Rational Arguments

I’ve been following with interest the ongoing fight debate between Paul Krugman and, well, no one yet.  I hold all of you to a high standard, so I’m not going to recap the whole thing.  I’ll give you the broad strokes.

Rep. Paul Ryan put together a “Roadmap” for the budgetary future.  It’s won a lot of acclaim from some for at last being an actual policy document that attempts to outline a conservative vision of deficit reduction.  I will admit, I was initially impressed with its existence.  I can’t say I agree with it’s methodology.  For instance, I think the replacing of Medicare with vouchers that will slowly become inadequate to purchase insurance will only result in the same problems I cite here when countering Avik Roy’s similar proposal for Medicaid.  Rep. Ryan was also going to freeze all discretionary spending at 2009 levels until 2019.  That’s simply stunning.

But at least it put something down on the table.  That way we can start to debate.

Rep. Ryan even had the plan scored by the CBO.  And it brought the deficit down impressively.  Massively, in fact.

Yes, some noted problems with the plan.  For instance, Jonathan Chait said:

Begin with his proposed tax changes. Ryan would not only retain the Bush tax cuts for the highest earners, he would further lower the top tax rate to 25%. On top of that, he would repeal all taxes on corporate income, inherited estates, capital gains, and dividends. In other words, he would completely eliminate the most progressive elements of the tax code, and slash the next most progressive element. In their place he would impose a value-added tax, which would not bring in nearly enough revenue to replace the revenue lost from his tax cuts, but would fall much more heavily on the poor and middle class.

I remember thinking that if he could really balance the budget and massively cut taxes, then he must be some sort of genius.  But then, a number of other groups said you couldn’t lower taxes so much and still balance the budget.  The cuts (even those massive ones) weren’t enough.  Rep. Ryan responded:

The tax reforms proposed and the rates specified were designed to maintain approximately our historic levels of revenue as a share of GDP, based on consultation with the Treasury Department and tax experts. If needed, adjustments can be easily made to the specified rates to hit the revenue targets and maximize economic growth. While minor tweaks can be made, it is clear that we simply cannot chase our unsustainable growth in spending with ever-higher levels of taxes. The purpose of the Roadmap is to get spending in line with revenue – not the other way around.

In other words, “we’ve got it covered.”  The exact quote was, “tax reforms would raise slightly less revenue than claimed“.

That was in March.  It’s been a busy year.

But this week, Rep. Ryan has been all over the news.  There was this mavericky profile in the Washington Post on Monday.  Ezra Klein had a long interview with him that made him look super-wonky.

But today.. hoo-boy.

Paul Krugman opened up a whole case of whoop ass on Rep. Ryan.  Remember the tax cuts that would result in “slightly less revenue than claimed”?  Turned out to be $4 trillion over a decade.  For those keeping score that’s four, count ‘em, four PPACA’s.  That’s… insane.  If you factor that in, it turns out that deficit in 2020 under the “roadmap” is not what the CBO claimed. It’s pretty much exactly where President Obama’s budget will get us.

Except that we will have those massive Medicare cuts.  Same to Medicaid.  And 2009 discretionary spending in 2019.  I was willing to at least listen to those kind of spending cuts when I thought it would help with the deficit.  But why would we consider them just to get the same deficit we would have without them?  How big are Rep. Ryan’s tax cuts to completely eat away the deficit savings?

The Tax Policy Center finds that the Ryan plan would cut taxes on the richest 1 percent of the population in half, giving them 117 percent of the plan’s total tax cuts. That’s not a misprint. Even as it slashed taxes at the top, the plan would raise taxes for 95 percent of the population.

I’m speechless.

It turns out that Rep. Ryan asked the CBO to score his plan as if revenue would be about the same as without the tax cuts.  He asked them to ignore the tax cuts.  He asked them to pretend the $4 trillion in lost revenue didn’t exist.

That’s not OK.  That’s cooking the books.

Paul Krugman gets sort of nasty.  So do a few others.  I try, really hard, not to do that here.  I will not question Rep. Ryan’s motives.  Nor will I pre-assume anything about his argument or answers to these issues. I hate when people do that.

