The uninsured get good care anyway and the only uninsured people are bad people, so it’s their fault that they get bad care (eh?) pt 2

The unstated point here of course is that there is mindset of the “deserving” and “undeserving” which equates material wealth with virtue. And the failure to be able to afford insurance makes you a bad person who therefore doesn’t deserve healthcare. The following are comments from a conservative American talkboard. Some are pretty repellent, and looking at this stuff requires you to take a shower afterwards, but it’s sometimes worth it as, like children being naughty when no-one’s watching them, they reveal their true beliefs when they think the only people who agree with them are listening.

“people are too stupid to shop around for the best insurance

You liberals stupidly think health care is a right [Actually 85% of Americans do believe healthcare is a right ]

Couldn't we solve the uninsured problem by deporting illegal aliens?

[Speaking of the California plan for universal insurance] Of the 4.2 million, 4.19999 million are illegal aliens that Perata would love to be able to get their votes. The State of Confusion is already screwed enough, not to insure all the bums and scumbag illegals that have invaded us. Perata talks of mostly the working poor. I think he meant the welfare receiving illegal poor.”

Yeah, what lovely people. And these views are not widely held. The illegal immigrant lie is particularly egregious (and I think we can see where these commentators are coming from, from the tone of their comments) and I will turn to this in a later entry, but suffice to say that the total cost of healthcare for undocument workers is vanishingly small (by the best estimates I could find perhaps between 0.1 and 0.2% of total US healthcare expenditure, even by the worst case scenarios made out by anti-immigration groups this climbs to 0.3%), and at least three quarters of the uninsured are not undocumented workers.

However, expressed less offensively this idea of “deserving and undeserving” mentality is widespread, both in American health policy, and in voter attitudes to healthcare. The morality of dividing groups into deserving and undeserving (which certainly could not be done by wealth, but perhaps could be on grounds of health related behaviours) is profoundly complex and we could debate for years without ever quite resolving it. This is perhaps why when health authorities were seriously considering explicit rationing in the UK in the 1990s it was very difficult to get further in what should be excluded for public purchase than tattoo removal.

So let’s consider the practical consequences, instead. This simplistic division creates massive extra costs. Obviously if some are excluded, then the included must prove their inclusion – this creates bureaucracy and cost around the transaction of proving inclusion, hence filling in 5 forms a the doctors before being seen.

More fundamentally though, the question remains of what does one do with the excluded, those without insurance. The logic of the undeserving position is to let them die in the street – but that’s very difficult to live with. The alternative is to treat those in extremis via emergency care. But this leads to worse outcomes and is incredibly expensive. If this was a sensible way of organizing healthcare – all healthcare would be organized like that. And someone has to pay for it – and that is of course those with insurance. Insurance premiums are more expensive to cover the free-rider problem caused by the uninsured having to get very expensive emergency care because they don’t get adequate preventive care up front.

The American College of Physicians calculated the costs of healthcare to the uninsured in 2001 as juts shy of $100bn, of which $35bn was not borne by the uninsured- increasing costs elsewhere. They also estimated that each hospital stay by an uninsured person was 13% or $650 per stay more than for insured individuals.

Given the real public concern about the unacceptable costs of uninsurance, rather than the philosophical problems of maintaining the idea of an undeserving population should be the focus of those wishing to challenge the first convenient untruth.

The uninsured get good care anyway and the only uninsured people are bad people, so it’s their fault that they get bad care (eh?) pt 1

I once commented on the irony of parts of the pro-life movement apparently believing that life stops at birth – combining a fanatical devotion to the well-being of the foetus and utter indifference to the well-being of poor adults, the inconsistency of which baffled me. I cited the 40+ million Americans without health insurance as an example of this. I received this charming response from someone without the courage to put his name to his comments.

“ the silly yet widespread mistake that if you don't have health insurance, you are denied medical care in the US.Nonsense! There are many ways to get covered medical care, including just walking into an emergency room to getting Medicaid from the federal and/or state government

The statement that these 'uninsured' people have their lives shortened is poppycock, a statement straight from the Democrat talking points, without source and foundation.”

