• My question to Mark Pauly

    I asked the final question put to Mark Pauly after his plenary talk yesterday.

    My question (paraphrased): Almost without exception, when I hear health economists describe their preferred health reform, it is rarely exactly the ACA, but it often has many similar features. Yet the health economics community is not uniformly pro-ACA. Should we be?

    Pauly’s answer (paraphrased): It’s not our role to endorse legislation, and I have never done so. We should remain unencumbered in our ability and willingness to comment about the strengths and weaknesses of any proposal.

    I think this is a good answer, and it is consistent with my own behavior, yet I still feel a little uncomfortable. In asking this question, I had in mind a slightly different one: could there ever be anything important enough to warrant putting aside the standard academic equipoise? (“On the one hand …, yet on the other …”) If so, what? Could making substantial progress on the problems of the cost and quality of and access to health care be in that category? Is it or should it be relevant that a failure of this health reform, like all comprehensive attempts in the past, likely means at least another decade or two before it is attempted again?

    I imagine a European colleague pulling me aside at the ASHE conference and asking, “Why can’t you American health economists figure out how to provide coverage for all your country’s citizens? What’s wrong with you?” I really do think it is a national embarrassment, or should be, that we are the wealthiest country on the planet, spend vastly more on health care than any other, and yet have enormous disparities in access. How we tolerate this, and for so long, is astonishing to me. What is wrong with us indeed!

    Is there ever a time when we just say, “Enough!” not just individually, but collectively? Sometimes it seems like madness that we do not.

    And yet (go ahead, groan), even if one can reasonably disagree with Pauly, he’s not wrong. Health care is so political and today’s American political environment is so fierce and unforgiving —  toxic, even — that it is dangerous to yoke oneself or a community to legislation. Doing so would alter one’s relationship with it and to the party that promoted it, as well as with the one that opposed. That way danger lies. I respect those of my profession who are willing and able to take such risks. Most of them are tenured. Many of the rest of us are not. This matters, and we all know it.

    So, I find myself conflicted. Facing the choice between madness and danger, I’ve tried to slide between, to be constructive without being partisan, to be honest without the hubris that I know best. I don’t. But, being honest, you don’t either. There is no such thing.

    For three years, on this blog, I’ve written that the ACA or something like it is better than no reform but is neither ideal reform nor the end of reform. I’ve written about the important problems the ACA would start to address and about its limitations. I’m as pleased by the law as I am disappointed, and I’ve expressed that. This seems to be consistent with Pauly’s way, but I am less certain than he is that it is the right way. It is the safe way, and hence the appropriate position for the stewardship of the community. It’s the right view from the podium. But I still wonder, does madness ever trump danger? Do we sleep well in the academic bunker?

    (Pauly’s talk, about the longstanding shortcomings of the private health insurance industry, was excellent. I believe it may appear in print in the future, but I didn’t quite catch where or when.)

    @afrakt

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    • The thrust of your post is similar to encounters with the bioethicists I work with:

      Q: Can we remove this patient from the ventilator?
      A: It depends?

      Geez, thanks for the consult.

      We need contributions from health economists to solve this problem, along with everyone else from the team. While I get the equipoise position, sometimes its time to put your nickel down. Its no different than the provider stating, “my job is to advocate for the patient in front or me only.”

      If we all took that posture, we would get nowhere. I could make an equally compelling case that docs should get the same pass. But we cant, and we shouldnt.

      Brad

    • “Pauly’s talk, about the longstanding shortcomings of the private health insurance industry, was excellent. I believe it may appear in print in the future, but I didn’t quite catch where or when.”

      Keep your eyes/ears open. I asked the conference’s contact email about videos/transcripts being posted and they said they had no plans. Let us know if you see abstracts/summaries/transcripts being posted anywhere.

    • “…we are the wealthiest country on the planet, spend vastly more on health care than any other, and yet have enormous disparities in access. How we tolerate this, and for so long, is astonishing to me.”

      As a society, we tolerate disparities of all kinds, not just health care. In fact, many of us celebrate them. Someone who has fallen for social Darwinism (I’m rich because I have better genes) can easily see disparities in wealth, education, job opportunity and healthcare as entirely appropriate.

    • Here’s my belief:

      When health economists, politicians, and interested folk talk about health care reform in the USA, what generally comes out is that everyone needs to be fully covered for everything, i.e. everyone deserves the moon.

      When public health care in Europe, Canada, or other westernized countries occured, everyone was satisfied with just the earth’s orbit. And attorneys were nearly locked out of the room.

      Until the US can get to that point, which requires some realistic thinking, then we will never get it right.

      • You are certainly entitled to your belief, but I would say that I have not seen any health care economists advocate for “moon” level coverage. Some advocate for universal coverage.

        Steve

        • And their “universal coverage” means everyone is entitled to the same, which again will increase cost unless limits are set into place.

      • It is also important to note, as the current European crisis shows, that none of those countries has figured out how to pay for theior healthcare.

        None of these ideal systems we should copy are nearly as old as the US either.

        Does anyone wish we had the Greek system right now? Spain isn’t far behind Greece and there only 30-40 years old.

        “For three years, on this blog, I’ve written that the ACA or something like it is better than no reform”

        Why is a bad bill that makes matters worse better then doing nothing? We would be better off today if HIPAA had never been inacted. Same for COBRA. Same for Medicare. Every time Reform has been passed it has failed to deliver what was promised, increased cost, and increased the number of uninsured. And oh ya we have 40+ trillion in debt.

        Please, give me another 10 years of nothing and 10 more after that. If Economist and politicians could shut up and find something else to do for a few deacdes we mibght actually be able to fix this mess they created.

        While the majority of economist might not have overty picked sides they have clearly advocated and pushed the liberal/reform side. How many economist have you seen ever go back and measure the damage from past failed reform effrots before trumpeting this newest failure to be?

        ACA, if it stands, will fail just like all the efforts before it for all the same reasons, it was created by people that have never worked a day in the field and don’t understand just because an idea looks good on paper doesn’t mean it can be implemented and work in the real world. Small group reform, passed over a deacde ago, should have solved at least some of the small group market problems, instead it just blew up cost and decreased coverage. ACA takes those same failures, doubles down on them, and does away with the few things that are actually working.

        The closer we get to community rating the fewer people have coverage, this is simple math economist more so then anyone should be able to notice. Healthy people will never fully subsidize people that choose to be unhealthy. See Greek tax collection for how this plays out. If the value of my insurance policy is $200 and I eat right and exercise I am not going to pay $700 so someone that smokes, drinks, sits around, and doesn’t do anything can also pay $700 instead of the $2000 they should be. It will never happen in America, any system based upon this will fail.

    • any opinion on this?
      http://www.pnhp.org/

      • Handy list of people you should never let treat you.

        “is is because private insurance bureaucracy and paperwork consume one-third (31 percent) of every health care dollar.”

        This is pretty amazing considering 50% of every healthcare dollar comes from the government. That means only 19% of the 2 trillion we spend on healthcare goes to treatment cost of 260 million americans.

        When you work that out they are claiming 260,000,000 privately insured and uninsured only consume $1,461 in healthcare per capita. I think that makes us the healthist and most frugal consumers in the industrialized world doesn’t it?

        2 T x 19% = 380 B / 260 M = $1,461.54