How beneficial is healthcare?

Mar 22 JDN 2458931

Healthcare has been a contentious issue in the US for generations, but became especially so during the Obama administration with the passage of the Affordable Care Act. To be honest, I never quite understood the opposition to transitioning to a single-payer healthcare system; we already spend as much public funds on healthcare as most other First World countries spend in their entire healthcare system (plus we spend even more than that on private spending!), so not only can we afford it—it would in fact save us trillions of dollars a year. We might not even have to raise taxes, but even if we did, we’d pay so much less out of pocket that most of us would end up with more money. I understand why the corporations that run HMOs don’t want single-payer; but why does anyone else oppose it?

It’s not as if there are no models to follow; we could literally just copy the Canadian system (or the British system, or the French system…). It’s always amusing to me when conservatives respond to the suggestion by: “But that’s socialism! Do you want to end up like Cuba?” First of all, I said copy Canada, not copy Cuba. But even if we did copy Cuba, healthcare is one of the few things that Cuba actually does extremely well. On a QALY-per-dollar basis, it’s probably the most cost-effective healthcare system in the world (and the US is probably the least). So yeah, you know what? I kinda do want to end up like Cuba.

And no, countries with single-payer healthcare systems do not have longer wait times. Even by standard measures, our wait types are in the middle of the pack. But in fact these standard measures are clearly biased in our favor. The main way that we reduce wait times is by excluding people from care entirely. That’s not a wait time of zero; it’s a wait time of the rest of your life. If we measured properly, we would clearly have the longest wait times in the First World, because of all those people who never get care at all.

But today I’m going to ask a different question:

How much harm is done by our awful healthcare system?

Or conversely:

How much benefit would we get from insuring everyone?

The largest randomized controlled experiment on health insurance in the United States was the RAND Health Insurance Experiment, and its results were quite surprising: The marginal benefit of better health insurance for most people was very small, in many cases statistically negligible. People who were very poor or very sick benefited from having health insurance, but everyone else used more medical care without getting much apparent benefit. Since this was a large randomized controlled experiment, it should probably be considered our most credible evidence.

On the other hand, the RAND study was done before I was born, so maybe it’s time for a new study?

More recent studies have used regression discontinuity analysis, looking to see if going on Medicare seems to change the trendline in your mortality rate. It doesn’t.Of course mortality rates go up as you get older, and people become eligible for Medicare by getting older… but still, if Medicare is helping, you’d think there would be some kind of kink in the trend, and as far as we can tell, there isn’t. Perhaps people are simply transitioning from one form of adequate health insurance (e.g. employer-provided insurance) to another.

There is some evidence that healthcare saves lives, if we restrict attention specifically to what is called mortality amenable to healthcare, deaths caused by diseases that we know can be effectively treated by medical intervention. (It’s really a continuum, with malaria at one end, and airstrikes at the other. Both kill thousands of people every year, but malaria can be treated with a few doses of quinine, while there’s nothing anyone can do for you if you were in the blast center of a Hellfire missile. In between we have diseases like cancer, which medicine can sometimes save you from but not always.) By this measure, the United States clearly lags behind other First World countries, and the reason is clearly that we deny a lot of people healthcare.

However, I think mortality is really the wrong measure to use, for the following reason: We already have a universal healthcare system when it’s literally a question of life or death, and that’s the ER system. The Emergency Medical Treatment and Labor Act, signed by Ronald Reagan (yes, Republicans also used to like saving poor people from diseases, not so long ago!), guarantees that anyone who needs emergency care can get it immediately, regardless of their ability to pay. They can still bill you later, which may be a big reason why medical costs are the leading cause of bankruptcy in the United States (and literally nowhere else in the world). But at least you won’t die.

A lot of it actually comes down to how we measure health. Self-reported measures are notoriously unreliable in various ways, yet ultimately I don’t see how we can tell whether someone is sleeping well, feeling energetic, or being in pain without asking them. Correlating self-reported measures with objective measures like records of doctor visits shows pretty good correspondence, albeit by no means perfect.

As healthcare spending has increased and medical technology has advanced, there has been a worldwide trend of reduced disability and mortality, and the US is no exception. Clearly healthcare is doing something.

Yet it remains a fair question whether most people need more healthcare—maybe we’re actually getting enough. Maybe most people’s health insurance is already adequate, and we don’t need to improve it in any substantial way.

On balance, I think the best evidence we have says that people who have no insurance at all, or really awful insurance, would strongly benefit from improved access to healthcare. There’s also evidence that people with severe chronic conditions benefit from having steady healthcare. But for most people most of the time, the benefits of more health insurance would be quite small.

