Inequalities in Health Care

"That some are able to afford, say, a treatment with very expensive new technology that significantly reduces (how much is that?) their chances to survive a devastating cancer compared to the chances of those who cannot afford it does not seem to me unjust, flatly or otherwise."

Surely this should be "significantly increases their chances to survive"?

Thanks. Fixed.

The other way works about as well. Robin Hanson argues that getting the latest expensive new medical technology is usually a mistake. Old, proven treatments are old, proven treatments because they've stood the test of time; we have better reason to believe they might live up to the marketing hype than we do for the latest, most expensive, still-being-researched treatments. The early adopters don't just provide the funding that makes things affordable later, they also take on a lot of extra risk.

"Some day" meaning in some sci-fi libertarian dream future?

The idea that the state ought to provide basic health insurance for its citizens is pretty old and endorsed by Hayek (in fact Hayek couched the rationale in terms of justice). Every other modern democratic state seems to agree on this point, specifically as a matter of justice. That's the dominant, widespread, settled view, and we are the outlier.

A libertarian claims "normal" for himself and asserts that others are prone to a "peculiar ideological reflex"...you said that without intending irony, right?

Public provision is not public production. You don't need government giving people health insurance to ensure everyone is covered. See Will's penultimate paragraph.

... but you do have to eliminate the profit motive from those otherwise private entities to make effective medicine possible, as nearly every other developed country in the world has found and implemented. See, for example, the somewhat recent example of Switzerland.

You don't have to remove the profit motive. Doing so would completely undermine the benefits from competition. Vouchers subsidize the individual, not the production of said good.

You what? No-one has eliminated the profit motive from medical care. Even in the United Kingdom - a useful example because its the purest single payer system and happens to be where I was born - general practitioners operate in practice partnerships which are private, profit making companies, and hospital doctors are individual contractors, paid on a piece-work basis just as they are in the US. The hospitals themselves are non-profit companies, just like most US hospitals.

No, you're incorrect. Take, for example, the Swiss system, where the supposedly private health insurers have instead become non-profit foundations. They changed this because for-profit medicine, quite naturally, made it irrational for insurers to cover those with pre-existing conditions. This caused the Swiss population to have an uninsured rate of some 5%, a small fraction of ours but more than enough to provoke the Swiss into outrage sufficient to change their system. I'll let you decide on your own what that says about our culture and its priorities.

You specifically mean removing the profit motive from insurers, or whatever entity plays their role. That's a more plausible argument. Empirically non-profit systems seem to have an easier time providing effective care. Certainly you need to remove the disincentive for insurers to actually pay for care. But you could do that by changing the way care is paid for (eg. capitation rather than fee for service), rather than by removing the profit motive.

I think you misread Will, he wasn't talking about government-run insurance, he's throwing peanuts at universal healthcare. Will doesn't see this is a basic question of justice. This is typically libertarian - they can't grapple with these grand problems of justice, the best they can do is mumble something about the market and communitarianism.

That seems unfair. Will said there was (or at least could be) a question of justice in access to basic care. Its not a "grand question of justice" to complain that there's unequal access to healthcare and t then jump instantly to some kind of universal health insurance. It just sloppy thinking - parroting predetermined conclusions and avoiding the difficult questions.

In particular - if you want universal coverage you have to deal with the question of what level of coverage? Is everyone entitled to a triple heart bypass? fertility treatment? treatment for injuries from risky activities? Are you entitled to walk into a cardiologist's office for a 20 minute consultation whenever you like? If the only requirement is that the level of coverage be equal, we may as well outlaw all forms of medical care completely and then the problem would be solved. Right?

Presumably the real problem for Little isn't that there are different levels of access, as such, so much as the lowest level of access (almost none) is unacceptable. I'd agree with this, as presumably would you and Will although we'd probably disagree about why and what to do about it. One solution, certainly, is universal coverage, but for reasons hinted at above, you can't make it universal coverage for all care anyone could possibly ever want. You have to limit it at some level. Having limited the universal coverage at some level, are people allow to pay for more coverage on top of that? If so, we're back to unequal access agan. Is this a problem?

