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Health Care
Who Should Ration Health Care?
In preparation for what should be a fun health policy forum on Thursday — hey, where are you going? — I’m reading Ezra Klein’s article “The Health of Nations” from the May issue of The American Prospect. The article includes an interesting omission that might explain Klein’s preference for letting experts — rather than consumers — ration health care:
[T]he right…has argued for a move toward high-deductible care, in which individuals bear more financial risk and vulnerability. As the thinking goes, this increased exposure to the economic consequences of purchasing care will create savvier health-care consumers and individuals will use less unnecessary care…
Problem is, studies show that individuals are pretty bad at distinguishing necessary care from unnecessary care, and so they tend to cut down on mundane-but-important things like hypertension medicine, which leads to far costlier complications.
(Actually, cost-conscious patients also tend to cut down on health care that harms them. That’s why the best evidence available indicates — contrary to what Klein suggests — that when patients control more of the money and do more of the rationing themselves, overall, it doesn’t harm their health.)
Later, Klein offers this explanation for his claim that Great Britain’s health care system is just as productive as the U.S. system, despite spending less than half as much on medical care:
Much of the health care we receive appears to do very little good, but we don’t yet know how to separate the wheat from the chaff. Purchasing less of it, however, doesn’t appear to do much damage.
So Klein acknowledges that neither individuals nor experts appear to do a good job of separating the wheat from the chaff. Agreed.
But he appears to prefer rationing by experts, because he believes that when consumers make the necessary tradeoffs, they hurt themselves. Except that this is not true overall — and it’s very hard to find evidence that supports an argument to the contrary.
So if Klein will acknowledge that letting consumers do the rationing does not lead to worse health outcomes — and I don’t see how he cannot — then why the preference for rationing by experts?
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Dear Massachusetts Taxpayer…
A friend of the Cato Institute shares the following nasty-gram mailed to him by Massachuestts’ Commonwealth Health Connector:
![Media Name: mass_tax.jpg](/sites/cato.org/files/styles/pubs_2x/public/download-remote-images/www.cato.org/172395922072/mass_tax.jpg?itok=56rQySEe)
Thank you for your cooperation. We will now connect you to the Massachusetts Department of Revenue…
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The “Public Health” Myth
A headline in the Washington Post blares:
Japan’s New Public Health Problem Is Getting Big
Obesity Has Grown, Along With Appetite For Western Foods
But no. Obesity is not a public health problem. It is apparently becoming more widespread in Japan, though still much less so than in the United States, but it remains an individual and non-contagious problem.
The meaning of “public health” has sprawled out lazily over the decades. Once, it referred to the project of securing health benefits that were public: clean water, improved sanitation, and the control of epidemics through treatment, quarantine, and immunization. Public health officials worked to drain swamps that might breed mosquitoes and thus spread malaria. They strove to ensure that water supplies were not contaminated with cholera, typhoid, or other diseases. The U.S. Public Health Service began as the Marine Hospital Service, and one of its primary functions was ensuring that sailors didn’t expose domestic populations to new and virulent illnesses from overseas.
Those were legitimate public health issues because they involved consumption of a collective good (air or water) and/or the communication of disease to parties who had not consented to put themselves at risk. It is difficult for individuals to protect themselves against illnesses found in air, water, or food. A breeding ground for disease-carrying insects poses a risk to entire communities.
The recent concern over a tuberculosis patient on an airplane raises public-health issues. You might unknowingly find yourself in an enclosed space with a TB carrier. But nobody accidentally ingests a Big Mac. And your Big Mac doesn’t make me fat. That’s why obesity is not a public health issue, even if it’s a widespread health problem. As I wrote before,
Language matters. Calling something a “public health problem” suggests that it is different from a personal health problem in ways that demand collective action. And while it doesn’t strictly follow, either in principle or historically, that “collective action” must be state action, that distinction is easily elided in the face of a “public health crisis.” If smoking and obesity are called public health problems, then it seems that we need a public health bureaucracy to solve them — and the Public Health Service and all its sister agencies don’t get to close up shop with the satisfaction of a job well done. So let’s start using honest language: Smoking and obesity are health problems. In fact, they are widespread health problems. But they are not public health problems.
