By Golly, a Two-Tier System!
An anesthesiologist slash right-wing crank who happens to share the name Ronald Dworkin with an important legal and political theorist has taken the august op-ed pages of the The Wall Street Journal to (a) whine about the fact that he, personally, might earn a lower income under a national health care system, and also that we should (b) “Expect a two-tier medical system and needless ER deaths if Congress and the White House have their way.”
It’s probably true that universal health care systems have a tendency to lead in a two-tier direction, as people with the means necessary to purchase additional services above the publicly provided “floor” wind up with somewhat more lavish care, though not necessarily better basic treatment for illness. That said, from this complaint you’d think that we were currently living in some Communist utopia in which health care is provided “to each according to his needs.” Even among Medicare recipients we have a two-tiered system according to whether or not you’re prosperous enough to afford “Medigap” coverage. Then there’s the tier separating people with really generous health care plans from those stuck in lower tiers that severely constrain your choice of doctor and access to specialists. And of course there’s the tier for people with catastrophic-only coverage and the tier for poor people on Medicaid and the tier for people with no insurance whatsoever. Probably more tiers than that, too. Our current system is clearly, obviously, and by design less egalitarian than all the major alternatives. That’s the whole point.
One question is why, with income inequality reaching unprecedented levels, we shouldn’t act to redress that inequity in our health care system? Dworkin appears to concede that inequity is bad, describing the residual inequity of a universal health care system as a great evil. But surely it’s progress relative to where we are.
26 Responses to “By Golly, a Two-Tier System!”
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August 20th, 2009 at 5:00 pm
America’s two tiered health care system is a longtime subject of discussion.
Health care economist Uwe Reinhardt compared it to horse poop. Those with resources get to eat oats before they enter the horse. Those without find their oats post digestion. A disturbing analogy to day the least, especially when Dr. Reinhardt’s conflicts of interest are taken into account. He’s clearly in the pre-digestion group.
http://stateofthedivision.blogspot.com/2009/04/dr-uwe-reinhardt-offers-magic-health.html
Uwe is on of the For-Profiteers.
August 20th, 2009 at 5:07 pm
Here’s some numbers from my latest trip to opensecrets:
2008 Election Cycle Contributions:
Health Professionals: $50,027,229 to Dems, $44,885,549 to GOPers
Insurance Companies: $ 20,961,971 to Dems, $25,777,768 to GOPers
Parmaceuticals: $14,669,583 to Dems, $14,702,202 to GOPers
TOTAL: $85,658,783 to Dems, $85,365,519 to GOPers
August 20th, 2009 at 5:15 pm
I wish I had that kind of free speech.
August 20th, 2009 at 5:19 pm
Is that guy really an anesthesiologist? Because I don’t want anyone that stupid anywhere near me if I’m going under the knife.
August 20th, 2009 at 5:31 pm
It’s very important for conservatives that any ameliorative effort on behalf of society’s have-nots establish private, conservative benefactors as the do-gooders. The idea that a liberal, publically-employed, progressive might play the role of do-gooder is threatening.
The contest isn’t over egalitarianism itself, it’s over which ideology and which social group becomes more indespensable in the effort at social amelioration.
For years, progressives have wanted health care reform. Message: I can fix that! Conservatives take no notice of people whose lives are ruined for lack of health insurance, but they do notice progressives attempting to gain social legitimacy.
So, for years of right-wing rule, conservatives did nothing as the problems with our health care “system” grew and grew. That’s not a problem, because no one on the left could use the problem to threaten their power. Now that progressives are on the verge of succeeding and potentially playing the hero once again, conservatives are playing the reactionaries:
1) demonize progressives as a foreign people from a land in which the only gods are Unintended Consequences, Slippery Slopes, and Liberal Elites
and
2) to the extent that some reform of health insurance is inevitable, discover at the 11-th hour various reformist schemes that preserve the power of private enterprise (hence the Cato folks’ enthusiasm of subsidies to individual buyers in the health care market).
A very old game, as old as capitalism itself, really.
August 20th, 2009 at 5:35 pm
OMG! Needless ER Deaths! How many people needlessly die now because they can’t get medical care to begin with or don’t have insurance to cover diagnostic and preventative medical care? How many people needlessly die now because the assault rifle plan was passed? How many people needlessly died in Iraq so that Bush could be a “War President”? How many people needlessly die because of poisons in our air and water from unregulated corporate pollution? How many people like Matthew Shepard are going to “needlessly die” because homophobia is tolerated by the right and measures like hate crimes laws are defeated?