But Rep. Ryan is a politican, and a pretty powerful one at that.  He has full access to the press and microphones. It’s time for him to step up.

You want to be a wonk?  Then you defend your plan.  Explain how you will account for the $4 trillion difference.  You don’t get to play with the big boys if you hem and haw and pretend that magically we will make up that money somewhere else.  That’s what politicians do.  And if he wants to be a politician, that’s fine, but then no special treatment from the press or people who know better.  You go back and play with the other politicians who have no idea what they are talking about.

I’m going to break my name calling rules just once here, because this is policy, and I take that seriously.  When you write a paper, or a blog, or a “roadmap”, you’re putting yourself out there.  I respect that.  But you have to be ready to defend your work.  If it gets attacked, that doesn’t mean it’s wrong.  Not everything is black and white, and some things are open to interpretation. But if someone makes a valid criticism of your work, you have only two honorable options.  You defend it, publicly for everyone to see, or you own up to your mistake.  Either one will do.  What you can’t do is run and hide, or pretend that you didn’t hear, or ignore the criticism and attack the criticizer.  If you do, then you’re not a serious player.

You’re a hack.

Per Avik Roy, the study we’ve been discussing is up online.  Unfortunately, it’s behind a paywall, so most of you won’t be able to see it yet.  Moreover, it’s complicated, and I don’t think it’s likely permissible for me to repost huge sections of it here.  So I’m going to have to summarize, and you will have to trust, but verify.

As has been said over and over, this study used a large inpatient database to examine the association between primary payer status and outcomes.  And, as has been said, it found that being uninsured or having Medicaid led to worse outcomes, including a higher risk of death.

I’ve read the whole thing now.  If you came looking for me to tell you the methodology is fatally flawed, I will have to disappoint you.  The authors were thorough, careful, and skilled.  Their analysis is complex, well controlled, and uses established methodology.  I do not doubt that their results are robust, nor do I think there is anything major that I would change.

Where Avik and I will likely agree is on the strict recitation of the findings:

Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality.

Patients with private insurance do best.  After controlling for important covariates, Medicaid had the longest length of stay and highest total costs.  I could come up with explanations as to why this is, but – to be honest – it’s irrelevant to the larger point I want to make, so let’s leave that for the moment.  The other key finding were that Medicaid and Uninsured patients were independently found to have higher mortality after adjusting for other factors.  So far, I bet Avik and I won’t quibble.

But one key point, and again it is not huge, is that all the comparisons showing significance were done with private insurance as the reference.  So it is totally correct to say that both Medicaid and Uninsured were significantly worse that private insurance.  But there was no test comparing Medicaid with Uninsured.  So this study did not show that Medicaid patients had a higher mortality than the uninsured.  Yes, the odds ratio was higher for Medicaid than for the Uninsured, but the confidence intervals overlap with respect to mortality, so we can’t make clear distinctions between those two groups.

But, again, I don’t want to spend too much time on that point.  I agree with the larger point that Medicaid patients and the Uninsured both fared much worse than those with private insurance.  I accept the results.

Now on to likely disagreements.

First off let me address this:

Aaron also notes that Medicaid is voluntary: but this is weak support for the implication that Medicaid, in its current form, is the best we can do. In the Vietnam days, some conservatives used to tell liberals to “love [America] or leave it.” I don’t remember liberals being too happy about that. Nor does Medicaid’s voluntary nature mean, ipso facto, that it must be doing some good. Does the voluntary nature of Medicare overutilization mean that Medicare overutilization is a good thing? Most liberal health policy types that I know believe otherwise.

It’s not that I think Medicaid is voluntary.  It’s that I don’t think Medicaid keeps you from seeing doctors you could otherwise see if you didn’t have it.  As I said before, Medicaid patients are able to see physicians that accept Medicaid plus those that they can pay for out of pocket.  I don’t believe this equals “doing some good”.  I do think this equals increasing the available pool of physicians over what they would have without Medicaid.  I think I know what a response might be to this argument, but I hate when people presuppose what the opposition must think, so I’m going to let others make their own arguments as to why this is wrong.

