In The Blogs

Healthcare in Extremis

| Wed Jul. 8, 2009 7:58 AM PDT

Megan McArdle argues that if healthcare reform includes a public plan, it might mean a reduction in service for a lot of people with severe problems:

Surely the point of worry is that many millions of people will be forced into the public system, because its existence will encourage their employers to dump their health care plans. Since private systems have so far found it virtually impossible to deny many treatments for long, this will mean that millions of budget constrained people will find themselves with less available treatment than before.

....This is not a crazy worry. What America is best at is delivering a lot of complicated care in extremis, and "quality of life" treatments. What European countries are best at is delivering a lot of ordinary care for the sorts of things that afflict people from 0-50, which is why most of the Europhile journalists writing about Europe genuinely have very good experiences to report. I'd rather be here to have a hip replacement, but I might rather be in the Netherlands to have a baby. Doing something moderately ordinary here is a hassle. Doing something extraordinary there is often not possible for the overwhelming majority of citizens, though that depends on what, and in what system.

Boy, I'd sure like to see some backup for that. If by "extraordinary" Megan means the most extreme 0.001% of procedures, then maybe she's right. Maybe. But nothing I've read about Western European healthcare systems makes me believe that there's any substantial difference between the way they treat severe illnesses and the way we do it. And no systematic difference in success rates for such treatment either. Nor should this come as a surprise, since most extreme medicine is practiced on older patients, who are covered by a public plan both here and in Europe.

No system is better at everything than any other system. There are always tradeoffs. But the overall evidence is crystal clear: European state healthcare systems, taken as a whole, provide better care than America's hodgepodege system at about half the price. If we adopted their approach and combined it with American funding levels, we'd have a system better than either. And rich people who wanted to pay for massive amounts of special care not covered by the state would still be free to do so.

Anyway, speaking of healthcare, the 24-hour bug I thought I had yesterday seems to be more like a 72-hour bug. Blah. Blogging will probably be a little light today again.

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Kevin Drum is a political blogger for Mother Jones. For more of his stories, click here.

Comments

You And Me Both

Submitted by Rook on Wed Jul. 8, 2009 8:20 AM PDT.

I've a cold that settled into my lungs. Now it's hard to cough, it hurts. At least it's not impeding my breathing.

If I had wanted cream and sugar, why order the damn coffee?

Hi, I have an opinion. Now

Submitted by mark robbins (not verified) on Wed Jul. 8, 2009 8:36 AM PDT.

Hi, I have an opinion.

Now I'll find some facts and some half-truths that will support it nicely.

-Megan

Wo! Back up...

Submitted by Wagster on Wed Jul. 8, 2009 8:46 AM PDT.

McArdle writes:

"Surely the point of worry is that many millions of people will be forced into the public system, because its existence will encourage their employers to dump their health care plans."

The public option would just be one of many private options. According to the Schumer compromise, it would not receive any taxpayer subsidy. I'd say the odds of winding up to the left of the Schumer compromise would be just about nil. So why should the public option encourage employee-dumping any more than the private options would?

Even if her contention that the public plan would ruthlessly curtail treatments that people want, rather than treatments that are unnecessary, is correct... isn't McArdle a libertarian? Why can't she trust people to make the choice that best suits them? If her "arguendo" is correct and the public option is so much more effective in curtailing treatment than the private plans are that it undercuts them, would the people 'forced' onto the public option really have less choice than they do now? After all, they could still pay for the more expensive plans. Or they could not afford them and have no health insurance, which is hardly a great choice either.

because its existence will

Submitted by kenga (not verified) on Wed Jul. 8, 2009 10:57 AM PDT.

because its existence will encourage their employers to dump their health care plans."
Can I see a show of hands?

How many of us are gonna let our employers just up and do that, without demanding a nice fat raise?
And those of you who will let them - how many of you aren't even going to bring up the topic of what to do with that money that's not going out the door every month?

Got me.

