He’s not setting the absolute value of the year or the definition of the word “productive>” He’s proposing the value and a definition in the eyes of the government.
Neither he nor the government is God.
I’ve seen this coming down the pike since I heard about some doctors’ reactions to results of AFP tests.
Singer’s article is disturbing on many levels. His attempted detachment is chilling. Whether he consciously knows this or not, he’s assuming that the bureaucrats who would be making these decisions are as ‘reasonable’ as he is. Anybody who has dealt with government on any level would never make this assumption. Singer and others who advocate government taking my money to pay for my neighbor’s healthcare never address the underlying argument of why exactly it is my responsibility to pay for my neighbor’s health. Singer does not take any account of an individual’s lifestyle choices (does one smoke? Exercise or not? Drink excessively? Etc, etc, etc. Finally, Singer’s comparison to Australia is completely invalid. Australia has a ethnically homogeneous population of 40 million give or take. We have 300 million+, the most ethnically diverse population in history. But this entire argument is not about healthcare for all anymore than HilaryCare was.
As much as I sometimes enjoy Peter’s articles, I’m not sure that his claim that it is hard to get additional privately-offered medical insurance if there is also a basic one provided by the Government – because “bureaucratic territoriality has made it extremely difficult to get private care” is actually true. In the country where I come from (Croatia) it is certainly not the case. Private health insurance (often offered as a package by the companies dealing in other forms of insurance as well) is readily available to anyone who has the means and the desire to buy it.
On the other hand, if the main objection is that such system would mean that “most health-care decisions are made using the government’s standardized, impersonal life-year valuation”, one could argue that the alternative (I’m guessing through employer-provided contracts with private insurers) is not necessarily better: health-care decisions that are ultimately based not only on one’s productivity and accomplishments, but also to an extent on the initial luck of getting born into a wealthy/middle class and having one’s talents honed as opposed to neglected.
Yeah, as someone who has flirted with the idea of a bare-minimum, means-tested healthcare subsidy, I don’t see what’s so wrong with the government deciding to execute its healthcare responsibilities efficiently. We can debate about two things 1) whether government should provide – through taxpayer dollars – any form of healthcare whatsoever and 2) whether Singer’s standard for evaluating a life’s worth is the right one. But if we accept the first – and I think most of us, deep down, do believe in some version of #1 – then there’s nothing unreasonable with the line “government should decide how much your life’s worth.” HOW it decides that value can be vigorously debated, and that’s why the focus should be on #2.
Putting it in simpler terms: For those who can afford to pick and choose their healthcare, by all means express how much you value your life through the package you purchase. But if I am too poor to buy my own healthcare (and thus fully express how much I value my own life), and I am relying on a government subsidized alternative, then wouldn’t the responsible public policy choice be to have government evaluate its spending decisions through some kind of cost-benefit analysis? I guess Singer’s analysis somewhat apocalyptic in the context of a single-payer system with no private alternatives, but that’s not what Singer or even Obama is proposing (though the current government plan is pretty weak sauce).
We can debate about two things 1) whether government should provide – through taxpayer dollars – any form of healthcare whatsoever and 2) whether Singer’s standard for evaluating a life’s worth is the right one. But if we accept the first – and I think most of us, deep down, do believe in some version of #1 – then there’s nothing unreasonable with the line “government should decide how much your life’s worth.”
As it happens, many people reject* your point one in part because it inevitably leads to such unsavory discussions as to whether and how the government puts a price on your life. I find your formulation an interesting inversion.
*To clarify, few would actually reject that the government should provide “any form of healthcare whatsoever”, but the scope of the program matters. A bare safety net for the most desperate will generate some of these actuarial concerns, I suppose, but a universal coverage program will make those concerns more immediate and invasive for more people. That’s because more people will be under the program, obviously, and also because such a program would be under greater pressure to control costs.
Blar: “As it happens, many people reject* your point one in part because it inevitably leads to such unsavory discussions as to whether and how the government puts a price on your life. I find your formulation an interesting inversion.”
I don’t think it’s an inversion at all. Note that Peter was complaining about the government evaluating your life worth, NOT the type of health care associated with it. I never said I supported a universal health care approach (and in fact, like I mentioned earlier, I’m more inclined towards the “bare-minimum” means tested variety, with a true free market left for everyone else).
