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Krugman on health care: "Choices Must Be Made"

Indeed. And some choose to suppress discussion of single payer and shill for the Ds and Obamacare, and some choose to advocate for a policy that saves lives and money. Krugman's lead:

Arguably the most important thing we can do to limit the growth in health care costs is learning to say no [pesky old people!]; we cannot afford a system in which Medicare in particular will pay for anything, especially when that’s combined with an industry structure that gives providers a strong financial incentive to engage in excessive care

"Pay for anything" is, of course, and very shamefully for a Nobelist let alone a self-professed liberal of conscience, a straw man. The real question should be this: Is there an "industry structure" that can be proved to save hundreds of billions of dollars a year, and which provides better health care outcomes? Why yes, there is, although again most shamefully, Krugman suppresses it. What could that "industry structure" be?

Dr. Elizabeth Rosenthal chose to travel to a country that's about 300 miles north of Manhattan* and investigate personally. She writes as follows:

Although some of us thought we were coming to the “promised land” of single-payer health care, where everyone has access to high-quality care regardless of ability to pay, our Canadian counterparts were much more blasé about their egalitarian, publicly financed system. They took it for granted. They don’t know anything else and are mainly focused on what is needed to improve it.

One thing that became clear to us is that figuring out what works and what doesn’t work, and how to make a change, is much easier to do in a unified system like Canada’s. We also saw that the single-payer system in practice is not as simple as we thought and that there are still political realities to deal with that control the funding and who gets what part of the pot.

There are still inequities in the system. There is a shortage of physicians and there can be long waits for elective procedures and non-urgent doctor visits. For most Canadians the cost of drugs, dental care and some psychiatric services is not included in the basic package provided by the government. The benefits vary somewhat by province.

But Canada’s medical outcomes are excellent; urgent needs get urgent care; and Canadians live two years longer on average than we do. Problems like medical bankruptcy are virtually unknown. The overwhelming majority of Canadians, when polled, say they’d prefer their system over ours any day.

We learned that doctors in Canada earn a good income not much different from most of those in the United States. Although most have a good quality of life with adequate free time, some are overworked and a few can’t find positions due to lack of facilities in some specialties. But few Canadian physicians emigrate, and in fact each year since 2004 more physicians have returned to Canada than have moved abroad.

Canadians were totally perplexed as to why Americans have put up with our faulty and expensive system for so long. It was hard for me to explain this as I cannot understand it myself. Although polling shows that two-thirds of American are in favor of Medicare for all, their voices are not heard in the media nor in the halls of Congress. On the contrary, our legislators are now debating whether to end Medicare are we know it.

I can give one explanation, at least: A liberal with one of the biggest bully pulpits in the country -- indeed, in the world -- has chosen to suppress a health care policy that would save $350 billion dollars a year and improve health outcomes. Yes, we all have choices to make...

Rosenthal's the one who should be on the Op-Ed page, and not Krugman. Why not give the country a make-good and turn the column over to her for a week, Professor?

NOTE * To be fair, this country about 330 miles north of Princeton, NJ.

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coyotecreek's picture
Submitted by coyotecreek on

Years ago I started paying into Medicare thinking that when I got "old", I would have help with my medical needs and be able to live to my full potential at the time I got "old" as a result of that help.

Now I understand that those of us "old" people - who have supported the system all these years (potentially to benefit our future - have no right to expect the level of care that currently exists.

Instead, all we "bought into" was the level of care that was available when we started to "invest" in this system. So think of all of those life-saving discoveries that exist but that we have no right to now.

There is, indeed, an ice-flow with my name on it out there somewhere. I want to think that my SO's name is there, too. Otherwise, it's going to be a very lonely death.

Buyers. Beware!

Submitted by Hugh on

Again this is all about distraction, and distraction is the principal weapon in class warfare. So instead of focusing on the fact that we have seriously dysfunctional and cruelly unfair healthcare system or, as lambert points out, that there are good alternatives out there, Krugman blames "excessive" care, the sick, and the old. That is he redirects attention away from the real problems and the real solutions and encourages us to fight among ourselves. This is the very essence of class warfare and Krugman is not on our side in it.

Kleptocracy is a system and the simple fact of the matter is that most public figures belong to the elites that are looting us. Drum, Yglesias, Klein, Alterman, Krugman, all these have shown in the last couple of weeks that when push comes to shove they stand with the kleptocrats, not us.

Bryan's picture
Submitted by Bryan on

Krugman talks about excessive care, so where is the data behind that claim?

