Lies, Damned Lies, and the Heathcare debate.

David Frum writes — or rather wrote — in the Times today (or rather a few days ago) an article which attempts the impressive feat of trying to convince a British audience of an American argument on healthcare reform.

As you can tell from the above, I have been on holiday. To Sweden (any one who thinks that I may have miraculously been persuaded of the “evils” of public healthcare will no doubt give up right here). Whilst there, I have had a peaceful, laid-back time, in which I have not even felt the urge to write a note. Well, I’ve felt the urge, but I’ve actually resisted it, which is at least something. Being away might turn out to have been a wise long-term choice. I may have missed the worst of Swine flu in Britain, but far, far more importantly, I may have missed the worst of the apoplectic style ranting about healthcare.

Indeed, the worst offenders I have come across have not been American, but rather British. Dan Hannon has been sticking his head out, and regrettably, since mouthing off against Gordon Brown, people seem to be more inclined to listen to what he says. Indeed, Hannon has evidently so taken to the American people that he wishes to save them singlehandedly from the misfortunes of a system where they would pay less in taxes for more public coverage, despite the fact that it isn’t even being offered anyway. No doubt he is proud of his life-saving interventions.

I have also discovered the existence of an even darker side to the Conservative party in the form of a blog that’s nutty as a fruitcake, but thankfully, at least, no-one seems to be listening to it, so I don’t think it’s high profile enough to be worth mentioning. The relevant people (or rather person) will know to whom it applies.

But in general, even from the enlightened holiday-place of Sweden, I have managed to notice an awful lot of rubbish being spouted about the healthcare debate. What has been pretty thin on the ground is a clever argument, what with all of the nonsense about death panels, healthcare rationing, monopolies, higher taxes, socialism, communism, pinko liberal communism, yadayadayada, etc.. Which is why I found David Frum’s article so refreshing as to be worth posting as a link, despite the fact that I still disagree with it, and I still think many of the arguments are just as misinformed. This is because it at least tries to engage meaningfully in debate about the issue, rather than rant incoherently about socialism and evil.

It’s a clever article. Frum clearly knows his audience, and tries to argue in such a way as to persuade it. For example, he uses none of the exaggerated language that most of the right in America does (and instead posts exaggerated examples of the arguments we use against the US system). Frum clearly tries to position himself on the open-minded side of the spectrum, ignoring the extremes from both sides and embracing the facts.

It’s an interesting article, but it fails. Because it doesn’t.

After a refreshing introduction, Frum starts to go wrong almost immediately.

Tens of millions of people lack insurance. Yet they do not go uncared for. Rather they use the most expensive care, emergency care, and hospitals add the cost on to the bills of paying patients.

In beginning the argument in defence of the way the American system treats the uninsured so simplistically, Frum is immediately condescending to their plight. Insurance is based around addressing long-term risks, but in making this argument Frum ignores the most obvious potential ailment, long-term illnesses.

Saying “they do not go uncared for” because the uninsured get emergency care is like saying “he did not go uncared for” once the proverbial good Samaritan fails to turn up because the victim gets a flashy funeral. The real scandal of US healthcare centres around conditions, not emergency care.

Not only are you screwed if you develop a long-term condition and cannot afford insurance, but you are often screwed full stop if you develop a long-term condition and do not have insurance, even if you had been able to afford it previously. The insurance system is wonderful at delivering the best coverage to the people who need it least. If you have a long-term condition, good luck in trying to find affordable coverage.

But apart from all this, it isn’t even factually in terms of detail. Many hospitals in the US will charge emergency care fees, even if they aren’t allowed to turf you out the door. So the costs are not always passed on to the paying patient, contrary to Mr. Frum’s claim.

On to paragraph number two…

Almost all the problems of the US health system trace back to a pair of unexpected ironies: profit-driven private insurance corporations find it much harder to say “no” than governments do, and American governments are more unsustainably generous than their European and Canadian counterparts.

I find it difficult to believe that profit-driven private insurance corporations find it much harder to say “no” when they are famed for putting such lucrative resources towards finding creative ways of denying costly coverage. I also find it difficult to believe in face of the numerous accounts of insurance companies denying treatment at the most needed times, due to smallprint clauses and other get-outs. I also find it difficult to believe in light of his second statement that “American governments are more unsustainably generous than their European and Canadian counterparts”.

But to throw Frum a bone here, I don’t agree with that statement anyway. When it comes to Medicare, he may have a point — I don’t know enough about it, really, to comment — but when it comes to Medicaid it is well known that the coverage is very, very basic.

I’ll add a caveat here — it is true that the American government spends more on healthcare than, for example, Britain or Canada — but this isn’t out of the spirit generosity but high costs. They don’t have a choice in this and it’s precisely because of the private insurance-based model. More on this point later.

I agree with Frum’s next paragraph, but unsurprisingly, it is a critical point of the US system in any case.


For all practical purposes, healthcare is just as much a right in the US as it is in Europe. Since 1986, federal law has required all hospitals that receive federal money (ie, just about all of them) to provide emergency care to any patient who presents himself or herself. Many states back this federal law with even stronger laws of their own.