But let’s assume we are going along with a universal health care approach. Given that there’s no market, wouldn’t Singer’s approach be one of the few, if only, reasonable method of allocating treatment? In that case, the real culprit wouldn’t be QALY but universal health care itself. QALY would in fact make it more palatable.
let individuals buy supplemental insurance to cover any additional care they want. Never mind that in Britain and Canada, both of which use rationing boards, bureaucratic territoriality has made it extremely difficult to get private care,
Yes, point at Britain and Canada to vaguely imply that private care will go away without any actual evidence. There are countries with private and public care to contrast with Canada’s almost public only; Medicare has not stopped Medicare Supplement plans here in the US. This is a fight against something no-one is actually trying to do.
As it happens, many people reject* *To clarify, few would actually reject
So people reject point 1, but they don’t actually.
“any form of healthcare whatsoever”, but the scope of the program matters. A bare safety net for the most desperate will generate some of these actuarial concerns, I suppose, but a universal coverage program will make those concerns more immediate and invasive for more people.
Ah. So it’s o.k. for the government to put a value on other people’s lives (e.g. poor people), but not yours.
Singer’s other point, which you elide, is that the government is putting a value on all our lives anyway – the EPA, the DOT, etc. So while I’m not a fan of (say) single-payer, QALY and so on aren’t the reason and I don’t really see why they would be.
So while I’m not a fan of (say) single-payer, QALY and so on aren’t the reason and I don’t really see why they would be.
I phrased this really badly.
To clarify:
I’m not a fan of strict single payer (e.g. only government healthcare, either de jure or de facto) for various reasons (the inevitable attempted government management of our lives to drive costs down, and some kind of limit to services is inevitable, whether via QALY or otherwise); but these problems are part of single payer, not part of QALY (or “rationing” in the sense Singer uses it). Which can be applied with a free hand for supplement or competing plans.
Singer’s enthusiasm for focusing on rationing health care as a necessary good fits right in with him being a sick fuck bent on killing the sick and disabled.
Why do other countries spend so much less on health care than the U.S.? Here’s a hint. It ain’t because they drastically ration that care. It’s because their universal systems do a better job controlling costs and promoting health than America’s. But Singer would rather blather on and on about rationing because that concept resonates more with a suck fuck bent on killing the sick and disabled.
But let’s assume we are going along with a universal health care approach. Given that there’s no market, wouldn’t Singer’s approach be one of the few, if only, reasonable method of allocating treatment? In that case, the real culprit wouldn’t be QALY but universal health care itself. QALY would in fact make it more palatable.
I agree with this entirely. The reason I called it an inversion is that QALY is the reason some give for disqualifying universal coverage, while your formulation gives people who support universal coverage reason to support QALY (though I understand you yourself do not support universal coverage).
Ah. So it’s o.k. for the government to put a value on other people’s lives (e.g. poor people), but not yours.
If government health management means that inevitably the government must sometimes put a price on lives, I would rather it involve as few lives as possible, in part because a more limited program will make icky life-pricing more rare. It has nothing to do with the kind of people involved.
Yes, point at Britain and Canada to vaguely imply that private care will go away without any actual evidence.
This report written by the Lewin Group and commissioned by Heritage offers a bit of evidence on that score. From section C…
Under current law, there will be about 158.1 million people who are covered under an employer
plan as workers, dependents or early retirees in 2011. It the act were fully implemented in that
year, about 88.1 million workers would shift from private employer insurance to the public
plan. However, about 89.5 million people would become covered under the public plan with an
employer paying a share of the premium. This is a net increase in the number of people with
coverage where the employer is paying a portion of the premium, reflecting the effect of the
employer mandate under the Act.
In other words, according to the analysis, employers will drop about 88 million private employee plans in favor of the public option.
In other words, according to the analysis, employers will drop about 88 million private employee plans in favor of the public option.
Except that’s not what Peter is talking about in the excerpt, or what I was talking about. Private health care will still be available (and still have tens or hundreds of millions in it). People will still be able to purchase supplemental insurance if they want to, so government won’t be exclusively setting the value of a life; and it won’t be “extremely difficult” to get private insurance.
Still, now that you’ve reminded me of that, the interaction between public health care and our current employment-based system is somewhat problematic.
The point of the analysis is that private insurance will be unable to compete with the public option, which for the purposes of this discussion means that a public option will put the government in a dominant position when it comes to setting the value of life. At any rate, it looked like you were making a more general point, that there was no evidence that public plans make acquiring private plans more difficult, and I thought the Lewin report provided basis for such a belief.
I agree that employer-backed plans are part of the problem with healthcare.
It seems to me that the point should be precisely that the Government will be in a position to “set the value to life”, but only in the sense that it will determine the maximal amount of money the society is willing to spend on the health of any of its members. This should in no way impede the provision of the supplementary health insurance i.e. the amount of extra money that the individuals are willing to spend on their own health (or the health of the loved ones).