The answers are pretty easy, do a brief survey of every other modern country and figure out what actual problems they've faced and what tradeoffs they've made. Learn and then make your own menu.

This isn't novel or hard, let's not pretend like we're embarking on some huge risky endeavor.

"...the only hope of eliminating the inequality is forbidding access to treatments that cannot be provided to all under the universal health insurance system."

I disagree. I can imagine a system where expensive treatments are given out via lottery; maybe something like:

10 people need the treatment and can afford to pay (some bureaucrat decides this), and are willing to pay. Take their money.
10 more people need the treatment but can't afford it.
Randomly pick half of the 20 people who need the treatment and give it to them.

That'll really piss off the people who don't get the treatment, but would be a "fair" way of rationing expensive treatments in that ability to pay didn't affect who gets the treatment and who doesn't.

You can get almost the same effect by just taxing everybody and then randomly picking a few lucky people to get the expensive treatments (some technocrat would decide how much to budget for each expensive treatment).

It's not practical, of course; you'll just create a black market in medical treatments for rich people. Even if you solve that problem (go the Canadian single-payer route, but also make it illegal for sick people to leave the country?), if you go the tax-everybody route you've gotta have inhumanly smart technocrats figure out which expensive new treatments should get enough resources so that they eventually become inexpensive old treatments.

"...the only hope of eliminating the inequality is forbidding access to treatments that cannot be provided to all under the universal health insurance system."

I disagree. I can imagine a system where expensive treatments are given out via lottery

But your system _does_ forbid access to such treatments. At least in the sense Will meant it, as far as I can see. If one rich man and one doctor wish to make an exchange of money for treatment, this is forbidden. And so you will have a black market / travel market.

What your lottery does solve, compared to straight forbidding, is that at least the doctor gets practice with those techniques, so there is hope they might become cheaper with time.

Strict guidelines for insurance companies? Sure. Tort reform? You bet. Wouldn't that prevent unnecessary tests and treatments that doctors use in cya mode? We do know that anything that our federal government takes over is rife with waste and corruption. Health care is not a right. There, I said it.

The real issue is that moral premises and conclusions are bunk all the way down. Note that my claim is not a self-refuting moral premise, but a premise about moral premises.

Robin Hanson is discussing related matters here:
http://www.overcomingbias.com/2009/10/beware-co...

I'm not sure this is helpful!

Why is your sense that moral propositions are bunk (meaningless? false?) not just another example of what Robin's talking about?

You are correct that an impression about moral impressions would be included in the things Robin is critiquing, I and a number of other commenters chime in for Hume contra Robin. I don't just link to people because I agree with every point they make!

there may well be a very good policy argument for universal health care. present them to me and i am all ears, but the "moral" egalitarian argument is non-existent. if little really believed such things then he would refrain from having his own children get routine vaccinations because it was unjust that they should have access while other children in the less developed world went without. until little begins to refuse all the material comforts of this world that are not equally distributed, i'm going to dismiss his argument as disingenuous pandering to a pre-conceived political stance.

"it seems a bitter but unavoidable truth that there are very substantial inequalities" in every discernable and measurable characteristic of the world. there's a reason we refer to the bell curve, and not the straight line, as the normal distribution. if you want to make the world a better place focus on leveling up, not down.

If "chance of survival" = "worth as a human being", as Little would have it, how do we avoid the conclusion that old people aren't worth as much?

If the level of inequality in health outcomes is not seen as a binary, black-and-white question (does inequality exist) but rather quantitatively (how much inequality exists), then we can begin to see increasing equality of outcome as one among many competing societal goals. This means that we don't have to deny people treatment, we just need to increase the level of treatment of the less-well-off. At a certain point enforcing equality becomes absurd and counter-productive. We stop before we get there, obviously.

This is a common problem with thinking philosophically. Real life is a practical compromise, not a black-and-white question.

"But a policy of coercively preventing exchanges that help someone (the doctor, at least!) but harm no one is flatly unjust. Which leads to the conclusion that the attempt to prevent some inequalities in the provision health care is ruled out by the requirements of justice."

WTF does that even mean? You need to get out in the real world, young man, and stop thinking and start doing something... anything... useful to society.