Most of the data I've seen that would support that claim is part of fraud trials, like the one that resulted in my current governor's corporation receiving the largest fine ever imposed on a Medicare - Medicaid fraud case.

Since the administrative costs for Medicare are so low, maybe they could be increased slightly to include more fraud investigators, who might support themselves with a significant increase in fines being leveled.

Why don't we try punishing the people and corporations who violate current laws, before we make any rash decisions about what must be done?

Send a few CEOs and boards of corporate criminals to prison, and then we have a reasoned discussion based on actual hard facts and real-world data, about what is excessive care.

I have a news flash for Dr. Krugman - I have been involved in my Mother's health care for more than a decade, and Medicare does not cover everything, no matter what the White House may have told him.

katiebird's picture
Submitted by katiebird on

or just a sloppy blogger?

Because this post is sloppy to the point of absurdity. Does he really think that denial of care is the only option for controlling the growth of Medicare expenses?

He must. Because he doesn't even pretend to present other options (like real-bargaining & opening the system to people-of-all-ages)

DCblogger's picture
Submitted by DCblogger on

and we cannot come down on him hard enough for this. Our problem is health insurance parasites siphoning off trillions from our health care system, not sick people who require expensive care.

madamab's picture
Submitted by madamab on

Krugman doesn't explain why Medicare costs so much. The high cost of health care did not spring, full-blown, from the head of Zeus. Health care costs so much because of the unrestrained greed of insurance companies, who can literally charge anything they want for any procedure or deny preventive care at will.

Yet instead of blaming the real culprits, Krugman tries to blame the citizens who have paid into Medicare all their lives and rightly expect quality care in return. Disgusting beyond words!

I can't believe this is the same man who wrote "The Great Unraveling."

Shame on you, Paul Krugman. SHAME.

a little night musing's picture
Submitted by a little night ... on

This is not an excuse (he has got that bully pulpit, after all, so he'd damned well better be up to it) but, as Krugman has noted more than once in the past, the economics of health care is not in his domain of expertise. In this matter he has alluded to relying on the expertise of others. And yet, he and his wife and collaborator wrote this once upon a time.

Telling final paragraphs:

The insertion of private intermediaries into the [Medicare] program has several unfortunate consequences. First, as millions of seniors have discovered, it makes the system extremely complex and obscure. It’s virtually impossible for most people to figure out which of the many drug plans now on offer is best. This complexity, coupled with the Katrina-like obliviousness of administration officials to a widely predicted disaster, also led to the program’s catastrophic initial failure to manage the problem of “dual eligibles,” i.e., older Medicaid recipients whose drug coverage was supposed to be transferred to Medicare. When the program started up in January, hundreds of thousands of these dual eligibles found that they had fallen through the cracks, that their old coverage had been canceled but their new coverage had not been put into effect.

Second, the private intermediaries add substantial administrative costs to the program. It’s reasonably certain that if seniors had been offered the choice of receiving a straightforward drug benefit directly from Medicare, the vast majority would have chosen to pass up the private drug plans, which wouldn’t have been able to offer comparable benefits because of their administrative expenses. But the drug bill avoided that embarrassing outcome by denying seniors that choice.

Finally, by fragmenting the purchase of drugs among many private plans, the administration denied Medicare the ability to bargain for lower prices from the drug companies. And the legislation, reflecting pressures from those companies, included a provision specifically prohibiting Medicare from intervening to help the private plans get lower prices.

In short, ideology and interest groups led the Bush administration to set up a new, costly Medicare benefit in such a way as to systematically forfeit all the advantages of public health insurance.


Beyond reform: How much health care should we have?

Imagine, for a moment, that some future US administration were to push through a fundamental reform of health care that covered all the uninsured, replaced private insurance with a single-payer system, and took heed of the VA’s lessons about the advantages of integrated health care. Would our health care problems be solved?

No. Although real reform would bring great improvement in our situation, continuing technological progress in health care still poses a deep dilemma: How much of what we can do should we do?

The medical profession, understandably, has a bias toward doing whatever will bring medical benefit. If that means performing an expensive surgical procedure on an elderly patient who probably has only a few years to live, so be it. But as medical technology advances, it becomes possible to spend ever larger sums on medically useful care. Indeed, at some point it will become possible to spend the entire GDP on health care. Obviously, we won’t do this. But how will we make choices about what not to do?

