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Show Notes (Health Care)
Here’s the FiveThirtyEight article detailing the biggest differences between the March AHCA bill and the current version that passed the House.
That piece of information about domestic violence, sexual assault and pregnancy potentially qualifying as pre-existing conditions comes from this Politifact piece.
In episode two, we talked about why health care is a unique market without demand elasticity.
This is an explainer video from Health Care Triage for the compromise plan that Republican Senators Susan Collins and Bill Cassidy put forth.
I mentioned the differential burdens on the health care system from healthier and sicker people. This comes from the Kaiser Family Foundation, a think tank devoted to health care policy. That’s also where we got much of our information on high-risk pools in this episode of the podcast. A good deal of information also came from the High-Risk Pools episode of Vox’s the Weeds podcast.
In the U.S. and other developed nations, population health care spending is highly concentrated: in any given year, the healthiest 50% of the population accounts for less than 3% of total health care expenditures, while the sickest 10% account for nearly two-thirds of population health spending (Figure 1). Private health insurance pools risks so that premiums paid by most enrollees, who have low claims costs, help pay claims for the small share of enrollees with high costs.
Who is included in the high-cost and low-cost groups changes from year to year. Most people are healthy most of the time, but illness and injury can and do onset unexpectedly for millions of people. Some high-cost conditions, such as hemophilia or HIV, persist and require treatment for extended periods, even a lifetime. Other high-cost conditions may improve or resolve, allowing patients to return to low annual health care spending. In any given year, among the 50% least expensive people in a year, 73% will remain in that group for a second year; similarly, of people who are among the most expensive 10% of the population in one year, only 45% would still be in that group the following year.
Single-payer health care is popular. The Washington Post argued that it was “complicated” but their piece concludes with polling evidence from 2016 and 2017 that indicated broad popularity and rising popularity. Though there were partisan splits, the only polls that showed less support for fully funded centralized health care were ones that introduced a negative into the question (none of them introduced a positive). That’s without a consistent marketing campaign from the DNC to sell the idea.
I read directly from a piece from Craig Garthwaite of the Center for Budget and Policy. That quote comes from this piece from the Kellogg center at Northwestern University.
There was a lot thrown out there about health outcomes and how the United States generates far worse health care outcomes (except when it comes to having technology!). That was drawn upon research done by health care economist Aaron Carroll at the Incidental Economist. It comes from two ten-part series, the introductory piece to the first of which is here. It also is where a lot of the information about spending the most on health care comes from. This chart was perhaps the most useful in terms of describing how the United States spends far more than it needs to after accounting for country wealth:
There’s a lot to digest in the series, however. The second ten-part series deals with quality and health care outcomes, which you can find here.
Let’s start with life expectancy, or how long a person can expect to live in a certain country when they are born:
Pretty consistently for the last 20 years, the United States has had the lowest life expectancy of comparable countries.
Pretty consistently for 20 years, the United States has had the highest infant mortality when compared to comparable countries. More than almost any other metric, this one is dismissed instantly by many people; most of those people claim that we measure it “differently” than one country or another. But remember, we are worse than all of them. And, since we are supplying our own data to the OECD, why would we not complain or change our own methodology to match others if we are such outliers only because of measurement methods?
Regardless, the next metric is more difficult to explain away … [M]aternal mortality, or how likely a mother is to die in childbirth. Back in the 1990s we were in the middle of the pack, but things haven’t been as good in recent years. More mothers die in childbirth in the United States per 100,000 births than in any other comparable country.
Here’s one last commonly used metric: years of preventable life lost. The OECD defines this as:
Potential Years of Life Lost (PYLL) is a summary measure of premature mortality which provides an explicit way of weighting deaths occurring at younger ages, which are, a priori, preventable. The calculation of PYLL involves summing up deaths occurring at each age and multiplying this with the number of remaining years to live up to a selected age limit.
So how does the US stack up?
The United States has more preventable years of life lost than any other comparable country.
We’re off to a bad start. When it comes to population statistics like these, the US looks absolutely horrible. This leads many to the conclusion that these metrics must all be fatally flawed. I’d be more likely to agree if we weren’t dead last in all of them.
Carroll also took on the idea that Americans have a lower life expectancy because of obesity (and other kinds of disease prevalence) in this post and generally those other arguments (land vehicle deaths, homicide, etc.) in this post.
All of those pieces by Carroll are amazing, but can be tough reads. An easier-to-read, more digestible version comes from the New York Times, here. It uses a fairly famous example of how a colonoscopy in the United States can cost several thousand dollars, all-told, to insurance companies and the federal government… but only several hundred dollars in many other countries. It compellingly makes the case that the United States pays more for care at every level of the system. Both the NYT and Carroll conclude that single-payer health care won’t solve all of the issue associated with the high cost of care in the US, but it’s a good bet that cost control can start there.
