June 9, 2009

Obamacare needs to move us closer to Canada, literally

From the Washington Post:

Take the case of Miami vs. La Crosse, Wis. In 2006, using inflation-adjusted figures, Medicare spent $5,812 on the average beneficiary in La Crosse, compared with $16,351 in Miami. Yet an examination of health status in both places, adjusted for age, finds no evidence that the extra spending resulted in better care, Weinstein said.

"That's the enigma here," he said. "Less is more, and more isn't better."...

Many fear that the push to contain costs will result in rationing.

In today's system, "we don't ration care, we ration people," said Donald M. Berwick, president of the independent Massachusetts-based Institute for Healthcare Improvement. "We know that if you are black and poor or a woman, there are all sorts of effective interventions you are not going to get."

Though the transition would be painful and the politics treacherous, Berwick said it is possible to spend less on medical care and have a healthier nation.

"If we could just become La Crosse, think of how much better off we would be," he said.

This reminds me of Sen. Daniel Patrick Moynihan's last well-known essay, "Defining Deviancy Down" in 1993:

Leroy L. Schwartz, M.D., and Mark W. Stanton argue that the, real quest regarding a government-run health system such as that of Canada or Germany is whether it would work "in a country that has social problems that countries like Canada and Germany don't share to the same extent." ...

In a 1992 study entitled America's Smallest School: The Family, Paul Barton came up with the elegant and persuasive concept of the parent-pupil ratio as a measure of school quality. Barton, who was on the policy planning staff in the Department of Labor in 1965, noted the great increase in the proportion of children living in single-parent families since then. He further noted that the proportion "varies widely among the states" and is related to "variation in achievement" among them. The correlation between the percentage of eighth graders living in two-parent families and average mathematics proficiency is a solid .74. North Dakota, highest on the math test, is second highest on the family compositions scale - that is, it is second in the percentage of kids coming from two-parent homes. The District of Columbia, lowest on the family scale, is second lowest in the test score.

A few months before Barton's study appeared, I published an article showing that the correlation between eighth-grade math scores and distance of state capitals from the Canadian border was .522, a respectable showing. By contrast, the correlation with per pupil expenditure was a derisory .203. I offered the policy proposal that states wishing to improve their schools should move closer to Canada. This would be difficult, of course, but so would it be to change the parent-pupil ratio.

I suspect, by the way, that there may be a health-related selection effect involved with oldsters in Eau Claire and in Miami. Perhaps the hardier or more stoic elderly in Wisconsin tend to stick it out in the frozen north while the more fragile or demanding tend to move to Florida?

I also wonder if the number of lawyers correlates with the expensiveness and inefficiency of services in a region? For example, the seemingly sizable number of lawyers in Los Angeles, combined with the deep pockets of the Los Angeles Unified School District, means that public education in LA appears to be badly hamstrung by consent decrees and by school administrations' not unrealistic fears of more lawsuits. Thus, school discipline is lower on the priority list than not getting sued over disciplining some kid whose mom is likely to sue.

Does Miami have a lot of lawyers?

My published articles are archived at iSteve.com -- Steve Sailer

31 comments:

dr kill said...

Check these fun facts from quickfacts.census.gov. They say from 2007.

White persons not Hispanic - 93.4%
Hispanic or Latino origin - 1.0%
Foreign born persons - 2.5%
Language other than English spoken at home - 5.6%

Now change the above percents to the following-
17.9%, 62%, 50.9%, 67.9%

It's a miracle that our health status here in Dade County is the same as in Wisconsin.

Ronduck said...

For example, the seemingly sizable number of lawyers in Los Angeles, combined with the deep pockets of the Los Angeles Unified School District,

Los Angeles should be broken up into smaller parts, and so should its school district.

Anonymous said...

Steve, are you familiar with the RAND Health Insurance Experiment?

http://en.wikipedia.org/wiki/RAND_Health_Insurance_Experiment

http://www.overcomingbias.com/2007/05/rand_health_ins.html

Basic upshot:

1. People avail themselves of more medical care, necessary or not, when the price of said medical care is "free" to the patient. (Shocking, I know.)

2. A greater use of more medical care by a patient is not a strong predictor of better health for the average patient.

3. The group that does benefit from free medical care is those people who are BOTH poor AND sick--that is, the sick members of that cohort, constituting probably 15% of the population, that is without health insurance and relies upon Medicaid and emergency room visits for its medical care.

In short, the average patient/consumer of health care services is made no healthier under a single payer health care system whose incentives induce its users to consume, at a greater cost to the individual user "account" as well as to the system as a whole, any number of medical procedures and tests that have a negligible benefit to overall health.

beowulf said...