Does this mean we should get rid of health insurance? Of course not. But it does mean that future reforms should be focused on getting it to people who have none, not improving it for people who already have it. We don’t need to lower co-pays or deductibles; we may not even need to raise or remove coverage caps. But we do need to get some kind of health insurance to people who don’t have any at all.
To this end, Obamacare has done fairly well: You can just look at a graph of the number of uninsured people in the US and see that not only did Obamacare reduce that number, the steady attempts to undermine Obamacare are starting to bring it back up.

Then again, a single-payer system would clearly do even better, maybe even get that number to zero… so explain to me again why we’re not doing this?

You know what? Let’s repeal Obamacare. Here’s my replacement.

Feb 18 JDN 2458168

By all reasonable measures, Obamacare has been a success. Healthcare costs are down but coverage rates are up. It reduced both the federal deficit and after-tax income inequality.

But Republicans have hated it the whole time, and in particular the individual mandate provision has always been unpopular. Under the Trump administration, the individual mandate has now been repealed.

By itself, this can only be disastrous. It threatens to undermine all the successes of the entire Obamacare system. Without the individual mandate, covering pre-existing conditions means that people can simply wait to get insurance until they need it—at which point it’s not insurance anymore. The risks stop being shared and end up concentrated on whoever gets sick, then we go back to people going bankrupt because they were unlucky enough to get cancer. The individual mandate was vital to making Obamacare work.

But I do actually understand why the individual mandate is unpopular: Nobody likes being forced into buying anything.

John Roberts ruled that the individual mandate was Constitutional on the grounds that it is economically equivalent to a tax. This is absolutely correct, and I applaud his sound reasoning.

That said, the individual mandate is not in fact psychologically equivalent to a tax.

Psychologically, being forced to specifically buy something or face punishment feels a lot more coercive than simply owing a certain amount of money that the government will use to buy something. Roberts is right; economically, these two things are equivalent. The same real goods get purchased, at the same people’s expense; the accounts balance in the same way. But it feels different.

And it would feel different to me too, if I were required to actually shop for that particular avionic component on that Apache helicopter my taxes paid for, or if I had to write a check for that particular section of Highway 405 that my taxes helped maintain. Yes, I know that I give the government a certain amount of money that they spent on salaries for US military personnel; but I’d find it pretty weird if they required me to actually hand over the money in cash to some specific Marine. (On the other hand, this sort of thing might actually give people a more visceral feel for the benefits of taxes, much as microfinance agencies like to show you the faces of particular people as you give them loans, whether or not those people are actually the ones getting your money.)

There’s another reason it feels different as well: We have framed the individual mandate as a penalty, as a loss. Human beings are loss averse; losing $10 feels about twice as bad as not getting $10. That makes the mandate more unpleasant, hence more unpopular.

What could we do instead? Well, obviously, we could implement a single-payer healthcare system like we already have in Medicare, like they have in Canada and the UK, or like they have in Scandinavia (#ScandinaviaIsBetter). And that’s really what we should do.

But since that doesn’t seem to be on the table right now, here’s my compromise proposal. Okay, yes, let’s repeal Obamacare. No more individual mandate. No fines for not having health insurance.

Here’s what we would do instead: You get a bonus refundable tax credit for having health insurance.

We top off the income tax rate to adjust so that revenue ends up the same.

Say goodbye to the “individual mandate” and welcome the “health care bonus rebate”.

Most of you reading this are economically savvy enough to realize that’s the same thing. If I tax you $100, then refund $100 if you have health insurance, that’s completely equivalent to charging you a fine of $100 if you don’t have health insurance.

But it doesn’t feel the same to most people. A fine feels like a punishment, like a loss. It hurts more than a mere foregone bonus, and it contains an element of disapproval and public shame.

Whereas, we forgo refundable tax credits all the time. You’ve probably forgone dozens of refundable tax credits you could have gotten, either because you didn’t know about them or because you realized they weren’t worth it to you.

Now instead of the government punishing you for such a petty crime as not having health insurance, the government is rewarding you for the responsible civic choice of having health insurance. We have replaced a mean, vindictive government with a friendly, supportive government.

Positive reinforcement is more reliable anyway. (Any child psychologist will tell you that while punishment is largely ineffective and corporal punishment is outright counterproductive, reward systems absolutely do work.) Uptake of health insurance should be at least as good as before, but the policy will be much more popular.

It’s a very simple change to make. It could be done in a single tax bill. Economically, it makes no difference at all. But psychologically—and politically—it could make all the difference in the world.