Economic aspects of health care

[wolfpup]

I was not my intention to get into an endless back-and-forth with someone so zealously supportive of a dysfunctional health care model and an associated set of claims unrelated to anything in the real world, but just to address the most obvious fallacies …

@puddleglum

Apparently those limitations are so obvious that they do not merit mentioning. Medicare and Medicaid are expensive programs that have not been shown to improve health at all. Medicare and Medicaid fraud accounts for more than most countries spend on healthcare. If the US were to go to government run healthcare completely they would be the model of what would happen. We would not get an efficient Swiss system, we would get a bigger version of Medicaid.

How do you know that? How can you make that claim when in actual fact, in the real world, every country on earth that has what is in effect “Medicare for all” has a highly successful health care system, without rampant fraud, with far lower costs and equivalent and often better outcomes than the US system?

As for how that’s possible while Medicare seems to suck, here’s a clue. The key is in having a comprehensive health care system rather than piecemeal solutions that are hammered into a ridiculous Rube Goldberg-like apparatus of staggering complexity and inefficiency that tries to pretend that the free market is the right way to provide health care – specifically, it works by discouraging rampant profiteering and making health care providers accountable for their actions while simultaneously granting them the power to act as trusted gatekeepers to health care services.

@puddleglum

All those studies are based on a study by a certain current senator who cannot be trusted to publish an honest study any more than she can be trusted to be truthful in stating whether or not she is an indian. For example, she says that 50-70% of bankruptcies are caused by medical bills despite the fact that only one third of the people in the data said it was because of a medical problem. In the period that was studied from 2001-2007 bankruptcies were cut in half, yet this fact is obscured in the study and the write ups. So unless people suddenly got twice as healthy in the time period, her study is a fraud.

You appear to be under the impression that a peer-reviewed paper by four qualified authors (two from the Harvard Medical School) published in the respected American Journal of Medicine and widely cited, can be characterized as a “fraud” perpetrated by some shady Senator who may or may not be of Native American descent. I gather that this rather incredible outrage on your part is due to the fact that you don’t like the conclusions. However, aside from the stature of that study and some earlier ones, those same conclusions are also supported by a survey by the Kaiser Family Foundation, by the New York Times investigation cited in the previous link, and by yet other independent studies like the one cited in this article in the* Atlantic*: Why Americans Are Drowning in Medical Debt, with the subtitle “Healthcare is the number-one cause of personal bankruptcy and is responsible for more collections than credit cards.”

Why do you think there is so much supporting factual data for what you claim is such a blatant fraud?

@puddleglum

There is no evidence that thousands of people die from lack of healthcare in the US. People on Medicaid are more likely to die than those without insurance, there was no spike in longevity after Medicare was implemented, and mortality has gone up since Obamacare was passed.

Apparently, the more health care people get, the sicker they become. You’ll pardon me if I just reject that concept without further comment.

@puddleglum

Insurance companies are not being paid to stand in the way between you and your doctor, government bureaucrats are. I’m sure where you are they are totally dedicated and never make a mistake, but our experience in the US is that they are not.

This is unmitigated bullshit. First of all your cite is about the VA, and whatever the merits of this specific case may be, I’m not arguing in favor of government-run health care, even if there’s an argument to be made for it – after all, the Brits seem quite happy with the NHS, and their medical outcomes are excellent. I’m arguing in favor of public responsibility for funding health care for all. I’m fine with a system such as in Canada where doctors and clinics are private enterprises and hospitals are mostly independent non-profits.

But your assertion here is dead wrong and completely backwards. Standing between you and the service provider is precisely what insurance companies do. On one side they have armies of actuaries who decide what you should pay in premiums, and on the claims side that have armies of claims adjusters who decide what they will pay out, and generally highly motivated to make sure that it’s as little as possible. We’ve all dealt with them in other areas of insurance. It’s unconscionable in health care. In health care, these functions are unnecessary and parasitic and add zero value.

And here’s the thing. In single-payer, and other equivalent community-rated UHC systems, these job functions don’t exist. You don’t seem to understand the fundamental concept behind Reinhardt’s Irony. When I go to my doctor about something, there is no bureaucrat in the way to say whether it’s a payable claim or not – the doctor just bills it. If the doctor decides to send me to the hospital for a procedure, there is no bureaucrat in the way to say whether it’s a payable claim or not – the hospital just bills it.

And yet, there’s no significant fraud – because the trusted gatekeepers in the system are accountable to the public system that funds them. It’s amazing how that all works out.

[DSeid]

Most of this discussion about a “free market” approach is frankly boring but clearly false statements require correction.