But the larger issue is to what this all means.   I agree that Medicaid is associated with bad outcomes.  I agree that Medicaid is flawed.  I agree that Medicaid could be improved.  But I don’t necessarily agree that Medicaid is the cause of the problem.

I wish I could repost huge tracts of the manuscript, because I think the authors do an excellent job of describing many of the reasons this association might exist.  Almost none of them are causal.  I will summarize as best I can:

• Elective operations were more common with Private Insurance and nonelective were more common in Medicaid and Uninsured patients, pointing to the fact that those populations don’t have the same choices up front.  Elective surgeries usually are planned for and have better outcomes.  Yes, this is controlled for, but still significant (and noted by the authors).
• Patients with private insurance may have better access to higher quality physicians or facilities.  There is a good amount of evidence that surgeons’ experience matters.  I don’t disagree with this.  I do disagree that Medicaid worsens this over being Uninsured because of the argument I made earlier.
• Other differences may exist between these populations that are unaccounted for.  The authors note:

Both Medicaid and Uninsured payer groups had the highest incidence of drug and alcohol abuse. In addition, Medicaid patients had the highest incidence of acquired immunodeficiency syndrome, depression, liver disease, neurologic disorders, and psychoses. Furthermore, Medicaid patients had the highest incidence of metastatic cancer, which likely reflects the combined influence of deficits in access to care, poor health maintenance, and delayed diagnosis resulting in the presentation of advanced disease stage within this population.

• Patients with Medicaid and the Uninsured use the system differently than those with private insurance. More of them get their primary care in the emergency department.  They are more likely to have language barriers or health literacy issues.  They are more likely to be malnourished and have other issues.

Again, though, we can’t know for sure.

So what should we do with this?  If I read Avik’s argument correctly, he thinks Medicaid is fatally flawed and should be replaced with, perhaps, subsidies to buy private insurance.

Now – in theory – that’s not the worst idea in the world.  In fact, it’s what the insurance exchanges in PPACA represent.  I am going to take Avik at his word and go with this a little further.

In a previous post, Avik seemed to endorse giving the poor a lump sum payment and letting them try and get insurance.  I don’t think that’s a good idea.  With individual ratings, insurance for much of the Medicaid population would still be out of reach even with the subsidy he cites.  But in his most recent post, Avik endorses the Swiss system.  Now, that is much more interesting.

The Swiss system has a powerful mandate.  They require everyone to buy private insurance.  They also give out subsidies so that insurance is not more than 8%-10% of anyone’s income.  All insurance companies are mandated to have a “basic” plan with regulated benefits.  This basic plan also must be non-profit.  All insurance is community rated.  The Swiss system also takes a pretty heavy hand with practitioners.  As Uwe Reinhardt notes:

On the surface, the Swiss health system may give the impression of a price-competitive, consumer-directed health care model. However, the heavy government regulation that pervades the entire system—including the health insurance sector—makes it a far cry from the vigorous, price-competitive health care market envisaged by the advocates of consumer-directed health plans in the United States. Some gestures to competition aside, the Swiss system so far has remained mainly a de facto cartel of insurers and health care practitioners who transact with one another in a tight web of government regulations.

I agree that the Swiss system costs less than ours, achieves comparable and sometimes better outcomes, and covers nearly 100% of their population.  If this is the direction Avik thinks is a good idea, then we may agree more than I think.

I remember this one moment back in the midst of health care reform when I was sitting in a radio studio, feeling pretty glum about the whole ordeal, and I mused aloud, “I wonder if anyone is enjoying this at all.”

For some of us, improving the health care system is more than a passing fancy.  I’m a health services researcher.  It’s my job.  Those people on the TV pay attention to it when it gets ratings, and those people in Washington get into it every other decade or so, but it’s what I do every day.

I really with I could make you believe that I couldn’t care less about the politics of it all.  Seriously.  Yes, like everyone else I care about who is in the White House of Congress, and I do lean different ways on different issues, but – on this I swear – I just want a better health care system.  That’s all.  I don’t care if it’s labelled conservative or liberal.  I don’t care what names you call it.  I just want it to be better.