Atal Gawande's piece on this topic in this week's New Yorker is amazing (not surprisingly, Obama is already quoting it).
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

Go read it, its a damn good read. You'll feel sorry for some of the suckers who agreed to talk with Dr. Gawande. I should note, the number of NAM in a city is quite irrelevant. Gawande looks at two cities along the Rio Grande, one is the highest cost city in the country, the other city-- with a similar poor, obese Mexican population-- is below average in cost.

Its a very good followup to Gawande's 2007 piece "The Checklist"-- which is about how medicine is more efficient and less error-prone when doctors follow airline cockpit-style checklists during surgical procedures. In the new article, Gawande's makes an implicit case for systems engineering. The most effective medical systems (in terms of both cost and, surprisingly, patient outcomes)-- the VA, Kaiser Permanente or the Mayo Clinic -- are very well engineered. One common denominator is that the doctors aren't also in the role of small businessmen. They're on salary and they let the accountants worry about the money.
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

Politically, however, I think this article will hurt Obama's push for health care reform for one simple reason. The insurance lobby now has a hook to lobby Democratic senators and congressmen from high-cost areas that Obama will pay for universal care by "rationing" care in high cost areas. Even though their constituents have almost certainly been overtreated by their docs, no one in politics wants to take the side of rationing.

Anonymous said...

I think Obama's plan will work just fine for me. I detest going to the doc, work extra hard to stay healthy, have a BMI of 19.5 and people in my family history don't have cancer or heart disease and live really long. It's gonna be rough for the rest of you.

Veracitor said...

A study of "...health status in both places, adjusted for age..."

How about health status adjusted for IQ?

Betcha that would knock your socks off.

Gottfredson has shown that smarter people are healthier.

I'm sure smarter oldsters are (a) more likely seek treatment for progressive illnesses before they become very acute (leading in many cases to better outcomes), (b) more likely to comprehend and comply with medical advice to restore or maintain their health, (c) less likely to injure themselves by accident or misjudgement.

We know that the proportion of stupid people is lower in the Northern tier states.

eh said...

CALIFORNIA - Per capita income in state is expected to sink over 20 years - Growth in poorly educated population is blamed in study

Californians' per capita income will drop 11 percent over the first two decades of this century unless the state closes the educational gap of its expanding Latino population, a nonpartisan research center forecast in a report released today...Latinos are the fastest-growing segment of the state's population and work force, and among the least-educated, said the National Center for Public Policy and Higher Education... According to 2000 census figures, in the 25-to-64 age group, 52 percent of Latinos lacked a high school diploma, compared with 8 percent of non-Latino whites, and 12 percent of Latinos had a college degree, compared with 46 percent of whites...If those rates persist as the population continues to change, the report said, the state's average educational level will decline through 2020 and drag down per capita income...

Are (elevated) healthcare costs really so malleable? With the rest of the country becoming more like California all the time, is some kind of reform that goes in the direction of government (taxpayer) funded, single payer really feasible? Somewhat related: why would an increasingly Latino and increasingly poor working population want to submit to taxation high enough to pay the costs of a disproportionately white and better off non-working (retired) population?

Speaking of lawyers, the two most prestigious professions that a common person might aspire to -- doctor and lawyer -- are not what I would call wealth producing occupations. They seem more wealth consuming to me.

Anonymous said...

"Somewhat related: why would an increasingly Latino and increasingly poor working population want to submit to taxation high enough to pay the costs of a disproportionately white and better off non-working (retired) population? "

Kind of like South Africa with an aging white majority.

Whee! what fun! I can hardly wait!

Anonymous said...

Diabetes eats up 70% of healthcare costs, blacks & Hispanics have 200-400% higher diabetes rates than caucasians-depending on the study.

You can't compare white population healthcare costs to non-white healhtcare costs, the non-whites have more than a 100% higher diabetes disease rate-easily enough to bankrupt any nation.

Big Bill said...

I suspect the LaCrosse/Miami difference has more to do with a culture of entitlement and Medicare fraud in Latino Miami.

The German, English, Norwegian and French settlers in LaCrosse are much higher quality stock on which to build a civilization.

They really are totally different peoples and cultures.

Squeeze said...

Eau Claire and La Crosse are different frozen Wisconsin cities.

ben tillman said...