@puddleglum

… Medicare and Medicaid are expensive programs that have not been shown to improve health at all. Medicare and Medicaid fraud accounts for more than most countries spend on healthcare. If the US were to go to government run healthcare completely they would be the model of what would happen. We would not get an efficient Swiss system, we would get a bigger version of Medicaid. …

Let’s start with the efficiency of Medicaid.

… Medicaid’s costs per beneficiary are substantially lower than for private insurance and have been growing more slowly than per-beneficiary costs under private employer coverage.

Medicaid provides more comprehensive benefits than private insurance at significantly lower out-of-pocket cost to beneficiaries …

More.

Administrative costs of Medicaid are less than 7 percent, or half the rate that’s typically seen in the private sector

And Medicare?

Medicare Is More Efficient Than Private Insurance … According to CMS, for common benefits, Medicare spending rose by an average of 4.3 percent each year between 1997 and 2009, while private insurance premiums grew at a rate of 6.5 percent per year. (See Table 13)
According to a calculation by the National Academy for Social Insurance, if spending on Medicare rose at the same rate as private insurance premiums during that period, Medicare would have cost an additional $114 billion (or 31.7 percent). … administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue.
Insurance industry-funded studies exclude private plans’ marketing costs and profits from their calculation of administrative costs. Even so, Medicare’s overhead is dramatically lower.
Medicare administrative cost figures include the collection of Medicare taxes, fraud and abuse controls, and building costs.

As for “improving healthcare at all” Medicare Advantage is the current vehicle tracking healthcare outcome metrics and it is so far clear that as organizations participate in the program longer the performance on those healthcare outcome measures improve.

More factchecking.

People on Medicaid are more likely to die than those without insurance, there was no spike in longevity after Medicare was implemented, and mortality has gone up since Obamacare was passed

I am sure your first bit is are referencing a debunked false claim by the Heritage Foundation.

As to the second, Medicare was implemented in 1966 and in fact you can seein this graph how life expectancy in fact did move from a plateau in the early 60s to a consistent upward trend coincident within a couple of years after the onset of that program, from about 70 in 1968 to more recently about 79. Likely that is not exclusively due to Medicare but factually you are simply wrong.

As to the last point - honestly it is too soon to have any meaningful data. The impact of the proverbial ounces of prevention and increased access the ACA facilitates will need to be weighed in a decade or so and are not realistically expected to be seen within a year or so of full implementation. I rate this point partly true as indeed United States life expectancy did drop 0.1 year in 2015 after those years of fairly steady increase that began with Medicare’s implementation (with a brief drop due to AIDS), driven mostly but not exclusively by the impact of greater suicide and drug associated deaths in working class Whites, especially in those states that opted out of many of the ACA provisions. Now I don’t attribute this to nonparticipation, again, too soon, but the poor who live in rrural areas, and it seems in particular being rural, female, and in your 40s, is on a consistent trend of dramaticallyincreasing death rates since 1995. More detail about these long term trends here. Will the ACA eventually provide more access to healthcare to the rural poor and by so doing bring them into the overall increase that other groups have been seeing? The jury is still out and to no small degree it depends on how it is handled from here.
Last is my being ever so slightly curious - what would a completely free market approach to healthcare look like to you?

[DSeid]

@Magiver

You’re comparing apples to oranges particularly if you’re comparing a universal health care system against a privately ensured system. My insurance cost more (per person) because I get more than someone in a country with universal healthcare.

Not in terms of healthcare outcomes you aren’t.

[Wesley_Clark]

@Magiver

You’re comparing apples to oranges particularly if you’re comparing a universal health care system against a privately ensured system. My insurance cost more (per person) because I get more than someone in a country with universal healthcare.

What are you basing that on?

In the US, we do have more surgeries, more CAT scans and PET scans, etc. But I don’t know if that translates into better health outcomes. A major part of that is just that we have a fee for service system, and surgeries and scans are major money makers for the medical profession.

Evenso, in some countries like Australia a person is free to buy private insurance that provides more/better care than the public system to augment their healthcare. That system could easily work here if we had medicare for all.

[Grim_Render]

@Magiver

You’re comparing apples to oranges particularly if you’re comparing a universal health care system against a privately ensured system. My insurance cost more (per person) because I get more than someone in a country with universal healthcare.

I am curious -what do you think you get that I or other people in UHC countries don’t get? Specifically?

Also a little point -not only do your insurance cost more per person than UHC, but you also, additionally pay more in taxes for healthcare.

[PatrickLondon]

@Grim_Render

I am curious -what do you think you get that I or other people in UHC countries don’t get? Specifically?