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Who’s Afraid of HSAs?
I have an article today over at The Weekly Standard online, wherein I praise my wife, admit to my own vulnerabilities, call my friend a sissy, and offer some advice to those who fear health savings accounts (HSAs) and the outrageous prices doctors charge.
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WSJ: Consumers Having a Tough Time with HSAs
An article in today’s Wall Street Journal will no doubt have opponents of health savings accounts (HSAs) hyperventilating about how HSAs have failed. But the difficulties that consumers are experiencing are predictable, if not welcome, and some dissatisfaction with HSAs is no doubt a good thing.
Vanessa Fuhrmans writes [$]:
President Bush and many big employers have hailed “consumer-directed” health plans and savings accounts as an effective weapon in the battle against runaway medical costs. But several years after the plans got off to a fast start, the approach appears to be stumbling — largely because of consumers’ unease in using them…
[L]ow enrollment and low satisfaction among workers who are offered them raise the question of whether consumer-directed plans will stall before they ever hit the mainstream.
In a paper responding to common criticisms of HSAs, I argued that some of the inevitable consumer dissatisfaction is necessary, but much of it can be mitigated by expanding HSAs:
Read the rest of this post →There are good reasons not to draw any firm conclusions based on current survey research…First…none of the surveys measures consumer satisfaction with HSAs alone, or at their full potential. Second, some dissatisfaction inevitably stems from unfamiliarity…This source of dissatisfaction can be expected to dissipate over time…
Finally, HSAs may be unpopular for reasons that should not sway policymakers… HSAs are designed to eliminate inefficiencies and hidden cross-subsidies. If that causes some dissatisfaction, it means that HSAs are achieving their purpose, not that they should be abandoned. If we stop robbing Peter to pay Paul, Paul’s dissatisfaction should not persuade us to change course…
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Canadian Journalists Can’t Swallow SiCKO
Michael Moore’s new film SiCKO praises the government-run health care systems of such countries as Canada. Moore claims the film was warmly received at Cannes by Americans from both sides of the political aisle.
Canadian journalists, however, were a little more skeptical. Here’s how Peter Howell, a film critic for the Toronto Star, described their response to SiCKO:
Michael Moore is handing out fake bandages to promote his new film Sicko, an exposé of the failings of the U.S. health care system. But he may feel like applying a couple to himself after the mauling he received yesterday from several Canadian journalists – present company included – following the film’s first viewing at the Cannes Film Festival.
“You Canadians! You used to be so funny!” an exasperated Moore said at a press conference in the Palais des Festivals. “You gave us all our best comedians. When did you turn so dark?”
We Canucks were taking issue with the large liberties Sicko takes with the facts, with its lavish praise for Canada’s government-funded medicare system compared with America’s for-profit alternative.
While justifiably demonstrating the evils of an American system where dollars are the major determinant of the quality of medicare care a person receives, and where restoring a severed finger could cost an American $60,000 compared to nothing at all for a Canadian, Sicko makes it seem as if Canada’s socialized medicine is flawless and that Canadians are satisfied with the status quo…
Other Canadian journalists spoke of the long wait times Canadians face for health care, much longer than the few minutes Moore suggests in Sicko. Moore, who has come under considerable fire for factual inaccuracies in his films, parried back with more questionable claims…
Sicko, to be released in North America on June 29, is by turns enlightening and manipulative, humorous and maudlin. It makes many valid and urgent points about the crisis of U.S. health care, but they are blunted by Moore’s habit of playing fast and loose with the facts. Whether it’s a case of the end justifying the means will ultimately be for individual viewers to decide.
On June 21 — the day after the D.C. premiere of SiCKO – the Cato Institute will help viewers decide when it hosts a screening of clips from SiCKO and short films by independent filmmakers who are more critical of Canada’s Medicare system. Click here to pre-register. And arrive early: seating is limited.