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Tag: "health care"

Their Galtian Overlords

[ 64 ] September 12, 2011 |

On the monetary side are even worse than ours.

In a bit of black comedy, on the other side of the page, Ross Douthat argues that the Obama administration did not pivot quickly enough to austerity. Really.     In its way, you have to admire this bit of hackwork:

Finally, instead of pivoting from the Recovery Act to deficits and entitlement reform, the Democratic majority spent all of its post-stimulus political capital trying to push both a costly new health care entitlement and a cap-and-trade bill through Congress. Both policies were advertised, intermittently, as deficit reduction, but neither came close to addressing the real long-term drivers of the nation’s debt.

So, on the one hand, the ACA is “costly.” On the other hand, he doesn’t actually dispute that it would control health care costs, but apparently it is “costly” because it wouldn’t, in itself, reduce the long-term structural deficit problems it would be crazy to focus on in the midst of horrible unemployment. Hacktacular!


6CA Rejects Radical Challenge to the ACA

[ 24 ] June 30, 2011 |

It’s a bit of an upset, but good to see the 6CA panel do the right thing. It should be noted that while both majority opinions do an excellent job of attacking the bad commerce clause arguments underlying the challenge to the ACA, James Graham’s dissent does a good job of self-refutation. Consider this passage:

Here, Congress’s exercise of power intrudes on both the States and the people. It brings an end to state experimentation and overrides the expressed legislative will of several states that have guaranteed to their citizens the freedom to choose not to purchase health insurance. The mandate forces law-abiding individuals to purchase a product – an expensive product, no less – and thereby invades the realm of an individual’s financial planning decisions. (“Neither here nor in Wickard had the Court declared that Congress may use a relatively trivial impact on commerce as an excuse for broad general regulation of state or private activities.”). In the absence of the mandate, individuals have the right to decide how to finance medical expenses. The mandate extinguishes that right.

Graham starts off with policy arguments that are irrelevant — the fact that the ACA “brings an end to [some] state experimentation and overrides the expressed legislative will of several states” means nothing in itself, since all kinds of valid federal legislation does so, and the stuff about state legislatures suggests that Graham stopped reading the Constitution before he got to Article VI. But the real key is the last sentences, which suggest that what’s at issue here is not really federalism but a desire to return to a radical Lochner-era liberty of contract — a state mandate, after all, would also “invade the realm of an individual’s financial planning decisions” and “extinguishes the right to decide how to finance medical expenses.” And at this point, the whole shaky edifice collapses, because in fact Lochner hasn’t been good law for many decades, and as Graham concedes the federal government could clear create a more centralized and government-controlled system than the ACA does, opening up the frightening possibility that the U.S. could cover more people for less money like every other major liberal democracy.

The quality of the opinions arguing against the constitutionality of the ACA we’ve seen so far have been remarkably bad, but in part that’s because the argument itself is inherently weak. The only coherent argument against the ACA requires reading quasi-libertarianism into the Constitution, a long-discredited project that has vanishingly tiny amounts of political support.

Health care and quality of death issues

[ 24 ] June 14, 2011 |

Over the past couple of years four people I’ve had some sort of relationship with were diagnosed with pancreatic cancer, so I’ve gotten to know more than I ever wanted to know about this especially terrible disease. It’s estimated that about 43,000 Americans will be diagnosed with pancreatic cancer this year, and around 38,000 will die from it. The most common form of the illness remains almost incurable, with a five-year survival rate of less than 5%. Only 20% of cases are diagnosed soon enough to allow for anything other than palliative treatment; this “lucky” minority undergo a grueling operation (the so-called Whipple procedure) that produces a median increase in life expectancy of about a year. Pancreatic cancer is usually a disease of old age: the average age at diagnosis is 73, and America’s aging population has seen a steady increase in its incidence, to the point where it is now the fourth-leading cause of cancer death. (For similar demographic reasons it is beginning to become much more common in the developing world).