Looking at this from a British perspective, I’m guessing that

• there is enough redundancy built into your system to allow for people to shop around as between doctors and other medical services (whereas the price of getting general practitioners to sign up to the NHS in the first place was to allow them to maintain their previous status for the bulk of people as someone who could get them in to the “best” specialist care, which has now morphed into gatekeeping for the specialist services: we can’t just decide we’d like the NHS to pay for us to go to this specific famous specialist surgeon or hospital, nor that our problem requires direct access to an orthopaedic or ENT surgeon, or whatever - we have to go to the GP first, or if we turn up in Emergency with something ordinary that should have gone to the GP, we get a weary lecture about it)

• you might have more luxuriously-appointed facilities and “hotel services” in hospitals than we do (but we get by)

• the one thing private medicine is commonly used for in this country (apart from those relatively few snobbish people who wouldn’t dream of queueing up with the great unwashed) is getting quicker access to hospital specialist services for annoying but not life-threatening conditions: the demand for this can wax and wane with levels of government funding, depending on how big a backlog is allowed to build up. There is a target maximum time of 18 weeks from first seeing the GP about a problem to starting hospital treatment if needed, and I think the median is still currently around 6-7 weeks, but that may be slipping at the moment because of the government squeeze.

[Evan_Drake]

@puddleglum

There is a way to coordinate people’s wants and desires with society’s ability to produce, the market. The market uses price signals to transmit information up and down the line to produce optimum coordination. Thus the choice as to whether the hep-c treatment is worth the money is left to each individual and so if the optimum balance of healthcare, education, and nutrition. The problem is that healthcare is an area where people hate using markets so the government tries to insulate people from costs as much as possible.

You are lucky in America that each and every citizen is highly informed and of a keen enough superior intelligence to simply make the optimal choice every time. Not all countries are so lucky.

The only reason so many people are on dialysis is that the government makes compensating people who donate kidneys for their time, pain, and missed work illegal. Yet because the government outlaws compensation it spends 50 billion a year on dialysis and allows thousands of people a year to die from kidney disease.

And if you imported them from the Third World they would be even cheaper !

[Evan_Drake]

@Shodan

If we spend a million dollars curing a sick child, and that child grows up and generates two million dollars of productivity over his life, then the million is an investment. If we spend a million dollars curing a 70 year old of his cancer, and he lives a further ten years collecting Social Security rather than working, then it is a net loss. That’s not to say we shouldn’t cure 70 year olds - just that we should recognize that some spending is deadweight, economically speaking. Of course we incur the same loss if the child never produces more than he consumes, or on cosmetic surgeries, or anything else that does not enhance productivity.
Shodan

Very Gradgrindian.

[puddleglum]

@wolfpup

I was not my intention to get into an endless back-and-forth with someone so zealously supportive of a dysfunctional health care model and an associated set of claims unrelated to anything in the real world, but just to address the most obvious fallacies …

How do you know that? How can you make that claim when in actual fact, in the real world, every country on earth that has what is in effect “Medicare for all” has a highly successful health care system, without rampant fraud, with far lower costs and equivalent and often better outcomes than the US system?

Medicare and Medicaid are exclusive to America and no other country has “Medicare for all”. They each have their own system. In order to get another country’s system to the US you would have to import the other country’s doctors, politicians, and voters. That is obviously impossible. So any Medicaid/Medicare for all in the US would necessarily build on the current system. Since the current system is fraud filled and barely hanging together, we should expect that doubling its size would not fix its problems but instead introduce new problems. For what the US pays in Medicaid fraud each year, we could pay the tuition of every college student in the country twice. The nation’s top expert in the subject wrote a book about it called License to Steal. 70% of the countries in the world have a GDP smaller than the amount wasted on Medicaid fraud. Maybe we should try to fix what is already broken before we doble its size.

As for how that’s possible while Medicare seems to suck, here’s a clue. The key is in having a comprehensive health care system rather than piecemeal solutions that are hammered into a ridiculous Rube Goldberg-like apparatus of staggering complexity and inefficiency that tries to pretend that the free market is the right way to provide health care – specifically, it works by discouraging rampant profiteering and making health care providers accountable for their actions while simultaneously granting them the power to act as trusted gatekeepers to health care services.

The whole reason we have a ridiculous Rube Goldberg apparatus of staggering complexity and inefficiency is that the government is intimately involved in every step of the process. The healthcare providers which are now unaccountable profiteers will suddenly be transformed into trusted gatekeepers as soon as we give the government a little more power. That makes no sense.