But I really fail to see why the government using a QALY-like measure is somehow immoral in some way that some other person is not immoral. (Cards on the table: I oppose on human-dignity grounds any attempt to rationalize human life and limb in commodity terms. Or as Peter puts it, “economic decisions about the value of life.”)
For example, when Peter says … “I agree that, in the end, we do have to make economic decisions about the value of life. But shouldn’t those be decisions made by individuals, their families, and their doctors? Do we really want bureaucrats in Washington handing down indiscriminate dictates on what a year of productive, healthy life is worth? Must everyone be blindly herded into the same pen?” … He really is whistling past the graveyard. And if one has no objection to “rationalistic” Quality-of-Life measures, he has no basis for objecting to the government doing it. One either objects to QoL measures per se, or not at all.
For one thing, an individual cannot be expected to put an economically rational value on his own life (and those of his immediate family) because, to cite the cliche, “there are some things money can’t buy.” A person’s own life is, subjectively, of infinite value TO HIM because it’s the grounding of everything else; and not of infinite value to any other person. If you’re really want to contain costs, they one you CAN’T do is have individuals make decisions for themselves.
For another, and from the other end, as long as medical care involves any insurance model whatsoever and is anything other than pay-as-you-go-and-can, like the market for potato chips is, the somebody other than the individuals concerned will make decisions — whether it’s the actuarial tables being run by an HMO bureaucrat (who for some reason I can’t fathom other than location prejudice is supposed to be better than a “bureaucrat in Washington”) or a doctor refusing to perform a service for which he cannot paid … someone will say “no” to someone else on the basis of some economic grounds.
Cost-benefit review of regulations of the type favored by many Republicans (and many Democrats, including myself to some extent) presumes that some non-infinite value can be placed on human life.
@Travis—I should have used the term ‘culture’ rather than ‘ethnicity’. But they both are terms useful in describing what I was trying to say. I’ve lived in three countries with nationalized healthcare (Taiwan, China and England). I won’t bore you with the details of the experiences I’ve had with healthcare in those places.
Whenever Singer or any other advocate of state-run healthcare for America uses another country as a comparison (England, Canada, etc.) it is a false comparison on many levels, but mainly because different cultures eat different diets and have different lifestyles and most importantly, have very different views on what they expect their fellow citizens to pay for and what ‘rights’ are. Taiwanese and mainland Chinese on the coasts eat diets rich in seafood and green vegetables as well as heavy doses of garlic. The instances of obesity and heart disease is low. But pollution is a huge problem as well as the tendency to fry almost everything. The English eat a diet high in starchy, processed food, drink excessively and exercise is not really something that is a huge part of their culture. Obesity, heart disease and cancer are all high (I think 3rd highest in the world behind us and Mexico). I was in Greece for 3 weeks in May and there seems to be a high rate of obesity but comparatively low rates of heart disease. The Greek (Mediterranean) diet is very high in vegetables, legumes, garlic and especially olive oil. Chinese, Taiwanese, Greeks and English (from what I’ve seen and heard) think it is their ‘right’ to have their health care paid for by their neighbor. And they pay for it in taxes (especially the English and Greeks) and get very bad service for their trouble.
Sorry to be long-winded but hopefully to answer your question, culture (ethnicity is a part) plays a huge, significant factor in talking about any health system. Singer, and advocates like him, make no mention of this.
There are many more points to be made but I’ll stop here. Hopefully I’ve cured your insomnia.
By essentially every measure, our country has the least efficient health care system of any Western nation. We spend more money, cover fewer people and have worse outcomes.
Yes, in England some people have longer wait times. In America, some people can’t get in line at all because they can’t afford it.
Tradeoffs are inherent in every system. Giving up longer wait times in order to get more people covered seems like a small price to pay.
By essentially every measure, our country has the least efficient health care system of any Western nation. We spend more money, cover fewer people and have worse outcomes.
Evidence for this statement?
What planet do you live on? We are so screwed if people actually believe the drivel that people like you and M. Bunge have written.
an HMO bureaucrat (who for some reason I can’t fathom other than location prejudice is supposed to be better than a “bureaucrat in Washington”)
and just now
that is not reason to institutionalize or rationalize such practices, whether by government or any other corporate entity.
I believe you misstate the choice. It’s not one HMO bureaucrat versus another in Washington; it’s a system of several HMO’s and other providers in competition versus a system of one federal agency making all the decisions.