Take the case of Miami vs. La Crosse, Wis. In 2006, using inflation-adjusted figures, Medicare spent $5,812 on the average beneficiary in La Crosse, compared with $16,351 in Miami. Yet an examination of health status in both places, adjusted for age, finds no evidence that the extra spending resulted in better care, Weinstein said.
Many fear that the push to contain costs will result in rationing.

... "We know that if you are black and poor or a woman, there are all sorts of effective interventions you are not going to get."


Doublethink at its finest.

Melykin said...

Anonymous wrote:
"In short, the average patient/consumer of health care services is made no healthier under a single payer health care system whose incentives induce its users to consume, at a greater cost to the individual user "account" as well as to the system as a whole, any number of medical procedures and tests that have a negligible benefit to overall health."


Not so. In Canada we can make as many appointments as we want with a family physician, but it is up to the physician what tests we get. We can't just demand test for which there is no apparent need. And we must get referred to a specialist by our family physician--who will generally not refer for no reason. I don't think people generally make doctor's appointments for no reason. Most people are too busy. People don't generally go to emergency rooms for no reason. Only mentally ill people would do that.

ben tillman said...

Diabetes eats up 70% of healthcare costs, blacks & Hispanics have 200-400% higher diabetes rates than caucasians-depending on the study.

You can't compare white population healthcare costs to non-white healhtcare costs, the non-whites have more than a 100% higher diabetes disease rate-easily enough to bankrupt any nation.


Read Taubes and Ccchran & Harpending.

Reactionary said...

I don't think people generally make doctor's appointments for no reason. Most people are too busy.

Retirees aren't.

People don't generally go to emergency rooms for no reason. Only mentally ill people would do that.

Or ignorant people. Or people looking to file a lawsuit.

Anonymous said...

Fraud in Miami explains the difference. A friend from law school headed the Medicaid fraud unit in Miami for a couple years. He told me that the Feds estimate that annual Medicaid fraud in FL runs into hundreds of millions. No-one within the bureacracy wants to admit to the scope of the problem, and the system is structured to pay first and ask questions later, which is how the providers (and the politicians they support) like it. Some day, an enterprising journalist is going to blow the lid off of it, and people will realize just how much taxpayer money is being actively funneled to outright criminals.

Anonymous said...

Diabetes eats up 70% of healthcare costs

lol

Melykin said...

Reactionary wrote:
"...Or people looking to file a lawsuit."
----------------------
Lawsuits aren't as common in Canada. That seems to be more of an American thing.

Melykin said...

Anonymous wrote:
"...the Feds estimate that annual Medicaid fraud in FL runs into hundreds of millions...."

How does Medicaid fraud work? Are the doctors and hospitals doing criminal things?

Anonymous said...

How does Medicaid fraud work? It's petty simple, really. You set up shop in some Miami storefront and start seeing "patients" who are Medicaid eligible. Then you bill the shit out of Medicaid for phantom services. Oftentimes, the provider is in cahoots with the "patient"--I've heard that some docs will run vans around Miami, picking up homeless drug addicts who are willing to be "patients" in exchange for $20 a week. After you collect several million in Medicaid reimbursements for services neither needed nor performed, the authorities will probably notice you and, if resources permit, they might start an investigation. If things get too hot, you close up shop...for a while. My buddy told me that the way the system is set up--i.e., job no. 1 is to get the doctors paid--the fraudsters are always way ahead of the investigators.

On a related tangent, when I was in college, I worked part time for a national department store chain processing credit card chargebacks (I.e., charges refused by the card companies). These usually resulted from either operator error (failure to properly swipe the card at the register) or fraud (e.g., stolen card, customer signed someone else's name and claimed it was a stolen card, or the cashier was in cahoots with the customer by neglecting to either swipe the card or get a valid signature). Fraud, particularly of the inside-job variety, was by far the most common in the Miami, Newark, Detroit, Las Vegas and Los Angeles stores. Hardly ever saw that kind of thing from the upper Midwest...

Reactionary said...

Lawsuits aren't as common in Canada. That seems to be more of an American thing.

Point being, socialized medicine combined with a common law tort system would provide even more incentive for abuse of resources.

And I'll bet tight, white Canada finds out just how people respond to the system's incentives when it's tribe vs. tribe, and not one big, happy, social democratic family loyally paying their taxes.

OneSTDV said...

"We know that if you are black and poor or a woman, there are all sorts of effective interventions you are not going to get."

Implicit is this statement is the identification of an external cause. Did it ever occur to him that maybe some social pathologies within the poor/black community (like higher drug use) is causing more health problems? That it's not the lack of intervention from Big Brother causing health problems, but rather individuals' unwillingness to care for their own bodies.