You appear to be under the impression that a peer-reviewed paper by four qualified authors (two from the Harvard Medical School) published in the respected American Journal of Medicine and widely cited, can be characterized as a “fraud” perpetrated by some shady Senator who may or may not be of Native American descent. I gather that this rather incredible outrage on your part is due to the fact that you don’t like the conclusions. However, aside from the stature of that study and some earlier ones, those same conclusions are also supported by a survey by the Kaiser Family Foundation, by the New York Times investigation cited in the previous link, and by yet other independent studies like the one cited in this article in the* Atlantic*: Why Americans Are Drowning in Medical Debt, with the subtitle “Healthcare is the number-one cause of personal bankruptcy and is responsible for more collections than credit cards.”

Why do you think there is so much supporting factual data for what you claim is such a blatant fraud?

The reason there is so much fraudulent data out there is because people like the narrative that Medical debt is a huge problem and the government will solve it. Fauxcahontas rode that narrative to the Senate. The truth is that no one knows how many people are declaring bankruptcy for medical reasons. If someone pays thousands of dollars for healthcare on their credit card that is listed as credit card debt and not medical when bankruptcy is declared. If medical bills are the chief reason bankruptcy is declared than the rate should not vary much over time or increase as boomers age. Instead over the last 7 years bankruptcies have gone down 62%. Also Canada and the US have a similar rate of bankruptcy with .3% of families in both countries filing per year.

Apparently, the more health care people get, the sicker they become. You’ll pardon me if I just reject that concept without further comment.

If you reject concepts without looking at the data, how are you going to learn? As a personal matter ignorance is bliss, but is seems a bad basis for policy.

This is unmitigated bullshit. First of all your cite is about the VA, and whatever the merits of this specific case may be, I’m not arguing in favor of government-run health care, even if there’s an argument to be made for it – after all, the Brits seem quite happy with the NHS, and their medical outcomes are excellent. I’m arguing in favor of public responsibility for funding health care for all. I’m fine with a system such as in Canada where doctors and clinics are private enterprises and hospitals are mostly independent non-profits.

The VA is an example of how the US government runs a healthcare system which is what is being proposed. Since there are no proposals to have the government of the UK run the the US system, we should look at how the US government functions and not some other country.

But your assertion here is dead wrong and completely backwards. Standing between you and the service provider is precisely what insurance companies do. On one side they have armies of actuaries who decide what you should pay in premiums, and on the claims side that have armies of claims adjusters who decide what they will pay out, and generally highly motivated to make sure that it’s as little as possible. We’ve all dealt with them in other areas of insurance. It’s unconscionable in health care. In health care, these functions are unnecessary and parasitic and add zero value.

And here’s the thing. In single-payer, and other equivalent community-rated UHC systems, these job functions don’t exist. You don’t seem to understand the fundamental concept behind Reinhardt’s Irony. When I go to my doctor about something, there is no bureaucrat in the way to say whether it’s a payable claim or not – the doctor just bills it. If the doctor decides to send me to the hospital for a procedure, there is no bureaucrat in the way to say whether it’s a payable claim or not – the hospital just bills it.

And yet, there’s no significant fraud – because the trusted gatekeepers in the system are accountable to the public system that funds them. It’s amazing how that all works out.

The way insurance work is that the insurance company provides a list of covered conditions, medicines, and a list of providers. If you don’t like the list you can try another company or pay out of pocket. In other countries the government provides the list of medicines, procedures, and providers it will pay. In some countries you are not allowed to go outside the list and in others you can pay out of pocket. The difference is that in the US you can change companies if you want a different list and in other places you have to move.

[puddleglum]

@DSeid

Most of this discussion about a “free market” approach is frankly boring but clearly false statements require correction.

Let’s start with the efficiency of Medicaid. More.
And Medicare?
As for “improving healthcare at all” Medicare Advantage is the current vehicle tracking healthcare outcome metrics and it is so far clear that as organizations participate in the program longer the performance on those healthcare outcome measures improve.

More factchecking.I am sure your first bit is are referencing a debunked false claim by the Heritage Foundation.

As to the second, Medicare was implemented in 1966 and in fact you can seein this graph how life expectancy in fact did move from a plateau in the early 60s to a consistent upward trend coincident within a couple of years after the onset of that program, from about 70 in 1968 to more recently about 79. Likely that is not exclusively due to Medicare but factually you are simply wrong.