When right wingers start getting all hyper and sanctimonious about people “needlessly” dieing, it really really makes this liberal heart bleed…
August 20th, 2009 at 5:40 pm
if Dworkin is so gung-ho about the free market health system, is he willing to take a stand against the AMA’s shameful restrictions on how many doctors can be educated each year, and how they are to be trained, along with the ridiculous per-state restrictions and licensing?
Substantially increasing the supply of doctors, along with allowing more flexibility in how they are trained, and where they can practice, would do as much as anything else to alleviate our current problems. But when it comes to the supply side of supply and demand, Dworkin and his AMA friends suddenly forget all their anti-government rhetoric and insist on how important it is that current licensing and training practices remain exactly as they are.
August 20th, 2009 at 5:48 pm
We should care about whether doctors and other health care professionals would earn less, and what that would mean for their incentives, and for the capabilities of those who are enticed to pursue such a career.
It should be said that the actual reforms that are being proposed rule out any significant tiering, because of the political need to slowly drive out private insurance through a public option and unfavorable regulation.
Most interesting is that Matt essentially concedes that egalitarianism is the only argument for the reform, which makes sense because else there’s no explanation at all. Matt doesn’t care about the absolute quality, only that everyone suffers or enjoys equally. For those who don’t think that’s a persuasive world view, well, there’s no reason to adopt this “reform”.
August 20th, 2009 at 5:51 pm
“Our current system is clearly, obviously, and by design less egalitarian than all the major alternatives”
The “system” is an accident of history far more than it is the result of design.
August 20th, 2009 at 6:08 pm
Cost savings.
August 20th, 2009 at 6:19 pm
Is that guy really an anesthesiologist?
He sounds greedy enough to be one.
August 20th, 2009 at 6:21 pm
Matt doesn’t care about the absolute quality, only that everyone suffers or enjoys equally. For those who don’t think that’s a persuasive world view, well, there’s no reason to adopt this “reform”.
Now that’s some high-grade quasi-logical horseshit.
August 20th, 2009 at 6:30 pm
Most interesting is that Matt essentially concedes that egalitarianism is the only argument for the reform, which makes sense because else there’s no explanation at all.
This is not ‘egalitarianism’. If you measure GDP per capita, the US rank high but at the price of larger inequalities than in other rich countries. With health care, the American system is bad on average.
If you also consider the costs, it is really inefficient, unless you value inequality itself as a good thing.
It is possible to have a better and cheaper system; very rarely do you face such a choice in politics. That is why this reform is called a ‘litmus test’ by Taibbi: if Democrats after the last elections can’t deliver a decent reform, well, we really live in an oligarchy.
August 20th, 2009 at 6:43 pm
A two-tier system is no problem so long as the bottom tier is excellent. Hardly anyone in this country would object to the wealthy spending unlimited sums for improved care about a high baseline that everyone gets.
August 20th, 2009 at 7:13 pm
Universal access and rational reviews of comparative effectiveness and drugs and devices will make health care more egalitarian.
While the wealthy will always be able to get quicker treatment, go to more doctors for more opinions, fly to Germany (like Farrah Fawcett did) for alternative treatments, and so on, there is a limit: if it is determined that a chemotherapy agent, for instance, doesn’t provide enough benefit under a rational regulatory process so as to justify approval, or inclusion in a public plan or Medicare, its manufacturer won’t market it and no one will get it.
What Dworkin might not even understand is that there are many drug companies and device manufacturers, and even hospitals, who won’t bother marketing or implementing a service unless enough people are there to pay for it. You can’t make money just giving a treatment to wealthy people. One of the reasons why pharma manufacturers market the way they do is because they need “blockbusters” not reasonably efficacious drugs that a fair number of people will use.
August 20th, 2009 at 7:49 pm
why oh why, I think that the question of the quality of the American health system is a little more contested than you suggest. Evaluations which explicitly weight cost and egalitarianism tend to say that the system isn’t very good, and that it could be improved by becoming more egalitarian and by the government fixing costs. But that’s really not an argument.
Rich, that isn’t true in the UK. What makes you think the left would be satisfied here?