This is largely the same stuff as two paragraphs previously. Emergency care =/= all healthcare — it’s not even close. Only the last statement is true, although I haven’t heard of a State introducing something truly radical, such as a single-payer system or a public service competing within the market. Massachusetts, which I have heard cited as one of the more progressive states in this area, has instead opted to make some form of insurance coverage compulsory.

Frum’s next paragraph is very interesting:

Government generosity drives private health costs higher and higher. Health insurance is regulated by state governments. Each government decides what local insurers must cover and how they may cover it. Fifteen of the 50 states require insurers to cover fertility treatments. Twenty-four states require coverage of eating disorders. Thirty-five states require coverage of reconstructive surgery after a mastectomy. New York state requires insurers to charge the same rate for all customers, regardless of health conditions, while 11 other states tightly restrict the ability to charge more for more sick patients.

I don’t really disagree with what he’s saying. Government “generosity” is driving private health costs high and higher because it’s all in the field of regulation, rather than provision.

This is a distinction I have been coming to more and more of late, which I believe is as fundamental as the distinction between the public and private sectors. When government regulates the private sector, it nearly always drives up costs in some way or other, because it’s an inherently clumsy control that the private sector rarely truly cooperates with because of its for-profit basis.

Whereas where government provides alternative services, it invariably removes the need for a certain amount of regulation. Where the US regulates healthcare is not, as the right mistakenly believes, due to government generosity, but due to the fact that they don’t have any choice. The government is pushed from two different powerful forces, the voice of the society, rising up against injustice, and the voice of powerful insurance lobbyists. The government mistakenly tries to reconcile these two, with the result that healthcare costs are driven higher and higher as the government tries, and fails, to placate both voices at the same time.

The result is that the insurance companies fight against the government anyway, and the public still aren’t covered well enough. Both have contempt for their political masters, who lack the guts to take any real action to improve anything. The government will have to prevent the worst injustices from happening in the system, otherwise the public will do them in, but they have to do it in the most expensive way possible, otherwise the insurance companies will do them in. It’s heads they win, tails you lose.

Again, in no other system is as much in tax spent in securing as little in healthcare. The US has the highest healthcare costs, for the least in treatment.

Frum goes on to point out how there is in fact less difference between parties in their record on healthcare than people realise, which is again fair enough, although it is worth noting what different governments attempt, and fail, as well as what they do. Again, the politics of government are different to the politics of political opposition. Governments are torn between the two forces, whether it is the Elephant or the Donkey.

Frum also tackles expensive medicare for the Elderly, which further complicates the equation. How to improve coverage without readjusting public priorities? Within the incredibly expensive private insurance system it seems an impossibility.

But again, only within such an expensive system need it be so. If the State actually provides an universal public alternative, rather than trying to play everything through the wealthy and powerful private entities, then it can secure far, far more public coverage per taxpayer dollar by slashing regulation on the private sector and allowing people to choose between public and private provision. But of course, this is what private providers fear the most: having to compete in a way that forces them to offer value for money to the consumer. Far better to have the government as their tool, as a way to increase and improve their domination of the healthcare market.

Then we have:

Objective studies find little difference in outcomes between America’s costly care and the much cheaper care in more statist systems.

Frum here makes the classic mistake, again disguised through placatory language: describing Universal Health Care systems as more “statist”.

Yet he provides no argument to actually back this assertion up. And what makes America’s regulation-heavy system less Statist than one that provides a public option to compete within the market? From a control perspective, certainly, Britain’s system is less Statist than America’s, as it revolves around State provision rather than State control/regulation. The “Statist” argument is a misconception that the US healthcare debate suffers from all too often.

All of these misconceptions that litter Frum’s article in defence of the American system undermine and deride his final points, that

What the US system offers to those who enjoy good coverage is much harder to measure: convenience, security, responsiveness to patients and personal attention from doctors who compete to attract customers.

Perhaps it is cynical, but I find it all too easy to think that the reason that this is “much harder to measure” is that it doesn’t really exist. A system which offers no security for those who need it most (those with constant long-term healthcare problems) is not a system which offers security in any meaningful way. A system which only offers convenience to those least in need of it is not a system which offers convenience in any good way. A system which offers responsiveness only to an elite with the most expensive coverage is no system worth defending.

And as for competitiveness, Frum fails to show how the US system makes providers in any way more competitive than a system which allows people the choice between a universal public service or private coverage, when common sense would dictate that the latter is far more competitive. He also ignores the facts: people have a choice between Doctors in the United Kingdom, and our personalised GP care is well-known, regardless of broader issues with the model. The UK health system is in fact one of only a few which allow access to a Doctor to be absolutely free at the point of delivery.

In essence, this is the problem with the debate on healthcare within the US. This is an example of one of the more nuanced arguments; yet it is wrong in nearly every detail that matters. In a debate where contributions are only more vitriolic and closed-minded, meaningful reform is only likely to be years, if not decades, away. Let us hope that this is not the case.


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