You can wax Pollyanahish all you like, and it won’t change the fact that healthcare is a scarce good, or a “commodity” as you put it, and as such some people who need it aren’t going to get it. I would rather that determination be made in the marketplace, in as decentralized a fashion as possible, rather than give a sole political entity the power of life and death.
But HMO bureaucrats make decisions binding on others, and that once made are final. The market for health care is not like the market for potato chips — comparison shopping and brand-switching are rather hard; need has a somewhat different meaning; and demand elasticity is … um … limited.
Oh … and I’m quite well aware that health care is a scarce resource and that people will not get everything they might want or need.
What I oppose is quite specific — any effort to “rationalize” (in the sense of “make rational,” not “to ration out”) health care through actuarial tables that attempt to set or specify for any social purpose the value of a human life as any given round number (whether that number be $100 or $1 billion is neither here nor there). If one finds that action immoral, dithering over the entity doing it is worse than trivial.
But HMO bureaucrats make decisions binding on others, and that once made are final. The market for health care is not like the market for potato chips — comparison shopping and brand-switching are rather hard; need has a somewhat different meaning; and demand elasticity is … um … limited.
Much the same could be said for rent. Actually, that would make a rather interesting comparison to study, but as I recall efforts to manage the cost of rent politically has seen some disasters.
Oh … and I’m quite well aware that health care is a scarce resource and that people will not get everything they might want or need.
What I oppose is quite specific — any effort to “rationalize” (in the sense of “make rational,” not “to ration out”) health care through actuarial tables that attempt to set or specify for any social purpose the value of a human life as any given round number.
What alternative do you have in mind, then, for dealing with scarcity?
“Much the same could be said for rent.” Actually, no it can’t. People can and do move around with little market friction, can and do comparison shop, and can meaningfully make do with less.
“What alternative do you have in mind, then, for dealing with scarcity?” On the one hand that has absolutely has no relevance whatever to whether a particular act is immoral in itself (and thus should not be done, period). But the very fact you respond in such a positivistic, programmatic way is exactly why Q-o-L measures are immoral — they impose that mindset.
Blar, you’re right. There are some resource-deprived societies that are unable to provide treatment for people even with the most easily preventable or curable ailments. The point is that we don’t want to be one of those places where the rich spend millions on cosmetic surgeries while the poor fight for clean water. Even if that’s what the market wants to do with our resources.
You may accept brutality as part of reality. But can’t we agree that some societies are less brutal than others? Maybe the market would work things out in the end, but I’m not willing to pay the immediate price for that uncertain efficiency. In the mean time, I have no argumentative recourse for convincing you that we should show solidarity with people who can’t afford healthcare, today.
<p><cite>I believe you misstate the choice. It’s not one HMO bureaucrat versus another in Washington; it’s a system of several HMO’s and other providers in competition versus a system of one federal agency making all the decisions.</cite></p>
<p><cite>You can wax Pollyanahish all you like, and it won’t change the fact that healthcare is a scarce good, or a “commodity” as you put it, and as such some people who need it aren’t going to get it. I would rather that determination be made in the marketplace, in as decentralized a fashion as possible, <strong>rather than give a sole political entity the power of life and death.</strong></cite></p>
<p>I believe YOU misstate the choice. It is quite easy to conceive of a system that would provide everybody with some level of medical insurance, while simultaneously allowing everyone to buy supplementary medical insurance</p>
<p>Such systems exist already in many countries, and the employers often offer supplementary insurance as just another perk that comes with the contract (like bonuses, company car, etc).</p>
Sorry for the unsuccessful formatting. Clearly the note “all HTML will be removed from your post, but with the Textile markup syntax you can do whatever you need. Links, images, formatting, it’s all there.” is not really true.
@Victor: Rent is relatively inelastic (gotta live somewhere), it is difficult to switch brands (leases, moving expenses, and the time it takes to move make moving prohibitive for many), and while you can shop around, there are a host of informational asymmetries that make it more difficult to know you are getting the best deal until you are locked into a lease (“what do you mean, you can’t do anything about the plumbing?”). It’s not a perfect comparison, but I believe that covers everything you said about healthcare. And yet few are clamoring these days against the unfair power of landlords, which was my point in making the comparison.
Also, I see you dodged my question about what to do about healthcare and scarcity.
@wfrost:
Maybe the market would work things out in the end, but I’m not willing to pay the immediate price for that uncertain efficiency. In the mean time, I have no argumentative recourse for convincing you that we should show solidarity with people who can’t afford healthcare, today.