As to the last point - honestly it is too soon to have any meaningful data. The impact of the proverbial ounces of prevention and increased access the ACA facilitates will need to be weighed in a decade or so and are not realistically expected to be seen within a year or so of full implementation. I rate this point partly true as indeed United States life expectancy did drop 0.1 year in 2015 after those years of fairly steady increase that began with Medicare’s implementation (with a brief drop due to AIDS), driven mostly but not exclusively by the impact of greater suicide and drug associated deaths in working class Whites, especially in those states that opted out of many of the ACA provisions. Now I don’t attribute this to nonparticipation, again, too soon, but the poor who live in rrural areas, and it seems in particular being rural, female, and in your 40s, is on a consistent trend of dramaticallyincreasing death rates since 1995. More detail about these long term trends here. Will the ACA eventually provide more access to healthcare to the rural poor and by so doing bring them into the overall increase that other groups have been seeing? The jury is still out and to no small degree it depends on how it is handled from here.
Last is my being ever so slightly curious - what would a completely free market approach to healthcare look like to you?

The Medicaid study you say was debunked was not. It was just pointed out that it only covered surgery patients not everyone. No one has debunked the data. There are other studies that have shown the same thing. The best study so far is a huge RCT of people who signed up for Medicaid in Oregon, and the results so far are that there have been no measurable improvements in people’s health as a result of being on Medicaid.

Here is a meta study of 15 studies of the effectiveness of Medicare that concludes “Medicare increases consumption of medical care and may modestly improve self reported health, but has no effect on mortality, at least in the short run.”
This has been true from the start of the program here is a study that shows there was no detectable improvement in mortality from the introduction of medicare.

Obamacare is almost all Medicaid expansion and as you say there have been no improvements in mortality.

A free market in health care would look like it does in every other field. You would pay out of pocket for routine procedures and insurance would cover catastrophes. All the prices would be about half of what they are now.

[puddleglum]

@Evan_Drake

You are lucky in America that each and every citizen is highly informed and of a keen enough superior intelligence to simply make the optimal choice every time. Not all countries are so lucky.

And if you imported them from the Third World they would be even cheaper !

Other countries are lucky in that their politicians are all experts on not only every medical procedure but the personal preference of everyone of their citizens. Unfortunately in America are politicians are only experts at getting elected.
Kidneys can not last more than 36 hours outside of the body so it would be difficult to import them.

[Evan_Drake]

I think they put them in cool-boxes and overnight them from China.

You can buy your own for emergencies, like if you sell yours and want only the best for your ex-organs. LifePort Kidney Transporter.

And frankly not a single politician in Britain has any operative decision over any medical procedure except for the Minister of Health. Any more than we would have them drive a train or work as croupiers because they nominally oversee these enterprises as elected things.

[DSeid]

@puddleglum

The Medicaid study you say was debunked was not. It was just pointed out that it only covered surgery patients not everyone. No one has debunked the data. There are other studies that have shown the same thing. The best study so far is a huge RCT of people who signed up for Medicaid in Oregon, and the results so far are that there have been no measurable improvements in people’s health as a result of being on Medicaid.

Here is a meta study of 15 studies of the effectiveness of Medicare that concludes “Medicare increases consumption of medical care and may modestly improve self reported health, but has no effect on mortality, at least in the short run.”
This has been true from the start of the program here is a study that shows there was no detectable improvement in mortality from the introduction of medicare.

Obamacare is almost all Medicaid expansion and as you say there have been no improvements in mortality.

A free market in health care would look like it does in every other field. You would pay out of pocket for routine procedures and insurance would cover catastrophes. All the prices would be about half of what they are now.

The data was not debunked; the misinterpretation and misrepresentation of it was.

I’m going to start going into more detail with that article that you (very inaccurately) described as being a meta-study of Medicare efficacy. You may actually want to really read it rather than try to glean particular quotes out of it. It really is a pretty thoughtful article about health insurance’s impact in general (inclusive of of Medicare) which recognizes the limits of the data that was available at the time the article was written a decade ago. No, it was not in any way a “meta-study” (and certainly not a meta-analysis) and no, the fifteen studies listed in the table that had sometimes conflictual results were not all about Medicare. Three were. They showed no short term impact on mortality and the two that looked found positive impacts on self-reported health

The authors correctly note that mortality rate is very insensitive outcome to measure: “using mortality as an outcome is likely to miss important changes in health, whereas self-reported health is likely to be more sensitive.” It is also a lagging indicator; few would rationally expect a short term impact. That is why so many studies on population wide healthcare interventions do not measure mortality as the outcome but other proxies relevant to the disease being targeted.

Their conclusion is mainly a bemoaning of the lack of evidence of high enough quality to definitively come to any conclusion.

That is a very reasonable conclusion but studies powered adequately and followed long enough to answer definitively may be hard to come by.

But let’s look at what has become available since that article was published.