I think you are basically right at least given your assumptions about how the health care market works. Most people on the left tend to think that European stile health care systems work better than America's and this is really at the heart of the matter. There are different forms this argument takes, but I think Yglesias makes a good point about blood letting and health care markets has a lot of merit. Also its really difficult to have a properly regulated health insurance market and if you can't make the market work there is going to be a tendency to want to have the government replace it.

I'd prefer the PC model of medicine. In 1977 the cheap Apple IIe cost $4000.00 in today's dollars; laptops which are better in all regards cost as little as $300.00 today. The government was and is much less intrusive in that market than in health care. The rich/savvy are the early adopters/Guinea pigs who make the market work. Everyone else follows. Nobody has to use guns to divide the pie when new pies are being baked that quickly.

Even laymen could list several government policies that jack up the price of health care today, but social-dems insist that what we have is free-market health care. When government restrictions and meddling in health care approach what we have in the PC market, we can start calling it that.

If you don't know anything about Minute Clinics, Zenni Optical, or PHRs, then you have no idea how many health problems could be taken care of immediately if social-dems were interested in improving medicine instead of enforcing impossible equality.

1) A primary driver of both the rising quality and falling prices of computers is Moore's Law. There is nothing remotely close to Moore's Law in medicine.

2) Early adoption in medicine leads to rising prices, not falling prices. The rich like spending tons of money on their health care... the savvy may be changing their tune, but verrrry slowly.

3) It is not difficult for a consumer to gauge the functional quality of a computer. It is more or less impossible for a consumer to gauge the efficacy of various medical treatments; even consulting studies gives you out-of-date and incomplete information. Medicine is more of a black box than computing.

4) It was decades before most Americans could afford computers. Is your contention that the poor, sick & disabled should simply hang out until the health care market finds them to be attractive buyers, years down the line?

Are Minute Clinics a good thing? Sure. Would things be better if the employer tax exemption was rescinded, and consumers had a clearer sense of what their health care cost them? Absolutely. But your analogy is nonsensical. To pretend that health care lends itself neatly to market solutions is to ignore, well, just about every salient detail of health care. This is not a simple problem.

"A primary driver of both the rising quality and falling prices of computers is Moore's Law. There is nothing remotely close to Moore's Law in medicine."

I'm not so sure about that. Mid-70's Heart disease care consisted of blood pressure meds, somewhat effective meds for cholesterol and open heart surgery
Mid-80's newer, more effective meds for cholesterol (HMG- CoA redu. inhib), catheter-based procedures (angioplasty), ACE inhibitors for heart failure
Mid 90's thrombolytics for acute MI, cardiac stenting
Mid '00's - new anti-platelet drugs, rapid MI diagnostics leading to rapid cath and stent

We've seen dramatic decreases in heart disease death rates but I don't believe we seen coincident decrease in cost.

so technology has made "it" better and faster but not cheaper?

"so technology has made "it" better and faster but not cheaper?"

Some health measures, like cardiac care, have gotten better over time... many haven't, and not many have gotten cheaper. Moreover, improved health care has the additional complication of longer lives leading to more health measures per person; that's a good thing, obviously, but it makes things more expensive. The longer we live, the more likely we are to run into cancer at some point, and there aren't many cheap ways to deal with cancer. It's more like going from a $4000 Apple IIe to a $4000 laptop that's more likely to need replacing in the near future. Better computer, but the cost problem is worse than before.

Of course, Will's original post is about health care, not medicine, so this is all sort of beside the point. But health care does not lend itself to easy analogies. Better computers do not force you to buy more computers -- you can not negotiate better prices on food simply by joining collectives with your follow consumers. Both Will and JB are pretending that health care is a discrete economic product so they can bluster about markets. I'd like to think that at least Will knows better.

"The longer we live, the more likely we are to run into cancer at some point, and there aren't many cheap ways to deal with cancer."

You don't know whether this is about to change. T. Colin Campbell has done fascinating work on this and cancer wouldn't be the first intractable seeming malady that someone just up and cured. You're assuming a lot.