I never said I had no solidarity with people who can’t afford healthcare, or that I didn’t want some kind of reform. But remember that my principle beef is with those who are arguing that Singer’s political QALY is indistinct from the QALY measurements we see in the marketplace. Since I think (like Peter, I believe) that some sort of QALY protocol is necessary to deal with the scarcity of healthcare, I would rather see such decisions made through diverse actors in the market than in the hands of a monolithic healthcare juggernaut.
Also, showing solidarity with the uninsured does not logically imply supporting government-run healthcare.
@Marko
It is quite easy to conceive of a system that would provide everybody with some level of medical insurance, while simultaneously allowing everyone to buy supplementary medical insurance.
I agree, but that wasn’t part of the framework that I was addressing. It was “one HMO bureaucrat making QALY decisions” vs. “one Washington bureaucrat making QALY decisions.” Of course there are other options between our current system and a political monopoly on healthcare, but I didn’t believe that our current system was accurately represented in that framework.
In other words, I wasn’t trying to present the only healthcare choices available to us; I was making a narrower point in addressing whether our current system at all resembles what Singer is advocating about the need to centralize QALY decisions.
(Though come to think of it, if the government is providing everyone with a baseline of insurance, that already centralizes QALY decisions quite a bit, even if purchasing supplemental insurance from private providers is possible.)
-You have persistent sciatica. You’ve gotten your MRI and it shows a disc pinching the nerves in your lower back. You doctor has recommended disc surgery. Is it “worth it”? Well according to this evidence-based review (http://www.cochrane.org/reviews/en/ab001350.html) you’ll probably get faster resolution of your pain (by maybe 12 – 18 months). But by 18 months you’ll likely be at the same place if you didn’t have the surgery. How much is avoiding 12 months of severe low back pain worth to you? Your employer? Your government? (A few additional bits of info: The average cost of the surgery itself was $12,754 ; over a quarter million such surgeries are done every year in the US. You can do the rest of the math)
-You have Stage IV non-small cell lung cancer (that’s bad). Your doctor has suggested Tarceva. Overall it will give you at least two maybe 6 or if you’re fortunate 12 more months of life (side effects may occur). How much is that worth to you? Your employer? Your government? (PS monthly cost of tarceva is about $2500) (PPS, the very agency we’ve excoriated has recommended it use. Who’d thunk it! See here http://www.nice.org.uk/nicemedia/pdf/Lungcancer_erlotinib_ERGreport.pdf or quick link here http://www.nice.org.uk/nicemedia/pdf/TA162QRGFINAL.PDF)
“Though come to think of it, if the government is providing everyone with a baseline of insurance, that already centralizes QALY decisions quite a bit, even if purchasing supplemental insurance from private providers is possible.”
Well, does it really? In the end, if everyone is allowed to purchase extra insurance then for all those people QALY decisions would not be centralized. They would be centralized only for those without any other insurance. And if those have no insurance now, that would still be an improvement.
Also, another thing. I might be naive, but I’d rather have such decisions in the hands of a government bureaucrat (even if he/she is acting under general intent to curb costs), than made by the companies who are operating under zero-sum conditions, in which any such expenditures take away directly from their profits. It is easy to imagine who would be less charitable.
Ah, Reason. One-time reasonable bastion of free markets and free ideas, and now a pro-pot offshoot of Republicanism.
Comment #2: “Singer is a sick fuck bent on killing sick and disabled”
Good luck.
— sidereal · Jul 21, 09:49 PM · #
He’s not setting the absolute value of the year or the definition of the word “productive>” He’s proposing the value and a definition in the eyes of the government.
Neither he nor the government is God.
I’ve seen this coming down the pike since I heard about some doctors’ reactions to results of AFP tests.
— Julana · Jul 21, 10:09 PM · #
Singer’s article is disturbing on many levels. His attempted detachment is chilling. Whether he consciously knows this or not, he’s assuming that the bureaucrats who would be making these decisions are as ‘reasonable’ as he is. Anybody who has dealt with government on any level would never make this assumption. Singer and others who advocate government taking my money to pay for my neighbor’s healthcare never address the underlying argument of why exactly it is my responsibility to pay for my neighbor’s health. Singer does not take any account of an individual’s lifestyle choices (does one smoke? Exercise or not? Drink excessively? Etc, etc, etc. Finally, Singer’s comparison to Australia is completely invalid. Australia has a ethnically homogeneous population of 40 million give or take. We have 300 million+, the most ethnically diverse population in history. But this entire argument is not about healthcare for all anymore than HilaryCare was.
— Nick · Jul 22, 12:50 AM · #
Last I checked, I don’t belong to the government.