Specifically, I want it to have phenomenal outcomes, I want everyone to have access to it, and I want it to be cost-effective.

I hope you notice I didn’t say cheap.  I think good things DO cost money.  I just wouldn’t like to spend any more than we have to.

People may think I’m closed minded, but I swear I’m not.  I am persuaded by good research.  That’s all.  Evidence.  Data.  Science.  I really don’t have a stake in who “wins” this.  It’s only the final product that matters.

Which brings me back to the title of this post.  I’m heartened by some recent activity I’ve seen.  I watched a debate occur between Austin Frakt and Avik Roy without it degenerating into partisan hackery.  I somehow managed to say a few words on the topic without resorting to sarcasm.  And I believe (maybe I’m delusional) that someone following the whole thread may have seen that it is possible to discuss good, unbiased research in a civil manner.  I stand by this:

I don’t think there is necessarily a right or wrong here.  Research is, more often than not, baby steps.  Each study adds a small amount to our understanding; each study is only so generalizable.

And I’d add that by talking about the body of work that exists, and discussing what from it we can agree on, we could find a starting point for moving forward.  Wouldn’t it be nice if we could devise pilot programs in health care reform in different ways, and then study them?  Agree to the methodology beforehand and then see what happens?  How great would it be if we all agreed to stand by the results, no matter what they might be, no matter what our ideology?

For instance, Avik cites the Medicaid program in Indiana which set up health savings accounts for Medicaid recipients and then coupled them with high deductible health care plans.  Why oh why did they not agree to allow an independent third body to set up a study to see how it worked?  Maybe good research would have shown that reform to be a spectacular success, vindicating the consumer-driven approach.  Maybe good research would have shown that reform to be a spectacular failure, suggesting that such an approach cannot succeed in a high-risk population.

It sure would have been nice to find out.  Instead, too many are driven by a desire to see their pre-chosen method of reform succeed, and so prevent any chance of it being seen in a bad light.  These types of people deny any flaws in a single-payer approach, no matter if such flaws exist.  They refuse to examine the downside of increasing out-of-pocket costs because it might hurt their “side”. They are more interested in the ideology than the goal of improving the health care system.

No good can come of that.

Anyone who reads this blog knows I think highly of Austin.  And, I opened by email this weekend to receive a very nice note from Avik concerning my recent posts.  Those personal contacts really do matter.  They remind me that some of us do have a shared goal – a better health care system.  We may disagree on how best to get there, but we can at least discuss our differences, and – perhaps – look for similarities. This kind of post gives me hope.

I hope this type of debate continues.  For my part, I’m going to keep an eye out for the study that started this all.  When I can finally read the whole thing, I will, and I will make sure I tell you what I think.  I’ll tell you if I think it’s a good study (or not), and how I think it adds to our body of knowledge about Medicaid.  And maybe, if more people keep on doing that, we can shift the discussion of health care reform away from politics and back to what really matters.

The debate continues.

As I said before, I think debate is good.  And I don’t think there is necessarily a right or wrong here.  Research is, more often than not, baby steps.  Each study adds a small amount to our understanding; each study is only so generalizable.  Avik believes that the research speaks to the harm Medicaid is doing.  I think that the evidence is not so clear.  But I come from the pediatric world, and the research in pediatrics and Medicaid isn’t necessarily the same as the research in surgery, which Avik cites:

As to Carroll’s point about the fact that the uninsured aren’t getting mammograms and colonoscopies, but Medicaid patients are: that isn’t true, because Medicaid patients can’t get appointments to see doctors (see above). If Carroll was right, it would only render even more striking the fact that the uninsured have their cancers detected earlier than do Medicaid patients. With breast cancer specifically (since he brings up mammograms), Medicaid patients were 31% more likely to have late-stage breast cancer than the uninsured. With surgical resections for colon cancer (since he brings up colonoscopies), in a separate study, Medicaid patients had a 27% higher risk of mortality than the uninsured, and a 9% higher risk of surgical complications.