Submitted by B on Wed Jul. 8, 2009 9:00 AM PDT.

Got me. My Dad's clinical trial bone marrow transplant was paid for by medicare.

My guess is that if you

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 9:02 AM PDT.

My guess is that if you stick 100 people into a room at random, and ask them about their health care concerns, you'd get a pretty representative sample.

I am not aware of any public forums in which our betters in congress really try to speak to the people, listen to their issues, and actually address what will be in the plan and what is a goal and will not be in the plan and what will not be in the plan.

The devil is in the details and for many people, better the devil you know.

I want to know, what about choice of doctors for a required surgery where my choice is not in my area. For example, I need heart surgery, and everyone agrees that I need it, and there is no question that the plan won't cover it somehow.

But do I get it here in my town where there is one cardio thoracic surgeon who does this specific operation I need every couple of months and where the hospital staff really has no idea what it takes, and may not even have the equipment I need the most or have trained on it?

Or can I, under plan coverage, get it covered at the world renowned Cleveland Clinic, and have it covered there in terms equivalent to my current employer provided health care plan, including a bit of travel back and forth as well as hotel costs the day before and after?

I very much want to support a public health care option. Telling people don't worry, better heads are thinking about this, isn't a winning strategy. Telling people that better heads have decided the test X you need is not needed is also not a winning strategy.

Sitting down and respecting people and describing a plan with appeals, and some amount of local control, and awareness of local context, and pointing out who they know, or who in their communiity will help make these decisions, and asking people what their concerns are and addressing them,

That's how you get people to vote for a new public health plan.

Just curious - the heart

Submitted by kenga (not verified) on Wed Jul. 8, 2009 11:00 AM PDT.

Just curious - the heart condition ... how many bone density and renal function tests
have you undergone for it? And did that visit to the podiatrist help with it?

It was a congenital bicuspid

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 11:30 AM PDT.

It was a congenital bicuspid heart valve that was replaced. However, the replacement isn't doing well and the whole thing may need to be redone. Very depressing.

My guess is that if you

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 9:02 AM PDT.

My guess is that if you stick 100 people into a room at random, and ask them about their health care concerns, you'd get a pretty representative sample.

The devil is in the details and for many people, better the devil you know.

That's how you get people to vote for a new public health plan.

As can be seen, I do have a

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 9:04 AM PDT.

As can be seen, I do have a stunning lack of motor skills, or modern concept of how buttons on a web browser work.

Hip Replacements

Submitted by Tom S (not verified) on Wed Jul. 8, 2009 9:16 AM PDT.

McArdle would like to be here for hip replacements. Most hip replacements are paid for by Medicare. So she is saying that America's existing public plan, Medicare, is better than Europe's. Am I missing something?

I would guess that a lot of the extraordinary care that she is thinking of is already paid for by Medicare.

Why does anyone take

Submitted by Napoleon (not verified) on Wed Jul. 8, 2009 9:20 AM PDT.

Why does anyone take anything McArdle writes seriously?

Kevin, please, stop engaging

Submitted by Jason L. (not verified) on Wed Jul. 8, 2009 9:44 AM PDT.

Kevin, please, stop engaging with Megan McArdle. No excuses. She's not going to be your dinner guest; you're not going to run into her at a DC cocktail party; she's not a former, current, or future colleague of yours. Just ignore her.

B: "My Dad's clinical trial

Submitted by alex (not verified) on Wed Jul. 8, 2009 9:46 AM PDT.

B: "My Dad's clinical trial bone marrow transplant was paid for by medicare."

Ok, your dad beats my dad. I was going to write that my 81 year old father received a triple bypass in a top notch hospital, and is thankfully doing quite well, all paid for by that Evil Big Government take away our Choices and Freedom program called Medicare, but your dad's story trumps it.

Well, to echo Kevin's later

Submitted by B on Wed Jul. 8, 2009 11:43 AM PDT.

Well, to echo Kevin's later points I think we'd probably choose not to do it again, and if I ever get cancer I'll probably opt for more traditional care.