— Will Hinton · Jul 22, 01:11 AM · #
Thank you very much. I am wonderring if I can share your article in the bookmarks of society,Then more friends can talk about
this problem.
— supra shoes · Jul 22, 06:20 AM · #
What, pray tell, does having an ethnically diverse population have to do with anything?
Why, for the purposes of national health care, would it matter what color someone’s skin is?
— Travis Mason-Bushman · Jul 22, 06:25 AM · #
As much as I sometimes enjoy Peter’s articles, I’m not sure that his claim that it is hard to get additional privately-offered medical insurance if there is also a basic one provided by the Government – because “bureaucratic territoriality has made it extremely difficult to get private care” is actually true. In the country where I come from (Croatia) it is certainly not the case. Private health insurance (often offered as a package by the companies dealing in other forms of insurance as well) is readily available to anyone who has the means and the desire to buy it.
On the other hand, if the main objection is that such system would mean that “most health-care decisions are made using the government’s standardized, impersonal life-year valuation”, one could argue that the alternative (I’m guessing through employer-provided contracts with private insurers) is not necessarily better: health-care decisions that are ultimately based not only on one’s productivity and accomplishments, but also to an extent on the initial luck of getting born into a wealthy/middle class and having one’s talents honed as opposed to neglected.
— Marko · Jul 22, 08:22 AM · #
Yeah, as someone who has flirted with the idea of a bare-minimum, means-tested healthcare subsidy, I don’t see what’s so wrong with the government deciding to execute its healthcare responsibilities efficiently. We can debate about two things 1) whether government should provide – through taxpayer dollars – any form of healthcare whatsoever and 2) whether Singer’s standard for evaluating a life’s worth is the right one. But if we accept the first – and I think most of us, deep down, do believe in some version of #1 – then there’s nothing unreasonable with the line “government should decide how much your life’s worth.” HOW it decides that value can be vigorously debated, and that’s why the focus should be on #2.
— Josh Xiong · Jul 22, 09:29 AM · #
Putting it in simpler terms: For those who can afford to pick and choose their healthcare, by all means express how much you value your life through the package you purchase. But if I am too poor to buy my own healthcare (and thus fully express how much I value my own life), and I am relying on a government subsidized alternative, then wouldn’t the responsible public policy choice be to have government evaluate its spending decisions through some kind of cost-benefit analysis? I guess Singer’s analysis somewhat apocalyptic in the context of a single-payer system with no private alternatives, but that’s not what Singer or even Obama is proposing (though the current government plan is pretty weak sauce).
— Josh Xiong · Jul 22, 09:38 AM · #
As it happens, many people reject* your point one in part because it inevitably leads to such unsavory discussions as to whether and how the government puts a price on your life. I find your formulation an interesting inversion.
*To clarify, few would actually reject that the government should provide “any form of healthcare whatsoever”, but the scope of the program matters. A bare safety net for the most desperate will generate some of these actuarial concerns, I suppose, but a universal coverage program will make those concerns more immediate and invasive for more people. That’s because more people will be under the program, obviously, and also because such a program would be under greater pressure to control costs.
— Blar · Jul 22, 01:39 PM · #
Blar: “As it happens, many people reject* your point one in part because it inevitably leads to such unsavory discussions as to whether and how the government puts a price on your life. I find your formulation an interesting inversion.”
I don’t think it’s an inversion at all. Note that Peter was complaining about the government evaluating your life worth, NOT the type of health care associated with it. I never said I supported a universal health care approach (and in fact, like I mentioned earlier, I’m more inclined towards the “bare-minimum” means tested variety, with a true free market left for everyone else).
But let’s assume we are going along with a universal health care approach. Given that there’s no market, wouldn’t Singer’s approach be one of the few, if only, reasonable method of allocating treatment? In that case, the real culprit wouldn’t be QALY but universal health care itself. QALY would in fact make it more palatable.
— Josh Xiong · Jul 22, 02:39 PM · #
From Suderman’s article:
Yes, point at Britain and Canada to vaguely imply that private care will go away without any actual evidence. There are countries with private and public care to contrast with Canada’s almost public only; Medicare has not stopped Medicare Supplement plans here in the US. This is a fight against something no-one is actually trying to do.
So people reject point 1, but they don’t actually.
Ah. So it’s o.k. for the government to put a value on other people’s lives (e.g. poor people), but not yours.
Singer’s other point, which you elide, is that the government is putting a value on all our lives anyway – the EPA, the DOT, etc. So while I’m not a fan of (say) single-payer, QALY and so on aren’t the reason and I don’t really see why they would be.
As a side note:
Singer’s always like that.
