The Best is Still the Best
Conservatives like to argue that “government-run health care” is doomed to failure, and thus any effort to reform the US health system is also doomed to failure since it’s destined to end in a government-run dystopia. One argument liberals make against this is to point out that it’s false. The World Health Organization’s ranking of health care systems around the world places a diverse group of systems ahead of the United States. That includes systems with Beveridge-style models (like the UK), systems with a single-payer insurance model (like Canada), and Bismark-style regulated-competition models (like Switzerland and the Netherlands)—all kinds of things work better than what we do. Another things liberals point out is that the Veterans’ Health Administration, which is an island of Beveridgism amidst America’s capitalist health fiasco, performs much better than the rest of the system.
That said, nothing is without its flaws, and this New York Times account of a rogue cancer unit at one VA hospital is certainly disturbing. Since the malfeasance has been discovered, I both hope and assume that the problems will be remedied. I also assume we’ll hear more of this kind of argument from Megan McArdle:
We often hear wonderful things about what the VA can do because it’s not a private sector system. I suspect this is also one of the things that can only happen at the VA.
This mode of argument seems beneath intelligent people. The case for the VA’s high quality is not constructed out of a handful of touching anecdotes. It’s a statistical comparison between the VA as a whole and alternative systems. As best I know, the information Phil Longman and others have presented regarding VHA quality remains valid. If it’s not—if some new studies have been done showing a dramatic erosion in VHA quality over the past couple of years—then that’s news worth reporting. If not, the exposure of problems at one sub-unit of one facility should be occasion to clean up the problem and maintain the VHA’s generally high standard of excellent, not an opportunity to randomly smear the hardworking people throughout the rest of the system.
That said, for the sake of readers’ understanding it should be noted that the whole debate over the VHA has very little to do with the health reform proposals facing congress. None of them entail creating anything resembling a VHA-style integrated system of government-run health providers. Some countries do operate on that model, but most countries with national health care systems don’t, and none of the bills in congress would have the United States move in that direction.
39 Responses to “The Best is Still the Best”
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June 22nd, 2009 at 10:49 am
It seems beneath intelligent people to worry so much about what Megan McArdle writes.
June 22nd, 2009 at 10:51 am
What Moral Panicker @#1 said. Matt why do you continue to print her arguments, one of which you at least admit here is beneath intelligent discourse?
June 22nd, 2009 at 10:51 am
I was going to comment, but Moral Panicker beat me to it.
June 22nd, 2009 at 10:54 am
Ignoring my earlier hurtful snark, this post seems right. Maybe the VA really isn’t that great, but available data (which on some level are, hurtful snark aside, a plural for anecdote) suggest the VA does a good job and it is 1) unreasonable to reach broad conclusions about government-run health-care based on this story and 2) only marginally relevant to apply conclusions about government-run health-care to questions about government-provided health insurance. Good post.
June 22nd, 2009 at 10:55 am
This mode of argument seems beneath intelligent people.
What does that have to do with Megan McAr…dammit!
June 22nd, 2009 at 11:05 am
This mode of argument seems beneath intelligent people.
Not when the person in question is committed by zealotry, partisanship, or a pecuniary interest to the relevant claim, and this is the best they can come up with.
June 22nd, 2009 at 11:11 am
This mode of argument seems beneath intelligent people.
So therefore not beneath Megan McArdle…which seems to be the general thrust of the comments so far.
June 22nd, 2009 at 11:22 am
This mode of argument seems beneath intelligent people.
It is, however, a mode of argumentation made popular by the well-known theoretician of rhetoric Al Davis.
June 22nd, 2009 at 11:27 am
Actually, if you read her post, there’s not an argument there at all, just some random squaking about government, and praise of lawsuits.
June 22nd, 2009 at 11:30 am
- “beneath intelligent people…” You ignored Megan’s sovereign immunity argument.
- Is an uncritical citation of the WHO still the best argument your side can make? People don’t purchase health care to improve aggregate outcomes; they purchase it for their personal benefit. WHO factors overall life expectancy instead of disease-specific outcomes. The closest it comes to looking at actual outcomes of what we normally think of as health care services is in its measure of responsiveness, where the U.S. ranked no. 1. It is not surprising that the WHO plugged in collectivist premises and came to collectivist conclusions. You never hear an argument for these premises.
June 22nd, 2009 at 11:31 am
How does Matt select his McArdle’s quotes? Most of her posts are equally stupid. I guess that one was an opportunity to discuss health care reform further.