Medicare and Medicaid pay less for health care than private insurers do by quite an amount. For adults, that difference can be a 13 percent change in premiums. Medicare pays, after adjusting for inflation, about what they did in 1996. If Medicaid patients all switched to private care, there’s evidence that they would end up paying 25 percent more than the government does now. That’s not the case for private insurers. There are criticisms of this study from everywhere, like this Forbes piece, that argues that Medicare and Medicaid see these gains because of legal monopolies, drug rebate laws and so on, but that’s the point.
The author of the piece then goes on to say that Medicaid patients end up suffering from quality problems, like doctors refusing to see them. That makes sense; in aggregate, doctors get paid less under Medicare, sometimes 80 percent less, per procedure. But given that Medicaid and Medicare patients often need more procedures and more care, the issue of doctors refusing to see those patients often gets balanced out by those more enthusiastic about a greater amount of compensated labor. That wouldn’t happen under a Medicare for All system, where healthy patients would also see doctors at that lower rate. The Urban Institute estimates that doctors would see a significant salary drop overall in a world where everyone paid Medicare rates.
But given that Medicare can set prices at every level of the market, as well as the gains hospitals will make in reducing costs from emergency care visits—an enormous portion of outpatient visit costs in the United States relative to the rest of the world—and administrative consolidation for both hospitals and Medicare itself, hospitals will save an enormous amount of money that they can choose to reinvest in doctors without having to worry about Medicare rates if the doctors really require that pay. Regardless, the doctor quantity problem will be harder to solve with lower salaries, so will need to be addressed.
The Medicare for All bill that gets introduced into congress every year nowadays (by Representative John Conyers of Michigan) is a good deal shorter than the ACA and AHCA, even after accounting for the fact that every provision in the bill likely needs to be expanded.
Universal health care is incredibly popular in countries that have it, and much more popular than any version of health care that has existed in the United States.
On availability of quality local healthcare, the median percentage of satisfied respondents among countries with universal health coverage is 79%, 13 percentage points higher than the median percentage among those without universal coverage (66%).
We talked about insurers leaving local markets for a variety of reasons. We’ve solved this problem in the past and we can use those solutions in the future as well, largely by creating larger market incentives to overcome the underestimation by insurers and the Obama administration.
Single payer does not mean longer wait times. Wait times are a function of doctor availability (supply of doctors) and patient appointment slots (demand). Increasing the number of appointment slots should in theory increase wait times, but resolving the supply end of it can and should resolve that problem. This also ignores the fact that patients will more likely seek preventative care, which increases doctor visits in the short run but reduces them in the long run. Not only that, but this argument is premised on a fundamentally callous foundation—why would patient demand increase? Because people who didn’t have access to care before have access to care now. The argument essentially becomes “people in need should not get medical care so that other people don’t have to wait as long for the doctor.”
Also, there’s a reason people use Canada for their argument, aside from the fact that its proximity is convenient. Canada is somewhat unique among countries with universal care in experiencing the wait time problem, and the United States already happens to be pretty bad at it relative to its peers.
Remember, block grants almost universally kill funding. It’s part of the CBO’s projected Medicaid cost savings, and the GOP incorporate this into their argument as to why this bill can be passed as a budget bill in reconciliation (a means to avoid a filibuster and pass a bill through the senate with only 51 votes).
If you want a (very brief) rundown on why health care is a unique market and how the universalized health care systems differ, there’s a good Crash Course video on that.
Show Notes (Macron and Le Pen)
Here’s the link to the Haaretz article we used as a jumping off point for a discussion on lessons learned from the Macron/Le Pen election.
After recording the episode, the Washington Post put together a different, probably better, article with the same premise. That one is built more for understanding the French election for the French itself and not about applying any lessons to American politics.
There’s a decent summary to Macron’s politics at this link that describe Macron’s center-right economic political ideology as well as his further left social ideology. He wants to lower the corporate tax rate and loosen labor laws in favor of employers, but also wants to handle immigration policy at the EU level instead of at the French level. He favors intervention in Syria, but also an open embrace of Muslims in the country—arguing for hands-off secularism (no banning of religious symbols in public spaces) and economic tools, like subsidies in poor-income neighborhoods, to deter terrorism.
Macron campaigned on integration into a global economic system and to disempower unions at a time when French unemployment was at ten percent, and still won. It will be fairly fascinating to watch going forward.