First that Oregon study (a very balanced and more comprehensive treatment of it than Wiki’s here). As even Wiki notes the population studied was very limited both in size, in geography, and to just a two year period.

Still what did it find in that very short term very limited study? First no surprise to me that people who have not had healthcare coverage have some pent-up demand for services. Some sick get identified and intervention courses initiated, some hospitalized and scripts written. In an initial phase there were more services used overall, including a significant rise in ED visits and “increased the use of preventive care, including cholesterol monitoring, by 50 percent, and more than doubled the likelihood that women older than age forty had mammograms within the past year compared to the control group, those who remained uninsured” and it raised the rates of diabetes identification and management. Use of those services and successful screening are the sensitive proxy for the long term outcomes in large populations. Identification of treatable conditions is the requisite first step. As your citation above also noted “self-reported health is likely to be more sensitive” as a proxy for important health outcomes (I’m thinking cognitive and physical disability myself) and indeed “enrollment increased the probability that people reported themselves to be in good to excellent health (compared with fair or poor health) by 24 percent”. It also reduced “rates of depression by 30 percent.”

So more screening, more early identification of treatable conditions, more treatment initiated, dramatically better self-reported health status, and dramatically less depression. These are real “measurable improvements in people’s health as a result of being on Medicaid.”

Indeed the study was too short and too under-powered to prove the results of that early identification and early treatment on mean lab measures. There were across the board trends of improvement on objective measures (per your wiki link “improvements associated with Medicaid coverage in every single category, with a 1.33 percentage point (8%) decrease in high blood pressure incidence, a 2.43 percentage point (17%) decrease in high cholesterol incidence, a .93 percentage point (18%) decrease in high glycated hemoglobin incidence, and a 0.21 percentage point (2.5%) decrease in Framingham risk score” but they did not individually reach statistical significance. So no proof that those consistent across the board trends are real and that the increased screening, identification, and treatment achieved translates into those proxies let alone mortality rates.

One who argues that the documented significant increase in screening and early identification/treatment would not over time result in savings is claiming that the extensive bodies of research and evidence that demonstrate a wide variety (but certainly not all) of screening, early identification/treatment is effective at reasonable costs is wrong. Spoiler alert: it aint.
Any more to add to the dataset since that 2007 article on its central question of whether coverage for healthcare improves health? Why yes there is.

One regarding the introduction of National Health Insurance (NHI) in Taiwan in 1995.

NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Another that looks at the staggered rollout of Thailand’s universal health coverage.

universal coverage reduced the likelihood of people reporting themselves to be too sick to work

How about returning to the U.S.?

Massachusetts. Implementation of near-universal coverage

led to better overall self-assessed health. Various robustness checks and placebo tests support a causal interpretation of the results. We also document improvements in several determinants of overall health: physical health, mental health, functional limitations, joint disorders, and body mass index. Next, we show that the effects on overall health were strongest among those with low incomes, nonwhites, near-elderly adults, and women.

Also more screening for breast and cervical cancer.

And this very interesting bit on the long term impact of Medicaid coverage of pregnant women.

We find that those whose mothers gained eligibility for prenatal coverage under Medicaid have lower rates of obesity and lower body mass indices as adults. Using administrative data on hospital discharges, we find that cohorts who gained in utero Medicaid eligibility have fewer preventable hospitalizations and fewer hospitalizations related to endocrine, nutritional and metabolic diseases, and immunity disorders as adults.

Wow. Really, wow.

But not something a two year follow up will document.
Lastly exploring your image of so called “free market” - do you mandate insurance that would cover catastrophes? Obviously doing such would not be very free market, so what happens to those who gamble that they are lower risk for such events and go without? Do they get turned away from the EDs? Not picked up by the ambulances? Or do they get handled as the uninsured get handled now, getting charged enough to go bankrupt and the cost of having provided that care buried into the charges that the insured pay?

[septimus]

I admire Dopers who can respond to posts like the following. I would be unable to respond in detail until the thread is moved to another subforum. However, I have highlighted one claim that I want to ask about.

