Monday, July 13, 2009

Health Care

Bill Moyers discusses health care with a former health insurance PR man.

NPR ran a special comparing care around the world a while back, some figures from that report are captured here.

I worry that outside of NPR, the picture of state funded care becomes really distorted. The Moyers interview cites Sicko, and seems to suggest that foreign state sponsored care is utopian. It also points to scare tactics used by opponents of national care who suggest state sponsored care can only be a horror story.

More of a middle ground is shown by the NPR figures. It seems like every country has its own solution with its own set of unique perks and problems. In Japan, you have universal coverage with some copay and increases to taxes (8%, including employer contributions), but you have doctor shortages and overuse of care problems. In France and Germany, you're looking at a 10-15% hit to wages to fund the programs. In the UK, costs are kept down through aggressive comparative effectiveness decisions. We can toss the US in here as just a different approach with different problems, coverage gaps and rising costs as well as low health care indicators. Cost per person for care is almost twice as high.*

I'm most attracted to the UK model, and I have real questions as to whether or not any more aggressive model could work when every decade or so the party in power will want the whole system to fail.

Those to the left of me seem attracted to a French or German model. Beyond my worries about getting a system to work under Republican administrations, I worry a lot about the costs. A high cost program would be funded through substantial wage taxes, which in turn lead to some combination of wage reductions and unemployment. Those effects disproportionately affect the poorest workers, the very group we are trying to help.

To the right of me, the current rhetoric has been attacking a public option for "rationed care." I'm surprised this is taking hold, since I always thought rationed care/refusal to cover certain procedures prompted the most public outrage in the current health care system. Moreover, unlike the outraged public, I think aggressively rationing care is essential to reducing the sort of wage effects that will most harm the working poor. I think rationing care through comparative effectiveness research helps us make better care decisions than we might on our own.

Several studies have shown that increased health care does not correlate with increased health outcomes. Some sources on this problem: Overcoming Bias discussion of largest health care cost study ever conducted, the RAND study, in parts one and two, which gave a bunch of random people free care and compared them to a bunch of similar people with pay care for several years. An NPR discussion of the lack of link between health care costs and results region by region. NPR report on drug coverage with conflicting results. The New York Times recently addressed this issue in the context of Prostate Cancer. No matter what the eventual plan, lets hope that increased cost effectiveness research is a big part of it.

*On costs:
When taken as a percentage of median income, the US expenditures on per capita healthcare are just over 10%, perfectly comparable to the income tax rates funding health care in other countries. Greg Mankiw explains how some cost differences are "artifacts of labeling". Cost comparisons are not as straightforward as they appear. Maybe this throws a wrench in my optimism over cost research.