I freely admit I’m not as well versed in the surgical literature as I am in the pediatric literature.  There are only so many hours in the day, and I really do have a full time job.  But I think we are fundametally interpreting this literature differently.  I have trouble understanding the idea that Medicaid patients have more trouble seeing doctors than uninsured patients because of Medicaid.  The pool of physicians uninsured people can see is equal to the ones they can afford to pay out of pocket.  The pool of physicians a patient a on Medicaid can see is equal to the ones that accept Medicaid plus the ones they can afford to pay out of pocket. So the pool of physicians a Medicaid patient can see is actually a superset of those that the uninsured can see.

Of course, it’s entirely possible that those on Medicaid can’t afford to see the same physicians that the uninsured can, because the Medicaid population if often poorer than the uninsured.  That would be a key difference, and not the fault of Medicaid.

This should not be taken as any sign that the studies Avik cites don’t show Medicaid is flawed.  It absolutely is. Not even single payer advocated believe that we should have Medicaid-for-all.  YES, Medicaid is flawed.  It’s state based, so it can run out of money.  It reimburses too little.  It needs to be improved.

But because Medicaid is state based, it can differ in quality from state to state.  It ranges in its benefits from state to state.  The number and quality of docs who accept it differ from state to state.

Contrary to what some believe, I welcome high quality research no matter what the outcome.  The only way we can improve the system is to first find out what is wrong with it.  And so I hope Avik is not talking about me when he says:

Skeptics of the study are setting themselves up for disappointment if they hope that the detailed results will exonerate Medicaid.

I’m not skeptical of this study.  I’m skeptical of all studies until I can personally evaluate their methods.  And I won’t be disappointed no matter what the final outcome because I have no vested interest in Medicaid.  I have a vested interest only in a high quality, cost-effective health care system.

As I have said before:

You can’t ignore [research] because it doesn’t fit your ideology… [w]hen you do science, you agree to accept the results…

That’s how it goes in research.

I’ve been away the last few days and trying to relax.  Now that I’m catching up, I see Austin Frakt and Avik Roy are having a slight disagreement as to the association of Medicaid on outcomes.  Long story short, Avik points to the literature that shows that Medicaid is associated with worse surgical outcomes.  Austin asks the important follow-up question: if you believe that’s true, are you suggesting that we make those on Medicaid more like the uninsured?  I don’t want to wade into this too deep.  I will make a number of small points:

-Insurance doesn’t equal care.  Insurance can affect how likely you are to get care and how quickly you might get it.  But any study that looks at insurance has to adjust for many, many other variables in order to get the true effect of insurance.

-There is a large body of literature out there on insurance.  A lot of it shows that people with private insurance do better than those with public insurance or those without insurance; that should not be a surprise.  Most people (and most of your docs) would rather have private insurance than Medicaid.  But would you really rather have no insurance than Medicaid?  If so, that is everyone’s right.  Don’t get the Medicaid.  I wager few would make that choice.

-I find it interesting that most of the literature that Avik cites is about surgery.  Surgery is different than other types of care (like emergency care) in that it is harder to refuse.  So it may be that the uninsured are getting care on a compassionate basis.  Few would provide a screening mammogram or yearly colonoscopy to someone uninsured, however, and you would get that with Medicaid.

On the whole, I think the debate is healthy and good.  No one is claiming that Medicaid is perfect, or that we should all just get Medicaid.  There is always room for improvement.  I also don’t necessarily think that Avik is arguing that we should just dump all the Medicaid people on the street, which is what I think some (not Austin) are implying he is saying.

And I’m stopping there.  Were I on the radio, I would be happy to debate this.  But blogging is too asynchronous when I’m joining in so late.  Except for one thing, and here I’m going to take a tiny issue with Avik’s first post.  It was based on (as far as I can tell) a meeting abstract.

I have a long-standing beef with promoting research that is presented in abstract form at scientific meetings.  It makes for great press and lots of splash, but I think it’s a real problem.  So much so that I have refused to participate in media events or press releases that about my work unless it has already appeared in the peer-reviewed literature.  Why?  It’s not rigorously reviewed.  Here is the total amount that we are able to know about the methods of the study Avik cites:

Methods: From 2003-2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n=491,829), Medicaid (n=40,259), Private Insurance (n=337,535), and Uninsured (n=24,035). Multivariate regression models were applied to assess outcomes.