I need to include a disclaimer - these views are not widespread. The majority of Americans do worry about the problems of the uninsured, as many of them are themselves, as the Clintons noted “one pay cheque away from catastrophe”. Nonetheless, I thought this was a revealing insight of the mind of perhaps 10% - and a very vocal 10% - who do much to shape the discourse.

On one level of course this silly little rant should just be ignored, but it is quite revealing of the logical incoherence, and ignorance (or dishonesty) of those who hold these views.

First the logical incoherence is that if it were true that the uninsured were able to get good care, nobody would bother being insured, as having insurance would not provide sufficient advantage to justify its cost. Were this to happen Stephen Levitt would have another chapter for his next book, if nothing else. Of course, this hasn’t happened. Indeed even Health Savings Accounts combined with consumer-directed policies which go a step in this direction have not encouraged this behaviour. (Basically Consumer Directed policies are a misnomer – they’re an exercise in cost-shifting from the insurer to the individual through high-deductibles and co-pays, incentivized by lower premiums and HSAs which allow tax-free savings to cover these potential greater costs). The next post will look at these in much greater detail but suffice to say that take up has been low and people with them are significantly less satisfied than those with conventional health insurance

The response was also, of course, loaded with factual inaccuracy, not least the view that people with Medicaid coverage are included in the population of the uninsured – the problem is the “hole” of the near poor who don’t qualify for Medicaid but can’t afford private insurance, and aren’t offered insurance through their employer. The majority of these people are in working families. Eight to nine million are children.

That the uninsured are likely to receive unacceptably poor care and that this has an effect on their health status seems from the evidence incontrovertible. The uninsured are far less likely to receive recommended screening and preventive care, are likely to delay getting necessary medical care, not fill prescriptions, not get recommended treatment for reasons of cost. The effect of this is estimated by the Institute of Medicine as an excess mortality of 18,000 people a year (or six Iraqs).

So the “uninsured get good healthcare” claim falls flat as soon as one looks at either the evidence or considers the behaviour of Americans in response to having their insurance limited.

Convenient untruths

We all have myths we hold onto, to defend us from the full horror of existence: the good guy wins in the end, virtue is its own reward, England are one of the teams that can win it… but if you really want to make things better you have to start with some cold-hearted analysis before you can get anywhere.

It’s an odd and broad contrast between Britain and America that the UK’s national myths are profoundly pessimistic, while America’s are basically optimistic. Both have advantages, but in extremis both can poison the discourse. What my wife and I have noted from sitting over here on the west coast is that those shouting loudest in the UK (and as we all know from Colbert , truth is now simply a matter of who shouts loudest) are possessed with a dishonest, hate-filled, nihilistic contempt (and this is the single biggest motivation for us not to bother returning). The extremist perversion of US optimism is somewhat more complex, on the one hand it becomes the uncritical and starry-eyed, “best-nation on earth, God’s-own-people, type schtick” on the other its way of dealing with the fact that the world is less than perfect is to find external and internal enemies who have poisoned the Edenic existence. And this is true of both sides – either “Bush, religious fundamentalists, Big Oil, Big Pharma, military industrial complex, Fox Noise” are to blame or “The Clintons, illegal immigrants, secular progressives, godless yurpeens, eco-fascists, femi-nazis, New York Times” are.

The common local understanding of healthcare shows many of these traits. Actually the most common response is "Yeah-healthcare's-a-real-worry-my-premium-goes-up-every-year-oh-look-Anna-Nicole-Smith's-just-died". But where there are strong views they divide in the following ways. The left tends to argue that healthcare would be great but is broken because big pharma and insurance companies are screwing the little guy – and if only we had a European system we’d be sorted. This is too simplistic, but it’s a logically coherent position, to which you can call some facts and arguments to support – the conspiracy theory bit is what can’t be supported (and which probably stops reform).

