Two myths, four charts
Wednesday, January 14 2009
In comments on a previous post, Peter has come to the defense of Dr. Rich – arguing that universal care will inevitably drive physicians away from “the government’s system”, and so “the government must absolutely prohibit self-pay”. So claim #1 is that doctors will be dissatisfied with a “government” healthcare system. Claim #2 is that government-run (-financed, -managed, -et cetera) healthcare requires that private care be banned. Was a time when answering these claims would have required significant verbiage. No more: I figured out images.
Taking claim #2 first: does universal healthcare require that private care be banned? This chart, clipped from a Commonwealth Fund Report*, shows several countries that are able to provide 100% (or close) coverage for their populations through public programs. Note the US at 45%.
If Peter is correct, there should be no private spending on medical care in these countries – but here’s another chart from the same report. It shows that even in universal health care systems, private spending is still 20% or more of total spending (except Britain, which has 19% despite particularly strict rules).
So much for universal healthcare eliminating private spending. Surely the doctors in these countries are oppressed, beleagured, and yearning to be free. Here’s table from a different Commonwealth Fund report**, showing the results of a survey of physicians and members of the public in several countries. (So I fudged a little in the title, and one of my charts is a table – big deal.)
The font may get a little tiny here, but the take-away is that physicians in the universal care countries have more positive views of their systems than American physicians have of theirs – more than even the public in those countries. A third chart reinforces this point: American doctors are the second-least satisfied of all the physicians in this survey group, albeit all five are pretty close. Still, if universal care was the hell for physicians – and the American system the paradise – that Peter and Dr. Rich think it is, the satisfaction numbers should be a lot lower in these countries than it is the U.S.
In sum, neither of the claims Peter makes about the consequences of universal care stand up to evidence, at least what I could find readily available. If anyone has better evidence, that would be a nice contribution to the dialogue. Otherwise, you – you Peter – can’t claim that bad things are necessary to universal health care, when in fact there are several functioning universal care systems that don’t evince those bad things at all.
*Health and Population Aging: A Multinational Comparison
**2000 International Health Policy Survey of Physicians
Another good, but slightly dated (1997) comparison of health care delivery in the developed world is in this report by the Canadian government: Public- and Private-sector involvement in health care system: a comparison of OECD countries
I do not think you understand what my point is. Let me try to explain it again:
The U.S. government is starting the National Health Insurance Exchange, a proposed method of providing cheap insurance to all Americans.
The U.S. government’s other insurance provider, the Medicare program, is already in a severe financial crisis.
The U.S. government will decrease payments to physicians substantially under the new and old programs in order to decrease costs and keep the programs from utter financial ruin.
Right now, physicians within the U.S. are dissatisfied with Medicare and Medicaid payments; a large percentage (30%) of them refuse to take on any new government-insured patients.
Growing numbers of physicians in the U.S. will refuse to work for the government when the government lowers the payment rates necessarily to prevent financial collapse of the programs.
Physicians in the U.S. will refuse to take the government’s insurance, leaving patients who are covered by the government but do not have any physicians to visit unless the patients pay with cash upfront.
The U.S. government hears the complaints from the masses, complaints that doctors are refusing to take government insurance.
The U.S. government enacts legislation to prohibit cash-only practices, concierge care, et cetera (Maryland is considering it).
It is not that complicated to see what the future entails. You do not need to cite data and graphs which have little to do with extrapolating how future cuts in payments by the United States government will impact financial decisions for physicians in the United States, namely, whether or not physicians will take low government payments or take private cash only.
Peter – in my defense, your point seems to be a moving target. But I will try to catch up:
You have misunderstood or misrepresented the NHIE. It is not a method of providing “cheap” insurance to “all” Americans. It’s not even expected to include all the uninsured. See this Heritage Foundation report, for example. Many people – maybe most – will retain some form of private insurance under the NHIE, if that is the plan we implement.
That Medicare is in crisis is at least partly due to the fact that the present (soon former) Administration is opposed to the program on principle, and has done what it could to cripple the program. You’re conflating the idea – which I think is sound – and the execution – which has been godawful. Where are you getting the 30% figure, anyway?
And in the end, it looks like you’ve come back more or less to claim #2 in my post – that universal care (which NHIE is not) requires the prohibition of private medicine.
You may not like my data and graphs, but you have no evidence as to how payment cuts will affect physicians – or even that there will be payment cuts. Instead, you’re extrapolating based on what you would do, but you’re not representative of the medical profession.
You don’t like universal care on principle, but at least one survey shows that most physicians in the United States – 59% – favor universal care. Sure, a few physicians might defect from the system, but there’s no evidence in your comments – and no other reason to think – that this will be the debacle you want it to be.
This commentary from the Washington Times sheds some light on this:
“Mr. Daschle is refreshingly frank about the enormous power of his Federal Health Board, which he says would act like a “Supreme Court of Health.” It would not only limit insurers in offering health benefits. Mr. Daschle admits it would further alter the already weakened doctor-patient relationship: “Doctors and patients might resent any encroachment on their ability to choose certain treatments, even if they are expensive or ineffective compared to the alternatives.” So forget about complaining to your congressman, even if he or she is funding your coverage with taxpayers’ money.
The decisions of this Federal Health Board would, at first, affect only those Americans enrolled in government health programs, such as Medicare and Medicaid. But Mr. Daschle suggests expanding its powers to health plans that cover all Americans. This could be done, he suggests, by linking “the tax exclusion for health insurance that complies with the board’s recommendations.”
In other words, if private-sector employers don’t comply, the price of that disobedience would be a severe tax penalty on employers and employees. So, don’t even think about noncompliance.”
Peter – what you’ve posted is a review of Daschle’s book by a selective and unsympathetic commentator, and I think he misrepresents Daschle’s proposal (based on other reviews – not, alas, the book itself). Anyway the FHB component of Daschle’s plan is not in the plan Obama campaigned on nor in the plan Max Baucus has offered. Again, we’ve moved on to a different, albeit related question.
I don’t think an FHB is a terrible idea; I think the government ought to have some means to determine what’s effective and what’s not. You may not want your taxpayers dollars spent on healthcare, but if it has to happen, at least it should be effective healthcare and not snake oil – right? And if the government shouldn’t pay for snake oil directly, why should it subsidize snake oil through tax breaks? Or is there something intrinsic to the doctor-patient relationship that requires physicians retain the ability to sell snake oil bought with taxpayer (or taxpayer-subsidized) money?