August 20th, 2009 at 8:14 pm
Jeez–how can anyone not know we already have a multi-tier system?
Maybe if you’re a WSJ reader you don’t know.
BTW don’t you hate it when people who do some of the same things (like write on public policy) have the same name?
August 20th, 2009 at 9:53 pm
At salary.com (http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000045.html), we learn that the average slary of an anesthesiologist is $256,300; the median salary is $314,300 (so the distribution of earnings is–predictably–positively skewed). At the 75th percentile of the distribution an anesthesiologist earns $369,400. (For family practice doctors, the mean is about $164,000, and the 90th percentile of the distribution is about #213,000…or, the best paid family practice doctors make less than the average anesthesiologist.)
So if the earnings of anesthesiologists fall a little bit–10%, 20%–I, for one, am not going to feel that they’ve been driven to the poorhouse.
August 20th, 2009 at 10:01 pm
Rich is on the right track here. Have a taxpayer funded basic policy that covers everyone and then companies or individuals who want to buy Medigap type insurance so they get a private room or dental and vision care, etc. are free to do so. Everyone gets doctor and hospital care and can pay for gucci service if they want. Most government funded health care systems are like this including our Medicare.
August 20th, 2009 at 10:23 pm
Maynard Handley #7:
if Dworkin is so gung-ho about the free market health system, is he willing to take a stand against the AMA’s shameful restrictions on how many doctors can be educated each year, and how they are to be trained, along with the ridiculous per-state restrictions and licensing?
Well, I know thatLew Rockwell would agree with you.
August 21st, 2009 at 12:33 am
Donald, I’m not going to either; they’ll still be well paid. But the question is, will they work as hard and do as much as they do now? It’s easy to guess that they won’t. Also, if the position doesn’t pay as well, will it attract the same sort of talent as it does now?
August 21st, 2009 at 1:41 am
Maybe we should think more about the mental experience of medical education. They generally have to study harder than their business major friends, who may start making investment banking or management consulting money at the age of 22. (I think engineering or computer science majors often work just as hard or harder than pre-meds, but they may not go to the same parties.) You have to get mostly As in hard classes while doing the right extracurriculars. The med student’s friends who go to law school finish a year earlier and start making big law six-figures. Then, a year later, they graduate med school and start residency training, a high-stress process with some forms of hazing mixed in it during which they might clear $10/hr. Most people in these high-achieving fields tell tales of frequent 80-hr weeks, but for most of my friends in business and law, that seems to include a suspicious amount of golf and whiskey.
Many of the patients they see during residency will be case studies in social Darwinism. Diabetics who don’t even try to manage their disease. A heroin addict who OD’d for the third time that month. A 400-lb. guy who won’t lose weight or even remember to take his blood pressure medication. These patients can be the most rude. These people who have had to be very disciplined and hard-working may now spend most of their time treating people who can’t be bothered with the most basic of personal maintenance.
I don’t know. The current process of becoming a doctor seems almost designed to make physicians feel that they deserve whatever compensation they can possibly get. That some don’t is likely because there are quicker, easier pathways to riches – and that the insanity of insurance procedures causes such a headache that many are willing to take less for less B.S. from them.
August 21st, 2009 at 3:12 am
I’m wondering why this doctor thinks he will earn less money. He won’t be able to soak his paying customers to make up for the non payers, but there won’t be any more non payers!
So how much income will doctors lose because of decreasing prices? how much will they gain by turning all their charity cases into paying customers? I don’t know and the doctor doesn’t either. There isn’t even a reform bill yet.
August 21st, 2009 at 7:57 am
I don’t know. The current process of becoming a doctor seems almost designed to make physicians feel that they deserve whatever compensation they can possibly get. That some don’t is likely because there are quicker, easier pathways to riches – and that the insanity of insurance procedures causes such a headache that many are willing to take less for less B.S. from them.
– Клипы онлайн
August 21st, 2009 at 8:01 am
Perhaps the Public Option can be made more palatable to the private insurers by including provisions for supplemental, Medigap-like policies they can sell? No Public Option can afford to cover everything.
August 21st, 2009 at 10:44 am
I wonder how much better the health is of the people who get the really “lavish” health-care. I strongly suspect that in may cases people with really good insurance are getting a lot of treatment they don’t need.