That’s it.  Was it a good study?  Valid?  How can you tell?

This ticked me off so much as a fellow, that I actually studied it.  Specifically, we looked at abstracts presented at the Pediatric Academic Societies meeting, which is the largest pediatric research meeting.  You can read the full paper, but here’s the abstract:

OBJECTIVE: The validity of research presented at scientific meetings continues to be a concern. Presentations are chosen on the basis of submitted abstracts, which may not contain sufficient information to assess the validity of the research. The objective of this study was to determine 1) the proportion of abstracts presented at the annual Pediatric Academic Society (PAS) meeting that were ultimately published in peer reviewed journals; 2) whether the presentation format of abstracts at the meeting predicts subsequent full publication; and whether the presentation format was related to 3) the time to full publication or 4) the impact factor of the journal in which research is subsequently published.

METHODS: We assembled a list of all abstracts submitted to the PAS meetings in general pediatrics categories in 1998 and 1999, using both CD-ROM and journal publications. In each year, we chose up to 80 abstracts from each presentation format (“publish only,” “poster,” “poster symposium,” “platform presentation”). We chose either 1) all abstracts in each format or 2) when there were >80 abstracts, a random selection of 80 of them. We assessed each selected abstract for subsequent full publication by searching Medline in March 2003; if published, then we recorded the journal, month, and year of publication. We used logistic and linear regression to determine whether publication, time to publication, and the journal’s impact factor were associated with the abstract’s presentation format.

RESULTS: Overall, 44.6% of abstracts presented at the PAS meeting achieved subsequent full publication within 4 to 5 years. There were significant differences between the rates of subsequent full publication of abstracts submitted but not chosen for presentation at the meeting (22.2%) and those that were chosen for presentation in poster sessions (40.0%), poster symposia (44.1%), and platform presentations (53.8%). There were no meaningful differences between the presentation formats in their mean time to publication and their mean journal impact factor.

CONCLUSIONS: PAS meeting attendees and the press should be cautious when interpreting the presentation format of an abstract as a predictor of either its subsequent publication in a peer-reviewed journal or the impact factor of the journal in which it will appear.

I know that can be overwhelming, so here’s the gist.  We looked at a sample of all abstracts sent in to the meeting, and whether they were ever published in peer-review journals.  The first thing I always remind people is that 87% of abstracts that were sent in were presented.  That’s a lot; very few were refused.  So I wouldn’t necessarily assume that just because an abstract is presented, it’s totally valid.  Second, less than 45%of the research presented was published in a peer-reviewed journal in the next four to five years.  So over half of what was presented at the meeting never was “really” published.

I’m not saying the results of Avik’s discussed study aren’t valid.  I’m saying I can’t tell.  And neither can you, without more information.  The peer review for a meeting just isn’t the same as for full publication.  You have less time, different criteria, and almost nothing by which to judge the work.  Ideally, meetings would stop publicizing abstracts as if they were full studies, but neither they, nor the press, seem likely to do so.

Every once in a while, someone has to wheel out the usual story on how Canada’s health care system is about to collapse.  Today, it was Reuter’s turn:

Pressured by an aging population and the need to rein in budget deficits, Canada’s provinces are taking tough measures to curb healthcare costs, a trend that could erode the principles of the popular state-funded system.

Before I even get into this, can we acknowledge that rising health care costs in not a Canadian problem, but a worldwide problem?  Please remember as we go through the rest of it that – today – we spend about twice per person what Canada does on health care.  If they are complaining that it costs too much, what are we doing?  And while they spend about 10% of GDP on health care, we spend 16%.  So anyone who points to their model as “unable to contain costs” should just shut up.

Anyway, here is my favorite line:

In some ways the Canadian debate is the mirror image of discussions going on in the United States.

Canada, fretting over budget strains, wants to prune its system, while the United States, worrying about an army of uninsured, aims to create a state-backed safety net.