But, the public option doesn't seem to take away your options more than private carriers. In fact, it's availability expands treatment options for the great majority of folks right now. The concept that private carriers are more likely to shell out cash and less likely to put you in a holding pattern is a little bizarre.

Cost controls are a whole other issue that have to be addressed no matter who is paying.

the wealthy want to pay no opportunity costs

Submitted by tpx on Wed Jul. 8, 2009 10:03 AM PDT.

What McArdle is saying, and accepted by America's upper classes, is excellent health care for the few with wealth and/or health insurance is more important than providing adequate health care for everyone else. The wealthy want to pay no opportunity costs so that everyone can have health care. As usual, the wealthy believe all opportunity costs, even for public goods, should be borne by others less well off or less privileged.

McArdle Is Simply Full Of Crap

Submitted by Chris Brown on Wed Jul. 8, 2009 10:26 AM PDT.

"What European countries are best at is delivering a lot of ordinary care for the sorts of things that afflict people from 0-50, which is why most of the Europhile journalists writing about Europe genuinely have very good experiences to report."

If that were in fact the case then why do folks in every affluent European nation, and some not so affluent, enjoy a longer "healthy life expectancy" than do we of the US? The following is from WHO 2002 statistics. I didn't want to spend the time to get more current statistics.

France 75
Italy 75
Spain 75
Sweden 75
Switzerland75
Austria 74
Canada 74
Finland 74
Germany 74
Iceland 74
Luxembourg74
Norway 74
Belgium 73
Greece 73
Malta 73
Netherlands73
Ireland 72
Israel 72
Portugal 72
Slovenia 72
United Kingdom 72
Czech Republic 71
Denmark 71
USA 71

Strive For The Ideal, But Deal With What's Real

Hmmm... I didn't think her

Submitted by Eagle (not verified) on Wed Jul. 8, 2009 10:34 AM PDT.

Hmmm... I didn't think her comments so complicated or so stupid. Of course medicare is paying for top notch care for our elderly and she says that outright, but her point is that it is doing so in part subsidized by higher costs of care on those of us who are younger. Hospitals and doctors know they can only get X return on my 80 year old mother-in-law's triple by-pass, but they can charge me much more to deliver my baby than it actually cost. This is often paid for by providing "services" that are aren't actually needed (say, the rise of cesarian section deliveries), but which most Americans have come to see as their right to at least ask for, if not have repeatedly.

you could live blog swine flu

Submitted by alan (not verified) on Wed Jul. 8, 2009 10:44 AM PDT.

Kevin, you could live blog swine flu!

Huh?

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 10:52 AM PDT.

"Since private systems have so far found it virtually impossible to deny many treatments for long"

Isn't the whole problem that this is demonstrably untrue?

Hip Replacement

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 11:49 AM PDT.

A few years ago my brother, in his early 50s at the time, needed a hip replacement desperately. With a bachelors degree from a state university, his employer folded and he was out of work for two years. He couldn't get hired anywhere until an old college buddy got him a job driving a street sweeper with union benes. When winter came he was laid off for 3 months and he finally got the operation, rehab and was back at work in the spring.

Still works there, still hates it, but stays on for the health care security. He was lucky. Stuff it Megan.

I'd rather be here to have a

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 1:30 PM PDT.

I'd rather be here to have a [uncommon] hip replacement, but I might rather be in the Netherlands to have a baby.

Isn`t a hip replacement one of the most common surgeries? It is among the older people I know in the Netherlands. I literally have trouble thinking of someone I known over 60 who has not had either hips or knees replaced. IIRC in at least one Dutch hospital they plan several of these on the same day so an expert can do all of them.

All the 50-70 years olds I known who had hip/knee replacements are really happy about the results. They have all gone from being too painful to walk to horsebackriding and walking the dog along the beach for hours. A small chunk of titanium delivers what peter popoff promises.