Dutch Boy said...

Anonymous is correct. Much of the disparity is due to fraud (which correlates with the culture of Miami's inhabitants).

DCS said...

I wonder if Don Berwick has ever visited La Crosse?

Melykin said...

Anonymous wrote:
"How does Medicaid fraud work? It's petty simple, really. You set up shop in some Miami storefront and start seeing "patients" who are Medicaid eligible. Then you bill the shit out of Medicaid for phantom services. Oftentimes, the provider is in cahoots with the "patient"--I've heard that some docs will run vans around Miami, picking up homeless drug addicts who are willing to be "patients" in exchange for $20 a week. After you collect several million in Medicaid reimbursements for services neither needed nor performed, the authorities will probably notice you and, if resources permit, they might start an investigation. If things get too hot, you close up shop...for a while. "

But wouldn't the doctor be stricken from the physicians registry for fraud? And why would the doctor have to make up fake patients? Are there not a lot of people who really do need a doctor? Have you got a surplus of doctors? We have a shortage in Canada.

I've never heard of fraud of this sort in Canada. If you go to this site:
https://www.cpsbc.ca/node/206
there is a list of physicians in B.C. who have been disciplined. Most of them are on the list for having inappropriate relationships with patients, although a few (mainly foreign names) are being disciplined for incompetence, and I found a few being disciplined for signing Internet prescriptions. For example:
https://www.cpsbc.ca/files/pdf/2005-02-01-herar.pdf

As I have said before, I worry more about the lack of morals than the lack of brains in many immigrants. They seem to think its ok to do dishonest things.

Anonymous said...

I worry more about the lack of morals than the lack of brains in many immigrants. They seem to think its ok to do dishonest things.

More fundamentally, they don't see those dishonest things as dishonest.

For instance Nigerians and credit card card fraud. Its so common that I dont believe they actually see it as wrong. I presume they have some sort of self-justifying rationale for it in which the very word dishonest just doesnt crop up at all.

Not helped either in that anywhere in the west SWPL types will be ready to defend such behaviour with the usual half-baked political justifications.

Reactionary said...

As I have said before, I worry more about the lack of morals than the lack of brains in many immigrants. They seem to think its ok to do dishonest things.

The "rule of law," or lex rex is a largely Anglo-Saxon ideal. And you will note that it is the common law jurisdictions to which immigrants will spend blood and treasure getting to. Of course, their tradition is civil law, rex lex. Our elites have made enthusiastic use of this Continental/Banana Republic attitude. I hope you're not just now finding this out.

The decline of Anglo-America goes hand in glove with the US tearing up its common law traditions and feeding them into the shredder. George Bush, lending eager ear to his (I'll use the polite term) "neo-conservative" advisers did as much or more to hasten that process along as anybody. You may have noticed he was also a big fan of Prince Abdullah and Vicente Fox.

Anonymous said...

"(which correlates with the culture of Miami's inhabitants)."

6/10/2009

You mean retired New Yorkers?

silly girl said...

"As I have said before, I worry more about the lack of morals than the lack of brains in many immigrants. They seem to think its ok to do dishonest things."

Yeah, this is a product of not believing they can succeed honestly, and not being trained to value fairness. A group of boys playing dodge ball won't tolerate a cheater. So my son would express frustration when playing cards or a game with girls because they either cheat or quit because they can't win vs. his male friends who would try to figure a way to beat him next time, but without cheating. Their competitive drive and confidence would make them concentrate and try harder to win. His male friends who lost would say, "one more, I know I can beat you next time" while the girls would say, "I don't like that game, it's dumb."

Years and years ago I read that women lobbying for a fair chance was a bad idea, because what they really need are special privileges in order to compete.

silly girl said...

Sorry, didn't finish my thought.

Maybe immigrants have that same underlying attitude that they can't make it honestly so they are entitled to cheat. They may feel justified because they are immigrants and at a theoretical disadvantage, even if there is no real disadvantage to them in the system.

Melykin said...

I think cheating and dishonesty is widespread in most of the countries the immigrants come from.

I teach at a small university, and I can tell you that many (but not all) students from Asia and the middle east seem to think cheating is normal. We have to watch them like hawks and take every possible precaution to prevent them from cheating. If we don't do this, they assume that we don't care if they cheat. It seems almost impossible to make some of them understand that this is not acceptable behaviour.

I think this sort of corruption is what largley distinguishes countries people want to live in from countries that people want to leave.

http://www.transparency.org/


The trouble is, when people move from the more corrupt countries to the less corrupt countries many of them bring their corruption with them.