Now, in Part Three, I will examine the article and point out some of the flaws in the author's arguments.
As they tack left and right state by state, the Democratic presidential contenders can't agree on much. But one cause they all support — along with Republicans such as former Massachusetts Gov. Mitt Romney and California's own Gov. Arnold Schwarzenegger — is universal health coverage. And all of them are wrong.
This is actually the biggest problem I have with their article. If all you read is this, you will have gotten most of what I have to say. First of all, they all propose various fixes to the health care system, but it is a mistake to lump them together, even if most of them are wrong. Many of them are wrong, because they propose universal coverage without going to a single-payer system. Without going to a single-payer system, the costs would be prohibitive. Kucinich proposes universal coverage and a single-payer system, which is different than the others. So don't lump him in with the rest.
Second, the entire article is devoted to pointing out potential problems with universal coverage in the USA. I underline "potential" because is is possible that these problems would not occur, with proper planning and a lot of political will.
The thing is, it is easy to find potential problems with any proposed solution. Simply finding problems does not mean that the proposal is wrong. If they all have problems, there still could be a correct choice; it would be the one with the fewest problems.
All the authors do is throw darts at universal coverage. They do propose some vague reforms, but make no effort to show how those proposals would stack up against any of the proposals for universal coverage. Without a point-by point comparison, the entire article is meaningless. If you point out the flaws in the opposition, then present your own plan without any discussion of its flaws, you have not presented a meaningful analysis.
What these politicians and many other Americans fail to understand is that there's a big difference between universal coverage and actual access to medical care.
Simply saying that people have health insurance is meaningless. Many countries provide universal insurance but deny critical procedures to patients who need them. Britain's Department of Health reported in 2006 that at any given time, nearly 900,000 Britons are waiting for admission to National Health Service hospitals, and shortages force the cancellation of more than 50,000 operations each year. In Sweden, the wait for heart surgery can be as long as 25 weeks, and the average wait for hip replacement surgery is more than a year. Many of these individuals suffer chronic pain, and judging by the numbers, some will probably die awaiting treatment. In a 2005 ruling of the Canadian Supreme Court, Chief Justice Beverly McLachlin wrote that "access to a waiting list is not access to healthcare."
Oh, where to start? How can they say that "these politicians fail to understand..." Who knows what they do and do not understand. Probably they do understand that insurance alone is not a guarantee of access to health care. You have to have enough providers or the right kind, in the right places, and have enough compensation to keep them at their jobs with sufficient morale. These points are pretty obvious, and I see no reason to suppose that "these politicians" do not understand that.
Furthermore, it is not helpful to present isolated statistics, taken out of context, and without providing references, in order to build a case. Take for example the quote from Chief Justice Beverly McLachlin. Usually, court rulings pertain to a specific case. Without context, we have no idea if she is making a sweeping condemnation of the system, or referring to a single instance of a problem. Plus, although Chief Justices generally are held in high regard, they may not be the best source of information regarding health care policy.
Or, look at the statement about the experience in the UK: "shortages force the cancellation of more than 50,000 operations each year." what operations are they? Were they really necessary to begin with? Might it be the case that it would not have been cost-effective to perform those operations? That is, would funding those operations provide a bigger impact on health outcomes, than could be achieved by spending those funds elsewhere? And when they refer to a "shortage," what is it that is in short supply? Hospital facilities? Surgeons? Nurses? Additional funding may or may not be able to solve those problems. If more money could solve the problem, why are the funds allocated the way they are? Perhaps there is a good reason.
Supporters of universal coverage fear that people without health insurance will be denied the healthcare they need. Of course, all Americans already have access to at least emergency care. Hospitals are legally obligated to provide care regardless of ability to pay, and although physicians do not face the same legal requirements, we do not hear of many who are willing to deny treatment because a patient lacks insurance.
It is not true that all Americans have access to emergency health care. Many emergency departments are understaffed and overwhelmed, with long waiting times. Plus, when Americans get emergency care they can't pay for, they still get billed for it. It shows up on their credit report as bad debt. Or they put it on a credit card, and fall farther behind. This is one of the things that makes it harder for them to achieve economic opportunity, advance their economic position, and get to the point where they could get their own insurance. In other words, it is one of the reasons that the poor get poorer.
It is estimated that 50% of bankruptcies are related to health care expenses. So even if people do get the care, the lack of universal coverage still has profoundly negative consequences. When bills go unpaid, it hurts the economy and everyone is affected.
As for the last statement, no we do not hear of many physicians who deny services for lack of insurance, but there are many, if not most, who expect to get payment of some sort. Even if they are willing to do some pro bono work, they will, of necessity, limit it to a small part of their overall practice.
Many physician offices are expensive to operate. Overhead costs of 50% are common. So seeing patients for free is not just lost income, it actually costs the doctor money to provide free care. In fact, many doctors will not take Medicaid patients, even though they do have insurance. The reason is that the reimbursement, in some cases, is so low that the physician cannot afford to see Medicaid patients.
You may think it is self-evident that the uninsured may forgo preventive care or receive a lower quality of care. And yet, in reviewing all the academic literature on the subject, Helen Levy of the University of Michigan's Economic Research Initiative on the Uninsured, and David Meltzer of the University of Chicago, were unable to establish a "causal relationship" between health insurance and better health. Believe it or not, there is "no evidence," Levy and Meltzer wrote, that expanding insurance coverage is a cost-effective way to promote health.