June 22nd, 2009 at 11:34 am
Andrew Sullivan: of no party or clique.
Megan McArdle: a mode of argument beneath intelligent people.
June 22nd, 2009 at 11:38 am
But not, interestingly enough, beneath McArdle.
June 22nd, 2009 at 11:43 am
WHO factors overall life expectancy instead of disease-specific outcomes. The closest it comes to looking at actual outcomes of what we normally think of as health care services is in its measure of responsiveness, where the U.S. ranked no. 1. It is not surprising that the WHO plugged in collectivist premises and came to collectivist conclusions. You never hear an argument for these premises.
Measuring life expectancy is communism, and something Ann Rand would frown upon. Surgeons should go Galt. Also, the only measures that matter are those ranking the US at #1.
June 22nd, 2009 at 11:52 am
Was there ever a rigorous, systematic attempt to establish a case for “government bad, private industry good,” or was it always just these sort of anecdotal, “boy, waiting in line at the DMV sucks; I sure hate government” critiques?
June 22nd, 2009 at 12:02 pm
Since Matt only quoted part of the post, allow me to quote the portion that I think gets to the actual point of the post.
Not because hospitals are above covering up malpractice, or because doctors don’t protect other doctors, but because any private hospital would have been terrified of getting sued. The VA is very hard to sue because of sovereign immunity.
June 22nd, 2009 at 12:02 pm
Interesting how anecdotes matter when talking about a system like the VA or systems like Canada or the UK or wherever.
Those “touching anecdotes” are used as examples of the malfeasance of a supposedly cold health care bureaucracies. But in the private US systems those “touching anecdotes” are used as an argument for more medical malpractice and tort reform rather than just better care.
In a quick Ezra Klein Slate article on the malpractice myth, he cites a VA program for reducing the cost of med mal…
And at the Lexington, Ky., Veterans Affairs Medical Center, a program of early disclosure and settlement of malpractice claims lowered average settlement costs to $15,000, compared with $83,000 for other VA hospitals.
June 22nd, 2009 at 12:05 pm
Funny how the people who rail against socialized medicine never propose closing the VA and kicking all the vets to the curb.
June 22nd, 2009 at 12:06 pm
aaron, my child, the best “argument” “our” side can make is that the US spends a considerably higher percentage of gdp on health care than any other country, yet our health-care outcomes are in no sense 30 – 50% better than anyone else’s.
that happens to be a fact-based, incontrovertible argument, to which a non-response (of your sort) is to say “i can find a specific area where the US system is excellent!” (greg mankiw, for instance, only this weekend referenced cancer survival rates). such a non-response is typical of those who actually have nothing to say beyond “i hate the idea that the government might actually live up to the preamble of the constitution.”
June 22nd, 2009 at 12:08 pm
Not because hospitals are above covering up malpractice, or because doctors don’t protect other doctors, but because any private hospital would have been terrified of getting sued. The VA is very hard to sue because of sovereign immunity.
It’s an interesting theory, though it has nothing to do with any health care reform proposal under discussion. It would be nice if someone tried to prove or disprove it using facts, rather than a single anecdote.
June 22nd, 2009 at 12:08 pm
Was there ever a rigorous, systematic attempt to establish a case for “government bad, private industry good,” or was it always just these sort of anecdotal, “boy, waiting in line at the DMV sucks; I sure hate government” critiques?
There’s also Katrina and the Iraq War.
June 22nd, 2009 at 12:11 pm
JH, what your honest conservative will say is this: thanks to the “invisible hand” and the profit motive, private business is more open to innovation, more data-driven, and more efficient than government, which must respond to different incentives, can ever hope to be.
and when it comes to manufacturing widgets, that’s true.
the problem, of course, is that what’s best for manufacturing widgets isn’t best for promoting the general welfare.
June 22nd, 2009 at 12:11 pm
It’s the accountability stupid. My health insurance company does a truly bad job of reviewing claims for psychological treatment. Does that mean there’s a unit of UHC(United Health Care) just ignoring the rules and screwing around with my benefits? I’ll never know because I can’t really complain to anyone with the authority to order an investigation.
But if that entity were a rouge bureaucrat within a national health service I could complain to Chuck Schumer who might have someone investigate this issue and then hold big press conference. Even if the some kind of national health care is somewhat more restrictive in terms of care it seems like it would inevitably be more responsive to the needs of patients than the current private sector set up.