I don`t know enough elderly people to guarantee I could know at least one medical screwup with hip replacement surgery if there was significant numbers of such screwups, but I do know enough to know this surgery isn`t uncommon in the Netherlands. Maybe American insurers cover less of this surgery, which gives people an opportunity to exercise and work until and after the retirement age, but may not be a life or death necessity.

Citing McArdle is a waste of bandwidth

Submitted by SRW1 (not verified) on Wed Jul. 8, 2009 1:45 PM PDT.

Kevin, just like some other commenter have already remarked on this, I find it puzzling that you give Megan McArdle so much attention in your postings.

Her latest outpouring on health care isn't any better than her previous writing on this topic, and as you noted yourself, she's throwing this stuff out without backing it up.

And what exactly is she advocating? That the vast majority of Americans need to accept sub par medical care during the years 0-50, and thereby a shorter life expectancy than Europeans, just so that those who need it can get 'care in extremis', whatever that may be. Btw, does she know that they perform heart transplantations in Europe? And on what basis does she claim that hip replacements surgery is performed in a superior manner in the US?

Dick Cheney was the 1% guy, Megan McArdle seems to be happy to become the 0.001% lady. Maybe you should make that the frequency of your posts that cite anything from Megan McArdle.

Hip Replacements? Better be in Europe

Submitted by mcdruid (not verified) on Wed Jul. 8, 2009 3:06 PM PDT.

Hip replacements/100000 pop
US: 102, OECD avg:138

One of McArdle's failings is a blinkered U.S. centric view of the world. On the other hand, I am glad Kevin reads her so I don't.

To those of you complaining

Submitted by Buggy McNot (not verified) on Wed Jul. 8, 2009 6:32 PM PDT.

To those of you complaining about Kevin reading and linking to McArdle:

I understand how you feel, but we need to know what these people are saying and debunk it. Ignoring them doesn't work. You have to challenge their poison, or else other people start to believe it.

By reading and responding to McArdle and people like her, Kevin and others like him do us a great service.

"extreme" "care" in Europe vs. US

Submitted by Chase (not verified) on Thu Jul. 9, 2009 7:36 AM PDT.

There are at least some significant differences in how disease is treated here and in Europe.

For example, the rate of prostate surgery is much higher in the US. Many of these surgeries use advanced robotic systems to attempt to preserve some sexual function. These surgeries don't make the death rate from prostate cancer any better in the US. But it is true that the US system offers more care, and more "advanced" care.

I know better....

Submitted by American Abroad (not verified) on Thu Jul. 9, 2009 1:04 PM PDT.

I'm an American doctor who's lived on the German Krankenkasse for many years, with broad experience in both systems. I favor the latter, because it's fair and accessible, but would like to point out that if you think the quality of care in Germany compares usefully to what is common, to say nothing of boutique, in the United States, then you're fooling yourself pitifully. The German system controls cost at the margins, recognizing that it there that the highest costs are incurred: in cases of very expensive treatments, end-of-life terminal decline, and elsewhere. Life has not the same - strictly monetary - value; in fact government healthcare auditors here tell me flatly how much, in appropriated funds, a citizen's life costs. Procedures are simply declined or disapproved, and much is saved in one's declining years by economizing on tertiary care. We cut no such corners in the US, at Yale or Pitt or the half-dozen poor community hospitals where I practiced. Costs factored only secondarily into care decisions, a habit which has brought us to our present impasse. That, and the fact that we pay doctors three times as much. But that is another, much thornier question, yet to be engaged usefully by the idiot media. How many practitioners will be able to pay off an excellent, $250,000 private med school education in a strictly cost-structured environment? Few, if any. And please don't sell me snake-oil arguments about sliding cost scales, either.

The system is little different in France, and substantially worse in England, Spain, and Italy. I cannot speak directly about others in Europe.

I favor the imposition of a public healthcare system in the US, primarily for civic, not medical reasons. But I think that our democracy would profit from a frank discussion of what scarcity will mean, an end not served by your remarks here.