Of Natelson and Snowbirds

Rob Natelson put up a surprisingly shallow piece on health care over at Electric City Weblog. Here are his talking points (he’s responding to a Mike Dennison piece in Lee newspapers:

First: Pure single-payer means the government pays all the bills. If you hire a doctor on the side using your own funds because your desperately-ill child is on a waiting list and can’t otherwise get care, you are committing a crime. Few countries have such a vicious system. And countries, like Britain, that used to have purely “regimented national plans” (Mike Dennison’s phrase) are headed toward more mixed systems. (I’ll give an example in a future post.)

Second: As anyone who works in government knows, the costs as reported for government programs are nearly always understated. They often don’t include capital expenses. Or costs are kept down by deferring necessary longer-term investment (that’s why it has been so difficult to get certain kinds of procedures in Canada). And, of course, they never count the costs to the economy from the taxes necessary to pay for the system.

Third: Under “regimented national plans” the waiting lists generated in government programs are themselves a form of uncounted cost – because pain and death saves money.

Fourth: The U.S. has the most innovative health care in the world for a reason – that despite the fact that government and insurance companies dominate the system, they have not yet quite taken it over completely. More government control means, of course, less of that innovation. Another prospective cost.

Fifth: The cost in privacy and autonomy of government medicine can be staggering. (Remember the British Columbia lost health records scandal?) Are you worried about a few hundred prisoners at Guantanamo? That human rights problem pales before the prospect of several hundred million prisoners of government-controlled medicine.

I responded (how could I not?):

Well spoken for the 37th best health care system in the world! We’re 37! We’re 37!

1. All countries that offer universal care must ration and triage based on need. Less important procedures must wait. We’d be doing that here except that we ration based on money and don’t provide services to 47 million except in emergencies, and then only to stabilize, and not treat.

2. If the costs of Medicare, Medicaid, SCHIP and VA are “understated”, you’d better put up something better than “everybody knows”. How about “All the Helen’s in the world agree”?

3. The American notion that ‘ferners ‘ are on waiting lists for vital health care needs is mostly useful domestic propaganda. Yes, there are waiting lists for non-life threatening illnesses. We’d be doing that here if we took care of everyone. All countries ration – our system is based on 1) money, 2) access to employer-sponsored care, 3) access to government-sponsored care, and 4) good luck after that.

4. Most innovation (not all) comes from government sponsorship of outfits like NIH, colleges and universities. It is already government sponsored.

5. Medical privacy is now protected not by private companies, who are dying to share information so they know who to reject for coverage, but rather by government.

In the comment section, Rob reiterates the right wing talking point that excessive consumption (a moral hazard) is driving up costs:

In my view, phrasing the question in terms of getting more people insured misses the crux of the problem, which is too much insurance, not too little. We are not going to make medical care affordable again unless patients pay directly for most day-to-day care, in which case it will almost certainly be far cheaper than it is now.

There is a role of third-party payments in the system, but it should be the exception, not the rule — catastrophic events and care for the poor come to mind.

That’s a right-wing talking point – they have attempted to re-channel the debate from the high cost and unavailability of care into less important areas where they have financial interests waiting to accommodate us: HSA’s.

Finally, here’s a study, Phantoms in the Snow, from the late 1990’s that measure the incidence of Canadian “refugees” coming down to the states to take advantage of our health care system. The number is virtually negligible – far less than 1% in the survey. Of that small number, very few were actually coming here specifically for health care. Most were here incidentally (like “snowbirds”). Canadians routinely buy travel insurance policies when they come here due to our high prices, and those policies are designed to cover traveling emergencies, and not chronic conditions.

Some Canadians were here under contracts between Canada and the US to use procedures we have not available there or to ease their waiting queue.

The report’s conclusion:

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.