Recently I looked at the data from a couple of major academic medical centers who specialize in the Whipple procedure, and I was struck by, among other things, how many of these surgeries are done on patients in their 80s. The ethics and economics — or perhaps the economic ethics — of performing this surgery on very elderly patients in particular are troubling. For all patients, the median survival after the Whipple procedure is about 18 to 24 months (for patients who don’t receive the surgery because their cancer is too advanced it is around six to ten months). But these medians are age-adjusted rather than absolute. In other words, median survival is measured relative to the overall mortality rate in the patients’ age cohort. Since an 85-year-old man without pancreatic cancer has about a 50% chance of dying over the next five years, to say that the five-year survival rate for 85-year-olds undergoing the surgery is 20% means that 90% of these patients will be dead within five years. (And this is assuming that the mortality rate from the surgery and its aftermath will not be higher among the very elderly than among patients in general, which seems like a very optimistic assumption).

How much do these treatments cost? The standard treatment protocol includes post-surgery chemotherapy, and sometimes radiation treatment as well. Re-hospitalization is very common as most patients will suffer a recurrence of the disease within a year or two. In sum, treatment costs can easily exceed six figures. Indeed treatment costs are often high even in the context of the large majority of cases in which surgery is not an option: palliative chemotherapy regimens that have some value in lessening suffering but that generally extend life by no more than a few weeks can cost thousands of dollars a month.

All this raises difficult issues. On the one hand, any time anyone raises the question of whether the cost of keeping very sick people alive for a year or two longer via extremely expensive treatments should be socialized, someone is sure to start shouting about “death panels” and the like. On the other, it’s not as if there are easy answers to the dilemmas these situations raise. After all, a small minority of people live for several years, and on rare occasions even a decade or more, after undergoing the Whipple surgery. Furthermore even if purely palliative treatments are quite expensive, we’re (still) a rich country. As a society should we be less willing to spend money on lessening the suffering of the dying than we are on, for example, building yet more big beautiful bombs? Furthermore some of the money spent on pancreatic cancer ends up funding clinical trials, which at least hold out hope for developing better treatments.

Of course another issue is why these treatments, whether potentially curative or merely palliative, are so expensive. What do rich nations with more just and efficient health care systems than our own, i.e., all of them, do when confronted with the dilemmas that diseases like pancreatic cancer engender? (I have no idea).

In the end we can’t pay for everything, but our current health care “system” pays or doesn’t pay for things in ways that have little apparent relation to justice, efficiency, or any other value beyond the continuing enrichment of those who benefit from the present state of affairs.

Bobo’s Unempirical World

[ 48 ] June 7, 2011 |

Bobo engages in his trademark style of argument, focusing on abstractions and ignoring evidence about whether or not markets actually work for a given problem. Cohn does a good job pointing out the problems, and I think the most important one is near the end — the comparison with other countries.   Brooks asserts that “there is no dispositive empirical proof about which method is best.”  But the policies of virtually every other country in the world give us the chance to compare a relatively “free market” in health care to more state-oriented approaches, and the evidence is unambiguous.   The “free market” delivers coverage to many fewer people for more money, and usually far more money.   Although Brooks likes portraying debates between an imaginary ‘Burke” and “Rousseau” while casting himself in the former position, in this case it’s Brooks who’s ignoring all the empirical evidence to cling to his abstract beliefs about the benefits of markets.    And he does this despite the fact that — between the inelasticity of demand, lack of informed consumers, and strong incentives insurers have to deny coverage to vulnerable groups  — there’s no good reason to expect health care markets to work even in theory.

No Credit

[ 61 ] May 28, 2011 |

Joe Nocera’s pleas to accept the Ryan plan as a conversation-starter notwithstanding, there’s no conversation less in need of starting than the conversation about how to reduce Social Security and Medicare benefits. It’s hard to think of another topic Beltway pundits are more likely to talk about. Nor can you contribute to the conversation with a worthless plan.

Let’s also be clear who started this. It is true that there’s an enormous amount of waste in the American system, and the example of virtually every other liberal democracy indicates that we could cover more people for less money by reducing or eliminating the role of private insurers. But, of course, even the cost reductions in the ACA — which were modest because of the need to buy off stakeholders created by the Madisonian system — were deemed by the GOP in 2010 as getting the government into your Medicare. The “leave Ryan alooooone!” argument is a plea for unilateral disarmament…against people who are ideologically opposed to the New Deal/Great Society social contract and aren’t honest. I’ll pass, thanks.


