Krugman on Socialized Health Care

Although this is a bit off topic for this blog, I find Paul Krugman’s op-ed pieces on health care to be among his best work. He manages to cover a good deal of ground in a confined space, and convey useful data without losing generalist readers.

Although he never mentions Michael Moore, Krugman’s piece, “The Waiting Game,” addresses the recent uptick in demonization of socialized medical systems in the wake of Moore’s favorable presentation of health care in Canada, France, England, and Cuba.

Kruman makes a simple point: the argument that care in these systems is rationed and people sometimes have to wait is specious. Our care is rationed too. What do you think those denials by your insurance company amount to? Personally, I’d rather have certainty of treatment, even on a delayed basis, than live in fear my insurance might not cover a serious ailment, or that it would take a protracted battle with an unknown date of resolution.

Krugman mentions in passing the use of emergency rooms as the de facto coverage of last resort for the uninsured, and I wish he had been able to spend more time on that issue. Emergency rooms are the highest cost outlet for service, and treating the poor that way is a triple whammy: what care they get is intrinsically expensive; because they are uninsured, they don’t seek care until their needs are reasonably dire (meaning they don’t seek routine or preventive care, which in most cases would have put then on a less costly treatment path); even thought this dynamic leads to an overallocation of resources to emergency rooms, it still means that emergency care is often inadequate (how long have you had to wait to see a doctor?).

This situation is more extreme than one might think. In “Million-Dollar Murray,” Malcolm Gladwell writes of one Murray Bart, homeless and a chronic alcoholic, who was routinely in the emergency room several times a week, and points out an unpleasant truth: it’s cheaper to give guy like Murray, who ran up over a million a year in emergency room costs for ten years, an apartment and a full time nurse, than let him go on as he is (well, actually Murray eventually took care of the problem. He died).

As Gladwell commented on a program in Denver to deal with Murray types:

Thousands of people in the Denver area no doubt live day to day, work two or three jobs, and are eminently deserving of a helping hand—and no one offers them the key to a new apartment. Yet that’s just what the guy screaming obscenities and swigging Dr. Tich gets. When the welfare mom’s time on public assistance runs out, we cut her off. Yet when the homeless man trashes his apartment we give him another. Social benefits are supposed to have some kind of moral justification. We give them to widows and disabled veterans and poor mothers with small children. Giving the homeless guy passed out on the sidewalk an apartment has a different rationale. It’s simply about efficiency…..Our usual moral intuitions are little use, then, when it comes to a few hard cases. Power-law problems leave us with an unpleasant choice. We can be true to our principles or we can fix the problem. We cannot do both.

Mind you, I’m not including this bit to advocate the Denver solution, merely to illustrate how large the emergency room problem is.

To Krugman:

Being without health insurance is no big deal. Just ask President Bush. “I mean, people have access to health care in America,” he said last week. “After all, you just go to an emergency room.”

This is what you might call callousness with consequences. The White House has announced that Mr. Bush will veto a bipartisan plan that would extend health insurance, and with it such essentials as regular checkups and preventive medical care, to an estimated 4.1 million currently uninsured children. After all, it’s not as if those kids really need insurance — they can just go to emergency rooms, right?

O.K., it’s not news that Mr. Bush has no empathy for people less fortunate than himself. But his willful ignorance here is part of a larger picture: by and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada.

The claim that the uninsured can get all the care they need in emergency rooms is just the beginning. Beyond that is the myth that Americans who are lucky enough to have insurance never face long waits for medical care.

Actually, the persistence of that myth puzzles me. I can understand how people like Mr. Bush or Fred Thompson, who declared recently that “the poorest Americans are getting far better service” than Canadians or the British, can wave away the desperation of uninsured Americans, who are often poor and voiceless. But how can they get away with pretending that insured Americans always get prompt care, when most of us can testify otherwise?

A recent article in Business Week put it bluntly: “In reality, both data and anecdotes show that the American people are already waiting as long or longer than patients living with universal health-care systems.”

A cross-national survey conducted by the Commonwealth Fund found that America ranks near the bottom among advanced countries in terms of how hard it is to get medical attention on short notice (although Canada was slightly worse), and that America is the worst place in the advanced world if you need care after hours or on a weekend.

We look better when it comes to seeing a specialist or receiving elective surgery. But Germany outperforms us even on those measures — and I suspect that France, which wasn’t included in the study, matches Germany’s performance.

Besides, not all medical delays are created equal. In Canada and Britain, delays are caused by doctors trying to devote limited medical resources to the most urgent cases. In the United States, they’re often caused by insurance companies trying to save money.

This can lead to ordeals like the one recently described by Mark Kleiman, a professor at U.C.L.A., who nearly died of cancer because his insurer kept delaying approval for a necessary biopsy. “It was only later,” writes Mr. Kleiman on his blog, “that I discovered why the insurance company was stalling; I had an option, which I didn’t know I had, to avoid all the approvals by going to ‘Tier II,’ which would have meant higher co-payments.”

He adds, “I don’t know how many people my insurance company waited to death that year, but I’m certain the number wasn’t zero.”

To be fair, Mr. Kleiman is only surmising that his insurance company risked his life in an attempt to get him to pay more of his treatment costs. But there’s no question that some Americans who seemingly have good insurance nonetheless die because insurers are trying to hold down their “medical losses” — the industry term for actually having to pay for care.

On the other hand, it’s true that Americans get hip replacements faster than Canadians. But there’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that’s what they call their system) because it has more lavish funding — end of story. The alleged virtues of private insurance have nothing to do with it.

The bottom line is that the opponents of universal health care appear to have run out of honest arguments. All they have left are fantasies: horror fiction about health care in other countries, and fairy tales about health care here in America.