June 22nd, 2009 at 12:13 pm
It’s also worth noting that the doctor who botched all these surgeries and hid it was not a VA doctor working under their socialized medical system.
He was a private contractor, a researcher at one of the most prestigious universities. Because of that, according to a regulator: “The V.A. put too much trust in the contractors, said Darrell G. Wiedeman, a senior health physicist for the nuclear commission. ‘They claim they hired experts, the best that money could buy from the local university, so therefore they didn’t require a lot of training and oversight,’ Mr. Wiedeman said”
It’s kind of bizarre to indict socialized medicine by pointing out that an incredibly well-credentialed private contractor did a terrible job when he was hired by this system, and they eventually caught him doing a horrible job.
It also raises the question of why this guy ended up a researcher and faculty at one of our nation’s best medical colleges. And whether, if he hadn’t chosen to work for the VA, anyone would have ever realized what kind of a doctor he was.
June 22nd, 2009 at 12:17 pm
The VA is very hard to sue because of sovereign immunity.
Why, it’s almost as if McArdle and JD haven’t taken the two minutes on google required to discover the Federal Tort Claims Act.
June 22nd, 2009 at 12:21 pm
There is one important take-away for Aaron’s comment up there: opponents of universal health care don’t EVER use quantitative analysis to back up their position, either because they are incapable of it, or because a rigorous analysis refutes everything they want to believe.
Instead, they console themselves by disparaging rigorous, quantitative, scientific analysis, much like their Young Earth Creationist allies.
June 22nd, 2009 at 12:22 pm
Since Matt only quoted part of the post, allow me to quote the portion that I think gets to the actual point of the post.
Except McArdle is guilty of the exact same problem. She links here in support of her claim “The VA is very hard to sue because of sovereign immunity”:
http://veteranmedicalmalpractice.com/faq.html
As explained there:
So in fact veterans can and do sue the VA for malpractice under the Tort Claims Act. Basically, the Tort Claims Act will require you to pursue an administrative remedy first (although it can’t take more than six months), and then to bring your claim in federal court. You also can’t get punitive damages. But the idea that they are hard to sue in general is just false.
June 22nd, 2009 at 12:26 pm
Why oh why @ 14 has won this comment section. That is all.
June 22nd, 2009 at 12:45 pm
I think this is actually a pretty genius way to look at things because it allows cons to play both sides of this. You can show how the government is unaccountable and therefore more susceptible to big time fuck-ups (apparently) but at the same time blame spiraling health costs on malpractice insurance rate increases because of liberal malpractice law or evil trial lawyer-friendliness or whatever.
Brilliant.
June 22nd, 2009 at 12:46 pm
You know, I enjoy a bit of McMegan-bashing as much as anyone, but the anonymous comment at #24 really nailed the appropriate response to this story. If anyone in the entire news media cared enough to dig six inches below the surface, this anecdote would be playing as an indictment of farming government work out to contractors, and a data point in favor of centralized record-keeping and analysis.
June 22nd, 2009 at 1:15 pm
Again, I wonder if the “beneath intelligent people” line was just a feed line for the obvious rejoinders about McArdle. She’s a lanky piñata, but one that offers little resistance, and needs as little promotion as possible.
But, anyway, what #24 said. It’s similar to the problems of audit, oversight and general trust that the NHS has encountered in the relatively new practice of contracting out to foreign-based doctors for locum work.
June 22nd, 2009 at 2:40 pm
Our lawyer and doctor friends and relatives will, now and then, spill a few beans on corruption and incompetence in the medical ranks. They’re pretty careful about it, only occasionally mentioning a name. But, hey, it’s not just this little story from a corner of the VA. It’s all over the place, and it’s covered up.
June 22nd, 2009 at 2:52 pm
Funny how the people who rail against socialized medicine never propose closing the VA and kicking all the vets to the curb.
Perhaps not closing, but vets’ benefits are attacked pretty regularly under the banner of budget reduction. It’s the kind of thing that happens in legislation rather than Sunday television appearances. There were lots of complaints about this under GWB, but it’s not isolated to that presidency. Veterans were also dramatically impacted by deinstitutionalization.
June 22nd, 2009 at 3:02 pm
There have been several attempts to respond to my comment at ten.
Why oh why: “Measuring life expectancy is communism.”
Joe from Lowell: “opponents of universal health care don’t EVER use quantitative analysis to back up their position, either because they are incapable of it, or because a rigorous analysis refutes everything they want to believe.”