[ 94 ] May 27, 2011 |


Watching Paul Ryan earlier today talking at the Peterson Fiscal Summit I was amazed by the number of times he said the word “Mediscare,” which is a conservative jargon term for telling the truth about proposals to eliminate Medicare.


Mr. Ryan may claim — and he may even believe — that he’s facing a backlash because his opponents are lying about his proposals. But the reality is that the Ryan plan is turning into a political disaster for Republicans, not because the plan’s critics are lying about it, but because they’re describing it accurately.

Take, for example, the statement that the Ryan plan would end Medicare as we know it. This may have Republicans screaming “Mediscare!” but it’s the absolute truth: The plan would replace our current system, in which the government pays major health costs, with a voucher system, in which seniors would, in effect, be handed a coupon and told to go find private coverage.

The new program might still be called Medicare — hey, we could replace government coverage of major expenses with an allowance of two free aspirins a day, and still call it “Medicare” — but it wouldn’t be the same program. And if the cost estimates of the Congressional Budget Office are at all right, the inadequate size of the vouchers — which by 2030 would cover only about a third of seniors’ health costs — would leave many if not most older Americans unable to afford essential care.

I’m also amused that Karl Rove has decided to advocate the same political strategery as Col. Mustard. Trying to find the “right messaging” for a plan to destroy Medicare to fund massive upper-class tax cuts is like trying to find the right metrics to show that Melky Cabrera is the greatest player in baseball.

Bernie vs. Rand

[ 103 ] May 12, 2011 |

On the question of whether Bernie Sanders is awesome, the answer is here.  And as for my Senator… well, he certainly has nice hair.

Potemkin Reformers

[ 27 ] April 27, 2011 |

I think this is an important point: arguments that various Democratic proposals on health care were once “Republican proposals” are misleading, in the sense that it’s not as if Republicans enacted them when they controlled government or anything. It’s misleading to imply that the Republicans favored even modest health care reform in any meaningful way.

Stating What Should be Obvious

[ 15 ] April 22, 2011 |

Health care is not a regular consumer good in which normal market incentives apply.

Another Judge Holds That ACA is Constitutional

[ 4 ] February 23, 2011 |

D.C. federal district judge Gladys Kessler issued the latest ruling, reinforcing the partisan trend.   Her opinion is a very solid piece of work, and provides a good account of the existing doctrine if you’re interested in such things.

An LGM Venn Diagram

[ 79 ] February 8, 2011 |

Group A: People who argue that the individual mandate in the ACA is unconstitutional because it must be unconstitutional to force people to “purchase a private product” irrespective of its effect on interstate commerce.

Group B: People who strongly support gutting Social Security and replacing to with a system where people are forced to purchase products from private money managers.

The Overlap Group: People whose opinions about the constitutionality of the ACA should be greeted with some mixture of laughter and contempt.

Estimated Extent of Overlap: >95%

The Importance of Severability

[ 14 ] February 1, 2011 |

Atrios is optimistic*:

Federal judge strikes down whole law, sez mandate is unconstitutional and cannot be severed from rest of law.

Maybe we’ll return to my crazy idea to pay for it out of taxes.

The problem is, though, that if the entire bill is struck down Humpty Dumpty isn’t going to be reassembled (let alone in a more pleasing form) for the foreseeable future. First, it’s likely to be be quite a while before we have 60th vote in the Senate as liberal as it was in early 2010 to go with a substantial Democratic House majority and a Democratic president. And, second, the new legislative coalition would have to be more liberal, as the most obvious way of buying off the vested interests without direct tax hikes is no longer available. So the Supreme Court striking down the ACA in its entirety would be very bad — as I suspect Duncan would agree, a decade or three more of the status quo in exchange for a slightly more rational bill isn’t a good tradeoff.

If the mandate is eliminated without severance, though, that’s a different story. As long as the pre-existing conditions ban remains in place (and it would be nearly impossible politically to get rid of it), vested interests would be intensely interested in finding a fix for the mandate, so you wouldn’t need a similarly liberal legislative coalition. I’d buy a conservatives-should-be-careful-what-they-wish-for in that case, but not if the whole ACA is struck down.

*UPDATE: Atrios is not, in fact, optimistic.

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