Thursday, March 25, 2010
Ezra Klein makes 11 predictions regarding health care "reform." Whether you think them spot on or naive (and I think there are items in both categories), there is something to be learned there. There is also one that exposes the massive difference in attitude between left and right:
7) There is a chance -- say, 30 percent -- that the Independent Payment Advisory Board (the Medicare commission) becomes an extremely, extremely important government body.
If that does not terrify you, you are a liberal. Or old and selfishly unconcerned with the future of American medicine.
I like that you respect and post/respond to Ezra's stuff. I think he's one of the few liberal writers and bloggers that can usually back up what he says, whether you agree with it or not. He often brings up some very good points and helps add to a great debate.
Ezra has too much faith in "peer reviewed" studies. He could easily be exactly right, however just because a study is "peer reviewed" doesn't mean it is worth anything (think anthropogenic global warming). Peer groups have biases just like everybody else. Let's look at Ezra's idea of the effect of insurance on stroke survival. Perhaps there is a correlation, but causation may prove much harder to nail down. The majority of strokes occur in Medicare patients (already insured) and therefore excluded from any analysis of the effect of insurance. The incidence of stroke in the under 65 age group goes down, and as it does, the power of any statistical analysis is reduced because a relatively more rare event is being studied. This typically requires many more subjects. The uninsured are about 20% of those under 65 (many of which are children; hardly likely to have strokes).
This reduces the study population even more etc.
Any study demonstrating an effect of insurance on stroke survival is going to be very difficult to do properly, but not difficult to get peer reviewed.
We already know that outcomes in many medical conditions are superior in America than in single payer countries. Some are not, but these are often confounded by other social differences such as murder rates that don't pertain to differences in insurance.
I predict that its going to take a greater and greater amount of money to get less and less results.
Eventually failing when the government can no longer extract enough money from the top 50% to pay the bills for the bottom 50%.
"just because a study is "peer reviewed" doesn't mean it is worth anything"
It means it has been checked by qualified experts for obvious logical flaws or bad experimental design. Peer review doesn't guarantee that future research will not overturn the conclusions in a paper, but it does avoid the publication of rubbish.
I can't think of a better system for keeping up the quality of scientific papers. Can you?
"Eventually failing when the government can no longer extract enough money from the top 50% to pay the bills for the bottom 50%."
Is this 50% the proportion of all people (including children and over-70s) paying tax? Or the proportion of working-age people? Or what?
Most tax comes from those on middle incomes, as there are so many of them.
Or old and selfishly unconcerned with the future of American medicine.
I'm not following this. My understanding of the Medicare advisory board is that it would suggest ways to cut Medicare spending which would seem to mean that those who are old would fear it more as it became more important. What am I missing?
First things first, Don Cox please check your facts on who pays the tax bills in America. In America the top 8% pay over 57% of the tax bill. Author's note: all stats are off the top of my head, but I believe the proportions to be true. The next 20% of earners contribute about 30% more; while the next 25% (from 48% to 73% wage earners) complete the total tax in-take (circa 12-15%). The next 30% pay effectively nothing into taxes since it is all given back in tax credits, etc. While the bottom rung takes in more than they put in.
Unlike all other modernized democracies where the middle and the lower income have to pay something into their government, America is now in a situation where the bottom half of our economic ladder has no financial stake in any of the services and yet they are still allowed to vote...?
The implications for this upside down equation is huge and based on the latest tax increases to fund this entitlement, these numbers begin to climb out of control in their proportions (top 10% will fund circa 70% of an expanded Federal Government).
In reading Ezra Klein's comments, his belief in the power of this legislation is almost infantile. I really respect Ezra and for the most part I think he is a reliable source for somewhat balanced arguments/thoughts. However, my high-level reading of this bill is that it has almost nothing to do with really positively effecting the delivery of care from either a cost or a quality perspective. His predictions require extraordinary amounts of measurement and faith in federal government bureacrats that work in Healthcare.
This bill was all about how to pay for 30 Million uninsured Americans and yet all the waste and inefficiences that are pervasive throughout healthcare were not addressed. If anything, with all of this added regulation it will ultimately make our care more costly and probably greatly degrade the high quality we enjoy today.
We've been told incessantly that the "Patient Protection and Affordable Care Act" will expand coverage and bring down costs ... that we can keep the insurance we have ... that it will reduce the deficit.
But several companies have announced that Healthcare will increase their costs and so have taken recent charges -- for AT&T it was $1 billion. Some of these companies have said in their recent SEC filings that Healthcare could even adversely affect their ability to provide health insurance to employees and retirees.
Here's an excerpt from AT&T's recent 8-K: "As a result of this legislation, including the additional tax burden, AT&T will be evaluating prospective changes to the active and retiree health care benefits offered by the company."
So Waxman and Stupak are summoning the CEOs of Deere, Caterpillar, Verizon and AT&T to a hearing on April 21 to investigate why they think that Healthcare won't expand coverage nor bring down costs. They want all the internal corporate e-mails on this subject by next week.
This hearing could turn into nerdish GAAP arcana. With Waxman leading the questioning, it could turn outright silly. These companies are reacting to the change in the tax treatment of the Medicare Part D subsidy -- a narrow point in the global scheme of Healthcare. The CEOs may have no interest in making points about the longer-term effect of Healthcare on employers dropping coverage entirely.
But it has the potential to turn into something really interesting.
Why Waxman and Stupak are doing this is beyond me.