@puddleglum

it is impossible to determine…
… politically popular.
… so obvious that they do not merit mentioning. Medicare and Medicaid are expensive programs that have not been shown to improve health at all. Medicare and Medicaid fraud accounts for more than most countries spend on healthcare…
… a certain current senator who cannot be trusted to publish an honest study any more than she can be trusted to be truthful in stating whether or not she is an indian.
… her study is a fraud.
There is no evidence that thousands of people die from lack of healthcare in the US. People on Medicaid are more likely to die than those without insurance, there was no spike in longevity after Medicare was implemented, and **mortality has gone up since Obamacare was passed. **

Insurance companies are not being paid to stand in the way between you and your doctor, government bureaucrats are. I’m sure where you are they are totally dedicated and never make a mistake, but …

I see that you’re too busy to provide citations for your claims, puddleglum, so I tried to help you by sourcing the highlighted claim. But my first hit was

Infant mortality is considered a basic measure of public health for countries around the world. Over the past decade, the overall infant mortality rate in the United States has improved, declining 15% from 6.86 infant deaths per 1,000 live births in 2005—a recent high—to 5.82 in 2014

This quote came from a U.S. government site so should be presumed to be a lie, I suppose. Can you provide a better cite, puddleglum ?

[Grim_Render]

@puddleglum

The fact there there are problems with markets does not mean that they are automatically worse than other solutions. In order to show that markets do not work you have to do more than show that they are not perfect, you have to show that other solutions have fewer problems and that the problems markets have can not be worked around.

*Have we not shown exactly this in exhausting detail ? *

We are not just talking theory here. We are also comparing the US experience with the other systems of the developed world. And it works out roughly as the theory predicts.

The US system costs more, covers a lower fraction of the population, and yields average or worse results on most measures. It has a host of issues not found in other systems. Other solutions do demonstrably have fewer problems.

@puddleglum

The most efficient healthcare system in the world, Singapore is one of the most market oriented in that every service provided has a cost attached.

Singapore’s health service is as I remember based on compulsory health savings accounts which is a level of government intrusiveness that would be hard to stomach in freer systems. Charges are generally subsidized by the government, but if you exhaust your savings account you are currently in some trouble. And an issue with medical care is that treatment for one condition in no way insures that you will not need treatment for another.

They did try a less heavily regulated model in the 80s, and that resulted in soaring costs. Currently there is heavy government regulation and oversight to keep cartels and monopolies from forming.

Its expenditures is also not out of line with those of other city-states (excluding the Vatican) that can theoretically cover their entire populations from one central hospital.

[DSeid]

@septimus

I admire Dopers who can respond to posts like the following. I would be unable to respond in detail until the thread is moved to another subforum. However, I have highlighted one claim that I want to ask about.

I see that you’re too busy to provide citations for your claims, puddleglum, so I tried to help you by sourcing the highlighted claim. But my first hit was

This quote came from a U.S. government site so should be presumed to be a lie, I suppose. Can you provide a better cite, puddleglum ?

Not puddleglum but the isolated factoid is not incorrect (even as infant mortality continues to improve). Here’s a NYT article about it and here is the actual CDC dashboard page. Use “age adjusted”.

It seems to be driven by increases in particular among young adults, under 44 and without college education, and those very premature deaths seem to be mostly driven by drug overdose deaths (opioids and alcohol related) which are more than oversetting other gains.

[Ramira]

The writing about markets by the non economist:

@puddleglum

There is a way to coordinate people’s wants and desires with society’s ability to produce, the market. The market uses price signals to transmit information up and down the line to produce optimum coordination.

yes this is the introductory undergradaute understanding of markets.

It is a gross simplification to introduce the idea of markets. It is also simplistic and not the real concept of market economics.

The issue of the ‘price signals’ is but one aspect of the market clearing, along with the aspect of the pricing power, the information transparency and the agency problems forthe decisions. All these aspects are very complicated in the market for the medical service market.

The remainder of the analysis is defectively superficial and not a correct free market economic analysis for the health care, but an ideological presentation from a undergraduate simplsitic idea of markets.

[Thudlow_Boink]

I just happened upon this relevant article/blog post:
Healthcare and the Free Market: Does Competition Work?

It’s short, but here are the main points:

But the reality in health care is that it’s not a free market, and it can’t be a free market, and we cannot rely on competition to keep prices down. One big reason: health care prices are a secret.
…
There are other reasons that health care doesn’t abide by free-market principles:

Hospitals and emergency departments have to provide care to everyone, even if they can’t pay.
…
The “barriers to entry” are too high to ensure competition.
…
Many people don’t pay their own health care bills.
…
Health care is often “purchased” under duress.

[Ramira]

@Magiver

You’re comparing apples to oranges particularly if you’re comparing a universal health care system against a privately ensured system. My insurance cost more (per person) because I get more than someone in a country with universal healthcare.

You say this based on what actual compartive data?

[puddleglum]

@DSeid

The data was not debunked; the misinterpretation and misrepresentation of it was.