They do not provide a link, but a summary of the review that (I think) they are talking about is here (small PDF). And let us look at what they actually say:
A review of the research, conducted for The Economic Research Initiative on the Uninsured (ERIU) at the University of Michigan by University of Chicago health economists Helen Levy, Ph.D., and David Meltzer, M.D., Ph.D., reveals that the vast majority of the studies examining the extent to which health insurance can improve health outcomes cannot determine a causal effect because they don’t adequately control for other key factors, such as age or income, that may contribute to health status. [biographical links added]
What does this mean, in simple terms. It means that the only way to be sure of a correlation would be to do a controlled study: take a large group of people, randomize them into two groups. One group gets health insurance, the other group does not. Follow them for many years. See how the health outcomes compare. Now, ask yourself, if you had health insurance, would you voluntarily give it up in order to participate in such a study? If you were on an institutional review board, would you think such a study would be ethical to conduct?
Let's dig a little deeper:
> Access to medical care through insurance is one of many factors determining health status. Other indicators include age, stress, income, education level, health behaviors, beliefs about Western medicine, and genetic predisposition to disease.
> Correlation does not mean causation. Of nearly 1,000 studies showing that people without health insurance have worse health status than those with insurance, less than a dozen are designed in a way to determine if the relationship is causal.
> Insurance expansion benefits children, elderly. The few studies designed to determine such a causal relationship show that health improvements have occurred for children and seniors under policies that have expanded Medicaid, children’s health, and Medicare coverage. But evidence is lacking that health insurance improves the health of non-elderly adults.
They say that nearly 1,000 studies do show a relationship between insurance and better health. True, most of them cannot establish causation. But don't you think if you do 1,000 studies and they all show the same thing, it probably is not random finding?
They conclude that there is definitive evidence that health insurance benefits the elderly and the young. What they don't say is this: Of the people in the middle (ages 20-40) the three leading causes of death are accidents, homicide, and suicide. True, health insurance does not make a big difference in those situations.
So how were these studies done? Did they look at the causes of death where health insurance could make a difference? Plus, some estimates place medical mistakes as the third leading cause of death. In those cases, it may be true that having insurance actually leads to worse outcomes. (That's another story.)
Going still deeper:
Q: It’s widely perceived that health insurance coverage affects health status or health outcomes. However, your work indicates that this is not the whole story. Why?
A: Our work doesn’t argue that health insurance does not impact health, only that much of the evidence that claims to show that is less conclusive than one would like. The literature clearly shows that health insurance coverage is correlated with health status, so that people who are better insured tend to be in better health. The questions are: “What drives that correlation? And is there a causal relationship that people who have better insurance have better health because they have insurance?” That’s a lot harder to know.
I think it is fair to say that the authors of the Cato article grossly misrepresented the literature they cited. Going back to their article:
Similarly, a study published in the New England Journal of Medicine last year found that, although far too many Americans were not receiving the appropriate standard of care, "health insurance status was largely unrelated to the quality of care."
This shows that, once a patient is in the doctor's office, the doctor treats the patients with the same efficacy, whether or not the patient has insurance. I would hope that would be the case. It does not show that the lack of insurance has no effect on outcome. Furthermore, is does not show that the provision of universal health coverage would not improve outcomes. In other words, it is irrelevant to the point they are trying to make.
Another common concern is that the young and healthy will go without insurance, leaving a risk pool of older and sicker people. This results in higher insurance premiums for those who are insured. But that's only true if the law forbids insurers from charging their customers according to the cost of covering them. If companies can charge more to cover people who are likely to need more care — smokers, the elderly, etc. — then it won't make any difference who does or doesn't buy insurance.
Yes, this is a concern. But if you allow insurance companies to charge the actual costs, you may as well dispense with the insurance altogether.
Finally, some suggest that when people without health insurance receive treatment, the cost of their care is passed along to the rest of us. This is undeniably true. Yet, it is a manageable problem. According to Jack Hadley and John Holahan of the left-leaning Urban Institute, uncompensated care for the uninsured amounts to less than 3% of total healthcare spending — a real cost, no doubt, but hardly a crisis.
No one said it was a crisis. But, it does drive up costs for people who wither pay out of pocket, or who have insurance. In fact, it has a much greater effect on those who pay out of pocket, since insurance companies cap the rates for insured patients. If you are a proponent of a free-market approach, this cost-shifting should be highly troubling to you.
Everyone agrees that far too many Americans lack health insurance. But covering the uninsured comes about as a byproduct of getting other things right. The real danger is that our national obsession with universal coverage will lead us to neglect reforms — such as enacting a standard health insurance deduction, expanding health savings accounts and deregulating insurance markets — that could truly expand coverage, improve quality and make care more affordable.
Again, part of the reason to have universal, single-payer coverage is that it would be simple. All of the schemes noted above would make the system more complex. Plus, none of those proposals would lead to universal coverage. Not good. I don't need to belabor this point; the New England Journal of Medicine just published a critique: Benefits with Risks — Bush's Tax-Based Health Care Proposals. It is one of their open-access articles. I don't blame the authors for failing to note it; it was published after they wrote their article. But the criticisms are valid.
As H. L. Mencken said: "For every problem, there is a solution that is simple, elegant, and wrong." Universal healthcare is a textbook case.
This would be a great, pithy conclusion, if they had built a valid case. Since they presented no valid points, is loses some of its luster.
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