— strech · Jul 22, 03:07 PM · #
I phrased this really badly.
To clarify:
I’m not a fan of strict single payer (e.g. only government healthcare, either de jure or de facto) for various reasons (the inevitable attempted government management of our lives to drive costs down, and some kind of limit to services is inevitable, whether via QALY or otherwise); but these problems are part of single payer, not part of QALY (or “rationing” in the sense Singer uses it). Which can be applied with a free hand for supplement or competing plans.
— strech · Jul 22, 03:16 PM · #
Singer’s enthusiasm for focusing on rationing health care as a necessary good fits right in with him being a sick fuck bent on killing the sick and disabled.
Why do other countries spend so much less on health care than the U.S.? Here’s a hint. It ain’t because they drastically ration that care. It’s because their universal systems do a better job controlling costs and promoting health than America’s. But Singer would rather blather on and on about rationing because that concept resonates more with a suck fuck bent on killing the sick and disabled.
Mike
— MBunge · Jul 22, 03:25 PM · #
I agree with this entirely. The reason I called it an inversion is that QALY is the reason some give for disqualifying universal coverage, while your formulation gives people who support universal coverage reason to support QALY (though I understand you yourself do not support universal coverage).
If government health management means that inevitably the government must sometimes put a price on lives, I would rather it involve as few lives as possible, in part because a more limited program will make icky life-pricing more rare. It has nothing to do with the kind of people involved.
This report written by the Lewin Group and commissioned by Heritage offers a bit of evidence on that score. From section C…
In other words, according to the analysis, employers will drop about 88 million private employee plans in favor of the public option.
— Blar · Jul 22, 03:47 PM · #
Except that’s not what Peter is talking about in the excerpt, or what I was talking about. Private health care will still be available (and still have tens or hundreds of millions in it). People will still be able to purchase supplemental insurance if they want to, so government won’t be exclusively setting the value of a life; and it won’t be “extremely difficult” to get private insurance.
Still, now that you’ve reminded me of that, the interaction between public health care and our current employment-based system is somewhat problematic.
— strech · Jul 22, 04:09 PM · #
The point of the analysis is that private insurance will be unable to compete with the public option, which for the purposes of this discussion means that a public option will put the government in a dominant position when it comes to setting the value of life. At any rate, it looked like you were making a more general point, that there was no evidence that public plans make acquiring private plans more difficult, and I thought the Lewin report provided basis for such a belief.
I agree that employer-backed plans are part of the problem with healthcare.
— Blar · Jul 22, 04:41 PM · #
It seems to me that the point should be precisely that the Government will be in a position to “set the value to life”, but only in the sense that it will determine the maximal amount of money the society is willing to spend on the health of any of its members. This should in no way impede the provision of the supplementary health insurance i.e. the amount of extra money that the individuals are willing to spend on their own health (or the health of the loved ones).
I really see no problem here.
— Marko · Jul 22, 06:08 PM · #
But I really fail to see why the government using a QALY-like measure is somehow immoral in some way that some other person is not immoral. (Cards on the table: I oppose on human-dignity grounds any attempt to rationalize human life and limb in commodity terms. Or as Peter puts it, “economic decisions about the value of life.”)
For example, when Peter says … “I agree that, in the end, we do have to make economic decisions about the value of life. But shouldn’t those be decisions made by individuals, their families, and their doctors? Do we really want bureaucrats in Washington handing down indiscriminate dictates on what a year of productive, healthy life is worth? Must everyone be blindly herded into the same pen?” … He really is whistling past the graveyard. And if one has no objection to “rationalistic” Quality-of-Life measures, he has no basis for objecting to the government doing it. One either objects to QoL measures per se, or not at all.
For one thing, an individual cannot be expected to put an economically rational value on his own life (and those of his immediate family) because, to cite the cliche, “there are some things money can’t buy.” A person’s own life is, subjectively, of infinite value TO HIM because it’s the grounding of everything else; and not of infinite value to any other person. If you’re really want to contain costs, they one you CAN’T do is have individuals make decisions for themselves.
For another, and from the other end, as long as medical care involves any insurance model whatsoever and is anything other than pay-as-you-go-and-can, like the market for potato chips is, the somebody other than the individuals concerned will make decisions — whether it’s the actuarial tables being run by an HMO bureaucrat (who for some reason I can’t fathom other than location prejudice is supposed to be better than a “bureaucrat in Washington”) or a doctor refusing to perform a service for which he cannot paid … someone will say “no” to someone else on the basis of some economic grounds.