Measuring something is just collecting facts; the interpretation we place on facts is a different matter. For instance, to a technocrat trying to produce good aggregate numbers, a dollar of health spending has to be justified based on some calculus of benefit to society; to an individual purchasing health care, it has to be justified based on benefit to himself or herself.
I have no objection to the practice of quantitative analysis of things that can be analyzed. I do prefer that what presents itself as analysis actually be analysis, and tend to prefer that people avoid confusing fact with interpretation.
For instance, a couple of people on this thread apparently find the characteristics (respect for dignity, confidentiality, autonomy, prompt attention, quality of amenities, access to support networks, and choice of provider) that WHO defines as “responsiveness,” to be trivial. For someone who believes that health care service exists for the benefit of its customers, this will not appear to be the case.
In much of its evaluation, the WHO actually employs the opposite of rigorous analysis. To provide intellectual cover to their attempt to relate life expectancy to health systems, they have to define “health system” in a practically unlimited fashion. They then have to combine this and several other factors, giving an arbitrary weight to each. Rigorous analysis would break things down, correlating specific processes with outcomes.
As I mentioned, the closest WHO comes to this is in their responsiveness category, where the U.S. ranks no. 1. Another way to do it would be to track disease specific mortality, or to look at specific statistics of the sort that Howard at 19 complains about Mankiw doing. Collectivism isn’t just a morally problematic assumption for WHO, it also turns out to be a methodological weakness.
Howard: “the US spends a considerably higher percentage of gdp on health care than any other country, yet our health-care outcomes are in no sense 30 – 50% better than anyone else’s.
“that happens to be a fact-based, incontrovertible argument, to which a non-response (of your sort) is to say ‘i can find a specific area where the US system is excellent!’”
Incontrovertible! I do not think that word means what you think it does. And it’s really more of an assertion than an argument.
There is no meaning in saying that our health outcomes are 30-50% better than those of another country, because biologically speaking only individuals have health outcomes, and comparing money to these outcomes is like comparing oranges with VCRs.
June 22nd, 2009 at 3:45 pm
For instance, a couple of people on this thread apparently find the characteristics (respect for dignity, confidentiality, autonomy, prompt attention, quality of amenities, access to support networks, and choice of provider) that WHO defines as “responsiveness,” to be trivial.
Talking about responsiveness without addressing accessibility is really just an expansion of the silly GOP line about third-world dictators travelling to the US for their medical treatment.
June 22nd, 2009 at 3:51 pm
I think Matt should start posting at firemeganmcardle.blogspot.com
I love that site btw.
June 22nd, 2009 at 3:53 pm
aaron, “incontrovertible” means exactly what i think it means: indisputable. and i wasn’t making an “assertion;” i was pointing to the definitive argument.
and, indeed, you have not disputed that argument: you’ve attempted to invent a parallel reality altogether in which costs and benefits need no longer have any relationship.
yes, i’m fully aware that individuals have health outcomes, but we can, in fact, aggregate the data into ways that provide us helpful insights. if every individual had a superior outcome, the aggregate would be superior; if every individual had an inferior outcome, the aggregate would be inferior. if there is a mix of outcomes (i.e., just like reality), then aggregates give us a way to have a window into those outcomes. “average” and “median” don’t cease to have analytical value just because they represent an analysis of large bodies of data; similiarly, percentage of gdp has meaning (in very real dollars), and telling us (as you are implying, without telling us anything) that, as i’ve already noted, pace mankiw, cancer survival rates are better in the US is hardly worth that incremental cost (particularly due to the complexities of cancer survival rates, which depend on cancer detection. as an example, we tend to diagnose prostate cancer early on, and so we have good results on survival; in a regime in which prostate cancer isn’t tested for so young, then the cancer survival rates will look less good, but males aren’t necessarily dying at a worse rate from prostate cancer, they’re simply being detected later).
which is to say, statistics can, of course, be misused, but at the level we are talking here, they aren’t being misused: as a percentage of gdp, we spend considerably more than any other country. tell me what we are buying for it.
June 23rd, 2009 at 9:19 am
[...] as I said yesterday we have hundreds of millions of people in the developed world and thus tens of billions of [...]
June 25th, 2009 at 5:10 pm
I think that healthcare is always going to be taboo subject since no one really knows the best way. Every nation is different and there are factors that affect each individual group. Personally, I just wish we could extend healthcare to those who can’t afford it, and France and Canada’s methods seem to be working pretty effectively. Like I said though, I understand that each system is different and their health plans would probably affect us negatively in many ways too.