Huh?  We already have a safety net. It’s called Medicaid.  It’s not as good as I like but it exists.  This reporter, however, seems to think that the ACA is about the safety net.  It’s not.  It’s mainly a huge plan to give taxpayer money to people to buy private insurance.  It’s an expansion of the private system, albeit with government money.  It’s not some new government plan.

Moreover, Canada wants to contain rising costs.  Like we should.  But as they take steps to be fiscally prudent, we deride them as failures.  Here’s a United States Senator:

What will happen in the U.S.? | Reuters: Soaring costs force Canada to reassess health model

Soaring health costs?  As opposed to here?  Am I losing my mind?

They quote four people in the article.  One is the Ontario Finance minister.  He says:

“Our objective is to preserve the quality healthcare system we have and indeed to enhance it. But there are difficult decisions ahead and we will continue to make them”

Seems reasonable enough.  I don’t disagree.  You would think, that if this was an article describing the upcoming demise of the single payer system, that there would be other politicians calling for, say, the demise of the single payer system.  But no.  Instead, we get the following three players:

1) A senior economist at Toronto-Dominion Bank.  You read that right.

2) A professor at University of Toronto’s Rotman School of Business.

3) A senior economist at Scotia Capital.  What is Scotia Capital?  This is Scotia Capital:

Scotia Capital is the marketing name covering the Scotiabank Group’s integrated global corporate and investment banking and capital markets functions. Scotia Capital’s global operations are divided into two primary business units:

Global Corporate and Investment Banking

Global Capital Markets

In Canada, Scotia Capital offers a full range of corporate and investment banking and capital markets products and services.

Really?  This is who they went to for health policy expertise?  Can you possibly predict what she will advise?

Scotia Capital’s Webb said one cost-saving idea may be to make patients aware of how much it costs each time they visit a healthcare professional. “(The public) will use the services more wisely if they know how much it’s costing,” she said.

“If it’s absolutely free with no information on the cost and the information of an alternative that would be have been more practical, then how can we expect the public to wisely use the service?”

Ah….  the moral hazard.  Like music to my ears.

No health policy experts.  No politicians advocating for change.  A bank economist, a business professor, and an economist for Scotia Capital.  The article never mentions that the single payer system in Canada is wildly popular.  The article never mentions that no serious politician is running on a platform of repealing it.

But most importantly, the article never mentions that the Canadian health care system is not like ours in any way.  No matter what headline you read, the ACA is not a single payer system.  The ACA changed very little structurally.

Our system is still mostly private.  Ours costs way more.  Ours covers far fewer people.  And ours has similar, if not worse, outcomes.

Our system is nothing like Canada’s.  We should be so lucky.

I know I harp on health care costs all the time.  Well, almost all the time.  But it’s because they are huge.  Way more than any other country.  And, they’re growing too fast as well.

Now, many claim that the ACA will “bend the curve” and slow the growth of costs.  But how much?  Well, since the CBO has been doing most of the heavy lifting so far, no reason to let them stop now.  CBO director Doug Elmendorf recently gave a talk to the Annual AAAS Forum on Science and Technology Policy on the economic and budget outlook.  What’s the verdict?  Here are outlays for 2020:

Do you see Medicare there?  It’s almost $900 billion.  We’ll be spending more on Medicare than on Defense.  This doesn’t include Medicaid (another $444 billion).  Together, they will cost more than Social Security.  More than interest on the debt.  more than all discretionary (other) spending total.

You want to balance the budget?  Ain’t gonna happen.  Not while health care costs this much.  And we haven’t even added in private spending on insurance, out-of-pocket costs, or the cost of reform (which is small compared to the big M’s).

We need to seriously get a handle on health care costs.  The sooner everyone starts to accept that, the better we’ll be.

OK.  My vacation was fantastic, and now I’m ready to get back into it.  There were lots of questions waiting for me when I returned, so I’m going to devote the next few days to trying to answer some of them.

A number of you don’t fully get Medicaid.  And that’s not surprising, given the lack of truly policy-directed coverage this year.

