate care between the haves and have-nots.

Labels: economics, health-care, politics