I’m going to start going into more detail with that article that you (very inaccurately) described as being a meta-study of Medicare efficacy. You may actually want to really read it rather than try to glean particular quotes out of it. It really is a pretty thoughtful article about health insurance’s impact in general (inclusive of of Medicare) which recognizes the limits of the data that was available at the time the article was written a decade ago. No, it was not in any way a “meta-study” (and certainly not a meta-analysis) and no, the fifteen studies listed in the table that had sometimes conflictual results were not all about Medicare. Three were. They showed no short term impact on mortality and the two that looked found positive impacts on self-reported health

The authors correctly note that mortality rate is very insensitive outcome to measure: “using mortality as an outcome is likely to miss important changes in health, whereas self-reported health is likely to be more sensitive.” It is also a lagging indicator; few would rationally expect a short term impact. That is why so many studies on population wide healthcare interventions do not measure mortality as the outcome but other proxies relevant to the disease being targeted.

Their conclusion is mainly a bemoaning of the lack of evidence of high enough quality to definitively come to any conclusion.

That is a very reasonable conclusion but studies powered adequately and followed long enough to answer definitively may be hard to come by.

But let’s look at what has become available since that article was published.

First that Oregon study (a very balanced and more comprehensive treatment of it than Wiki’s here). As even Wiki notes the population studied was very limited both in size, in geography, and to just a two year period.

Still what did it find in that very short term very limited study? First no surprise to me that people who have not had healthcare coverage have some pent-up demand for services. Some sick get identified and intervention courses initiated, some hospitalized and scripts written. In an initial phase there were more services used overall, including a significant rise in ED visits and “increased the use of preventive care, including cholesterol monitoring, by 50 percent, and more than doubled the likelihood that women older than age forty had mammograms within the past year compared to the control group, those who remained uninsured” and it raised the rates of diabetes identification and management. Use of those services and successful screening are the sensitive proxy for the long term outcomes in large populations. Identification of treatable conditions is the requisite first step. As your citation above also noted “self-reported health is likely to be more sensitive” as a proxy for important health outcomes (I’m thinking cognitive and physical disability myself) and indeed “enrollment increased the probability that people reported themselves to be in good to excellent health (compared with fair or poor health) by 24 percent”. It also reduced “rates of depression by 30 percent.”

So more screening, more early identification of treatable conditions, more treatment initiated, dramatically better self-reported health status, and dramatically less depression. These are real “measurable improvements in people’s health as a result of being on Medicaid.”

Indeed the study was too short and too under-powered to prove the results of that early identification and early treatment on mean lab measures. There were across the board trends of improvement on objective measures (per your wiki link “improvements associated with Medicaid coverage in every single category, with a 1.33 percentage point (8%) decrease in high blood pressure incidence, a 2.43 percentage point (17%) decrease in high cholesterol incidence, a .93 percentage point (18%) decrease in high glycated hemoglobin incidence, and a 0.21 percentage point (2.5%) decrease in Framingham risk score” but they did not individually reach statistical significance. So no proof that those consistent across the board trends are real and that the increased screening, identification, and treatment achieved translates into those proxies let alone mortality rates.

One who argues that the documented significant increase in screening and early identification/treatment would not over time result in savings is claiming that the extensive bodies of research and evidence that demonstrate a wide variety (but certainly not all) of screening, early identification/treatment is effective at reasonable costs is wrong. Spoiler alert: it aint.
Any more to add to the dataset since that 2007 article on its central question of whether coverage for healthcare improves health? Why yes there is.

One regarding the introduction of National Health Insurance (NHI) in Taiwan in 1995.

Another that looks at the staggered rollout of Thailand’s universal health coverage.

How about returning to the U.S.?

Massachusetts. Implementation of near-universal coverage
Also more screening for breast and cervical cancer.

And this very interesting bit on the long term impact of Medicaid coverage of pregnant women.Wow. Really, wow.

But not something a two year follow up will document.
Lastly exploring your image of so called “free market” - do you mandate insurance that would cover catastrophes? Obviously doing such would not be very free market, so what happens to those who gamble that they are lower risk for such events and go without? Do they get turned away from the EDs? Not picked up by the ambulances? Or do they get handled as the uninsured get handled now, getting charged enough to go bankrupt and the cost of having provided that care buried into the charges that the insured pay?

The Taiwan and Thailand experiences are about different populations and different systems, they do not apply to Medicare or Medicaid.
The other studies are as I described them except the survey was about private insurance and only 3 of the studies were about Medicaid. That is a quibble.
All of the studies are consistent in that they show more utilization, more screenings, and no measurable improvement in health. If you think that a 10,000 people study is underpowered then there is no basis to have an opinion because that is the largest study of its kind ever.
It may be that as the study goes on it will find difference in health, but for now it shows no difference and we should base opinions on facts and not speculations.