"Of course, Will's original post is about health care, not medicine, so this is all sort of beside the point. But health care does not lend itself to easy analogies. Better computers do not force you to buy more computers... "

Don't take this the wrong way, but you sound like the usual pie-slicer; "all we have is this one pie that needs to be sliced up fairly by technocrats." Clearly, this isn't how the world works. People are always baking new pies. The proven method for maximum pie production is the freest market possible, not some clowns in a room with guns telling everyone what to do.

"... you can not negotiate better prices on food simply by joining collectives with your follow consumers."

Because the margins are already super-thin. We don't have a health care market.

"Both Will and JB are pretending that health care is a discrete economic product so they can bluster about markets."

What does this even mean? No one thinks that health care is a "discrete economic product." The primary thing people can do to improve their health is moderate, regular exercise. Beyond that, their are thousands of OTC products before we even get to an actual health care provider. Am I "blustering about markets" when I say that people should buy their own food? There's no "discrete economic product" there; are you saying there's no market for food?

Moore's Law is just a description of how quickly costs fall for one kind of technology. We have no idea how quickly health care costs could fall if, say, B. Mackey's ideas were instituted. There's low-hanging fruit everywhere:

1)All medical records could be held online. Several systems are available. With easy access to these records, customers could shop doctors without having to do all the same paperwork and all the same pointlessly repeated initial check-ups. This could drive insurance providers to use the same e-forms, etc.

2)Patients can now keep very accurate records of skin conditions with digital cameras. They can send these to clinicians who can offer algorithms. Some of this is already being done. Perusing these could be easier than perusing X-rays is now.

3)It could become the norm for people to start with WebMD symptom checker or whatever better product is soon to follow. How often do people show up at a clinic when all they needed was someone/thing to say, "eczema? hydrocortisone."

4)Liberals could start pressing the idea of lifestyle changes because there is no medical substitute for regular exercise, but instead liberals spend most of their energy trying to force other people to pay for the health care of strangers.

5)Etc. times a million. We have no idea what would be produced to make things cheaper, better, faster because no one ever knows what solutions are around the corner in any field. You could probably think of dozens of shortcuts that might work because we have such a non-market for health care that even easy stuff hasn't been tried.

Plus, why does some guy have to go to post-secondary school for several years to scrape plaque off my teeth?

"2) Early adoption in medicine leads to rising prices, not falling prices. The rich like spending tons of money on their health care... the savvy may be changing their tune, but verrrry slowly. "

There's no reason why most health care has to be different from every other service or product. We're generally talking about people in buildings with skills and capital goods. Now, all we need is some kind of price-discovery process and people with the standard algorithm "get more for less" and we'll have a system. There's little point in trying to be savvy now, because prices are often completely opaque because of our retarded government.

"3) It is not difficult for a consumer to gauge the functional quality of a computer. It is more or less impossible for a consumer to gauge the efficacy of various medical treatments; even consulting studies gives you out-of-date and incomplete information. Medicine is more of a black box than computing."

If that's the case, then Robin Hanson and Tyler Cowen are right: people should avoid new treatments and avoid any screening that doesn't have a proven track record. Medicine's black-boxiness is no reason to have government take it over completely.

"4) It was decades before most Americans could afford computers. Is your contention that the poor, sick & disabled should simply hang out until the health care market finds them to be attractive buyers, years down the line?"

Why are liberals and social-dems categorically unwilling to be charitable? It seems that they only think a solution is sufficient if it involves coercion. I'm serious about this. There are tens of millions of libs/social-dems and many of them are rich, rich, but none of them seem to have the wherewithal to do anything about this problem but bring in the guns. Plus, the idea of socializing all of health care to take care of a small minority is bad policy.

"Are Minute Clinics a good thing? Sure. Would things be better if the employer tax exemption was rescinded, and consumers had a clearer sense of what their health care cost them? Absolutely. But your analogy is nonsensical. To pretend that health care lends itself neatly to market solutions is to ignore, well, just about every salient detail of health care."

You don't know this for the reason you just mentioned and more. We don't have a real market for health care. ERs are forced to take all comers no matter how often they show up (where else is that the case.) People can't buy insurance from outside their own state (why don't liberals use the commerce clause to fix that the way they use it on everything else?) Prices are opaque. Roadblocks to trying different providers are everywhere. And to top it off, thanks to generations of social-dems, Americans think they are owed free health care.