The approach of the right though is far more interesting in that it creates a fascinating double think which is very hard for an outsider to understand. American healthcare is simultaneously the best in the world and bad because of bad people. This is bizarre but the following is a useful summation of the points that you will often see made by the same people three sentences apart. Interestingly these arguments are not only factually incorrect but frequently logically inconsistent so showing the evidence and unpicking the flawed logic of will take an entry for each, but here they are, in all their inglory.

Convenient untruth 1: The uninsured problem isn’t a problem because every one still gets good care which is better than anything else in the world and the only uninsured people are bad people, so it’s their fault that they get bad care.

Convenient untruth 2: Any sort of socialized medicine is a bad thing because it leads to rationing but health savings accounts are good because they limit the care that you can buy to what you really need (which isn't rationing... how?). Oh and by the way we shouldn’t have so much bureaucracy in our system.

Convenient untruth 3: We can see who we want – when we want – you have to wait

Convenient untruth 4: We have to have responsibility for our own health...yum donuts

Convenient untruth 5: It’s all the fault of illegal immigrants

The next series of posts deal with each of these arguments in turn.

Yet more gratuitous name-dropping and atypicality

Meeting Senator Durbin (see the other blog) he asked us what we were here for, we said to study US healthcare, and he responded along the lines of whatever you do don’t take it back with you. Which rather set me thinking about why are we here then?

It’s a bit of a truism that America has the best and worst healthcare in the world, but it’s worth thinking what is meant by this. Typically, the point is made about ground breaking innovation – particularly for pharmaceuticals - and contrasts this with the failure to provide proper access for the uninsured (and before any right-wing lunatic anonymouse who might have stumbled here unbidden claims that the uninsured have proper access through an emergency room and that this is better than anything available anywhere else in the rest of the world can I recommend that 1/ you consider the point that waiting until something is an emergency before seeking help is not “proper access” and 2/ you follow the logic of your own position and get rid of your health insurance because if ER based access is so good you are clearly wasting your money).

However I think there is a more interesting contrast to be drawn between the excellence of the really good systems that I and my colleagues are at – Group Health, Kaiser, VA - and much of the rest of the system. I’ve been hugely impressed with the innovation and imagination that I’ve seen in terms of rethinking the process of care, commitment to quality and evidence-based care and use of information technology. So in a sense, those of us inside these systems have much to learn and take back with us. The point is though we are studying the atypical. Extrapolating that US healthcare is therefore superior is like looking at an Aston Martin DB5 and assuming that Austin Allegros had to be good too because both were built in Britain.

Where Durbin is right is that the US system as a whole (or more correctly lack of system) is something which can teach you only what to avoid. The comparison of three simple metrics give some clues (although obviously there is a lifetime’s study in disaggregating some of these effects, it’s not that simple, measurement and comparison issues etc etc). Cost per capita is about 2-3 times the rest of the west , life expectancy is lower than most of the rest of the west and the medical error rate is a third higher than the UK or Germany.

The US is clearly a very diverse country and opinions on all this divide. What is interesting is that the informed voices, regardless of political position, recognize the enormous problems inherent in the system (although in my judgement those on the right are unable to find rational solutions to it because they are hidebound by their ideology – and it’s worth saying that I don’t think the solution here is a single payer system, yet alone a single provider system with equity as a guiding principle like the NHS – so I’m not being a darn socialistic Yurpeen commie here).

What is fascinating though is the self-delusion inherent in the thinking of Red-State America in their refusal to acknowledge the weaknesses of provision of healthcare. This is not meant to patronize, because any attempt to transform the healthcare system will require public support. And interests vested in keeping the current system despite its flaws are very adept at dong two things:
1 Scaring populations into thinking that what they have will be taken away from them
2 Convincing that any progressive reform is a plot of “coastal elites” to show contempt for the “heartlands” [some of this belongs on the other blog, I think]

Drawing on some polling data, and some qualitative arguments from various right wing bloggy types the next post will try to list out the mythology used to avoid addressing the issues and look at some of the facts which debunk these arguments.