Basically, Medicaid is supposed to provide health care coverage for the poorest among us.  There are some minimal federal guidelines that are set for Medicaid.  Then, each state gets to implement it as it sees fit.  Some states are more generous, and some less.  Generally, Medicaid is meant to cover those at the low end of the socioeconomic spectrum.  The government defines poor this way:

While you consider the table, remember this amazing fact – a single parent, with a child, who makes minimum wage earns MORE than the poverty level.  That’s how low the line is.

Regardless, Medicaid must cover:

• Kids under 6 years of age to 133% FPL
• Kids 6-18 to 100% FPL
  • SCHIP upps these to 300% FPL in most states
• Pregnant women up to 133% FPL
• Parents to 1996 welfare levels
• The elderly and those with disabilities who receive SSI

Now, states get to implement things above that as they see fit.  But the first important thing to note is that adults without children aren’t mentioned at all.  And in most states, they can’t get Medicaid.

Let me say that again – in most states even the poorest adults without children don’t get Medicaid.

And it gets worse.  Those 1996 welfare levels can be super low.  So low that, for instance, in Alabama a couple with two children making $2500 a year don’t qualify for Medicaid.  Granted, some states are more generous.  But in many, parents have to be insanely poor in order to get Medicaid:

Remember, these are percentages of the table above.  In many states, parents, if they work at all, can’t get Medicaid.

One of the overlooked benefits of health care reform is that it sets guidelines that vastly increase Medicaid coverage nationally.  The federal rules will change such that everyone, even those without children, making 133% FPL (Senate version) or 150% FPL (House version) would get Medicaid.  In some states, that might not be a big deal.  But for those in the states on the left side of the chart, this would result in millions of the poorest among us getting the coverage that many of us already assume they get.

They don’t right now.  And they desperately need it.  And if we fail to pass any reform, they will get nothing.

Ben Nelson has been taking a lot of heat for his last minute deal to secure federal funding to cover Medicaid in his home state of Nebraska.  Turns out he wants to get the same gift for all states:

Senator Ben Nelson, Democrat of Nebraska, has been under fire in recent days over his success in winning some plum provisions for his home state in exchange for his commitment to vote for the Democrats’ big health care legislation. But in a statement on Thursday, Mr. Nelson said he would fight for all states to get the same benefits as Nebraska — a move that some of his Senate colleagues had predicted as inevitable.

I guess he got a “sweetheart” deal.  But come on.  If your “pork” is money to pay for public health insurance for poor people, I really can’t get that upset about it.  His “special interest group” is people making less than 133% of the poverty line?  Yeah, that’s a fearsome lobby.  We better put a stop to them immediately.

I wish more legislators were so “corrupt”.

UPDATE: Austin Frakt points out to me that:

But really what [Nelson's deal] is for is freeing up state money for other things. So, it’s only good for the poor as a side benefit.

I agree that Nelson was getting money for his state, but really – this wasn’t for a company or lobbyist or even the Ben Nelson Bridge.  If you have to get pork for your state, getting it for Medicaid has to be one of the least offensive ways to do it.  I concede it’s unfair that Nebraska gets what other states don’t, but of all the things to come out of health care reform, this isn’t the one that gets me the angriest.

One of the little-noticed gems in the House version of the bill is that one of the way is saves money is by putting more people on Medicaid.  You heard me:

A previous version of the House bill carried an estimated cost of $1.04 trillion over 10 years, but House negotiators were able to lower the price tag in part by expanding Medicaid coverage to a broader slice of the population, the equivalent of all individuals who earn about $16,200 per year. The original House legislation had sought an increase to 133 percent of the federal poverty level, or about $14,400 per year, the same level proposed in the Senate bill.

The adjustment reflects findings by congressional budget analysts that covering the poor through Medicaid — which pays providers far less than Medicare — is far more cost-effective than offering subsidies for private insurance policies, something the bill would provide to middle class individuals who lack access to affordable coverage through their employers.

Medicaid costs less than private insurance.  So it actually costs us as a country less to give people Medicaid than to give people money to buy private insurance.  So…  maybe we’d save even more if we put more people on Medicaid, say up to 250% of the poverty line.  Or… maybe everyone?

And before you start screaming about Medicaid’s low levels of reimbursement, Ezra notes that the bill contains legislation to increase Medicaid’s reimbursements to Medicare levels.