In a classic 1984 book, Painful Prescription: Rationing Hospital Care, Henry Aaron and William Schwartz studied the medical choices made by the British system, which has long operated under tight budget limits that force it to make hard choices in a way that US medical care does not. Can We Say No? is an update of that work. It’s a valuable survey of the real medical issues involved in British rationing, and gives a taste of the dilemmas the US system will eventually face.

The operative word, however, is “eventually.” Reading Can We Say No?, one might come away with the impression that the problem of how to ration care is the central issue in current health care policy. This impression is reinforced by Aaron and his co-authors’ decision to compare the US system only with that of Britain, which spends far less on health care than other advanced countries, and correspondingly is forced to do a lot of rationing. A comparison with, say, France, which spends far less than the United States but considerably more than Britain, would give a very different impression: in many respects France consumes more, not less, health care than the United States, but it can do so at lower cost because our system is so inefficient.

The result of Aaron et al.’s single-minded focus on the problem of rationing is a somewhat skewed perspective on current policy issues. Most notably, they argue that the reason we need universal health coverage is that a universal system can ration care in a way that private insurance can’t. This seems to miss the two main immediate arguments for universal care—that it would cover those now uninsured, and that it would be cheaper than our current system. A national health care system will also be better at rationing when the time comes, but that hardly seems like the prime argument for adopting such a system today.

Our Princeton colleague Uwe Reinhardt, a leading economic expert on health care, put it this way: our focus right now should be on eliminating the gross inefficiencies we know exist in the US health care system. If we do that, we will be able to cover the uninsured while spending less than we do now. Only then should we address the issue of what not to do; that’s tomorrow’s issue, not today’s.


Can we fix health care?

Health policy experts know a lot more about the economics of health care now than they did when Bill Clinton tried to remake the US health care system. And there’s overwhelming evidence that the United States could get better health care at lower cost if we were willing to put that knowledge into practice. But the political obstacles remain daunting.

A mere shift of power from Republicans to Democrats would not, in itself, be enough to give us sensible health care reform. While Democrats would have written a less perverse drug bill, it’s not clear that they are ready to embrace a single-payer system. Even liberal economists and scholars at progressive think tanks tend to shy away from proposing a straightforward system of national health insurance. Instead, they propose fairly complex compromise plans. Typically, such plans try to achieve universal coverage by requiring everyone to buy health insurance, the way everyone is forced to buy car insurance, and deal with those who can’t afford to purchase insurance through a system of subsidies. Proponents of such plans make a few arguments for their superiority to a single-payer system, mainly the (dubious) claim that single-payer would reduce medical innovation. But the main reason for not proposing single-payer is political fear: reformers believe that private insurers are too powerful to cut out of the loop, and that a single-payer plan would be too easily demonized by business and political propagandists as “big government.”

These are the same political calculations that led Bill Clinton to reject a single-payer system in 1993, even though his advisers believed that a single-payer system would be the least expensive way to provide universal coverage. Instead, he proposed a complex plan designed to preserve a role for private health insurers. But the plan backfired. The insurers opposed it anyway, most famously with their “Harry and Louise” ads. And the plan’s complexity left the public baffled.

We believe that the compromise plans being proposed by the cautious reformers would run into the same political problems, and that it would be politically smarter as well as economically superior to go for broke: to propose a straightforward single-payer system, and try to sell voters on the huge advantages such a system would bring. But this would mean taking on the drug and insurance companies rather than trying to co-opt them, and even progressive policy wonks, let alone Democratic politicians, still seem too timid to do that.

So what will really happen to American health care? Many people in this field believe that in the end America will end up with national health insurance, and perhaps with a lot of direct government provision of health care, simply because nothing else works. But things may have to get much worse before reality can break through the combination of powerful interest groups and free-market ideology.

Medicare costs are indeed being driven up by the insane overhead of our patchwork system as well as by some measure of overusage of unproven treatments, and it is very important to tease apart the contributions of those two parts. But given the experience of other countries like our neighbor to the north, I have my suspicions. Pretending that these are even possibly comparable is indefensible crap as far as I can tell.

I feel I should also link my post Mom's experience with Medicare Part C.

Submitted by jawbone on

with Obama again? Has he been to some private fundraisers for Obma and been given a refresher "treatment" so that he will fudge and spin for his president? I can hear it now: You know, Professor, your ideas are correct, but how can Obama get a second term if you keep pointing out his flaws? Just tone it down a bit; don't be quite so, well, shrill."


Hope people are commenting at his site/column.

This coming from Krugman is very,very disappointing.

How much more disappointment must we endure?

And to Madamab --Sing it, sister!