— Victor Morton · Jul 22, 06:21 PM · #
Cost-benefit review of regulations of the type favored by many Republicans (and many Democrats, including myself to some extent) presumes that some non-infinite value can be placed on human life.
— alkali · Jul 22, 08:45 PM · #
@Travis—I should have used the term ‘culture’ rather than ‘ethnicity’. But they both are terms useful in describing what I was trying to say. I’ve lived in three countries with nationalized healthcare (Taiwan, China and England). I won’t bore you with the details of the experiences I’ve had with healthcare in those places.
Whenever Singer or any other advocate of state-run healthcare for America uses another country as a comparison (England, Canada, etc.) it is a false comparison on many levels, but mainly because different cultures eat different diets and have different lifestyles and most importantly, have very different views on what they expect their fellow citizens to pay for and what ‘rights’ are. Taiwanese and mainland Chinese on the coasts eat diets rich in seafood and green vegetables as well as heavy doses of garlic. The instances of obesity and heart disease is low. But pollution is a huge problem as well as the tendency to fry almost everything. The English eat a diet high in starchy, processed food, drink excessively and exercise is not really something that is a huge part of their culture. Obesity, heart disease and cancer are all high (I think 3rd highest in the world behind us and Mexico). I was in Greece for 3 weeks in May and there seems to be a high rate of obesity but comparatively low rates of heart disease. The Greek (Mediterranean) diet is very high in vegetables, legumes, garlic and especially olive oil. Chinese, Taiwanese, Greeks and English (from what I’ve seen and heard) think it is their ‘right’ to have their health care paid for by their neighbor. And they pay for it in taxes (especially the English and Greeks) and get very bad service for their trouble.
Sorry to be long-winded but hopefully to answer your question, culture (ethnicity is a part) plays a huge, significant factor in talking about any health system. Singer, and advocates like him, make no mention of this.
There are many more points to be made but I’ll stop here. Hopefully I’ve cured your insomnia.
— Nick · Jul 22, 09:07 PM · #
“and get very bad service for their trouble”
Evidence for this statement?
By essentially every measure, our country has the least efficient health care system of any Western nation. We spend more money, cover fewer people and have worse outcomes.
Yes, in England some people have longer wait times. In America, some people can’t get in line at all because they can’t afford it.
Tradeoffs are inherent in every system. Giving up longer wait times in order to get more people covered seems like a small price to pay.
— Travis Mason-Bushman · Jul 22, 09:17 PM · #
Evidence for this statement?
What planet do you live on? We are so screwed if people actually believe the drivel that people like you and M. Bunge have written.
— jd · Jul 23, 11:36 AM · #
“Rather than let individual preferences and agreements work out prices and reach an equilibrium…”
Wow. Brutal. Maybe we can start writing on headstones: “Here lies the single mother of five who was ‘equilibrized’ by a vicious bout of diarrhea.”
— wfrost · Jul 23, 01:14 PM · #
Or maybe: “Here lies a single mother of five who was ‘rationed’…” etc., etc.
Sometimes people seem brutal because brutality is part of reality.
— Blar · Jul 23, 02:27 PM · #
“Sometimes people seem brutal because brutality is part of reality.”
Yes, but that is not reason to institutionalize or rationalize such practices, whether by government or any other corporate entity.
— Victor Morton · Jul 23, 06:17 PM · #
How much is a year of Pete Singer’s life worth?
To whom?
— Julana · Jul 23, 07:55 PM · #
Victor, earlier you wrote upthread of
and just now
I believe you misstate the choice. It’s not one HMO bureaucrat versus another in Washington; it’s a system of several HMO’s and other providers in competition versus a system of one federal agency making all the decisions.
You can wax Pollyanahish all you like, and it won’t change the fact that healthcare is a scarce good, or a “commodity” as you put it, and as such some people who need it aren’t going to get it. I would rather that determination be made in the marketplace, in as decentralized a fashion as possible, rather than give a sole political entity the power of life and death.
— Blar · Jul 23, 08:03 PM · #
But HMO bureaucrats make decisions binding on others, and that once made are final. The market for health care is not like the market for potato chips — comparison shopping and brand-switching are rather hard; need has a somewhat different meaning; and demand elasticity is … um … limited.
— Victor Morton · Jul 23, 09:10 PM · #
Oh … and I’m quite well aware that health care is a scarce resource and that people will not get everything they might want or need.
What I oppose is quite specific — any effort to “rationalize” (in the sense of “make rational,” not “to ration out”) health care through actuarial tables that attempt to set or specify for any social purpose the value of a human life as any given round number (whether that number be $100 or $1 billion is neither here nor there). If one finds that action immoral, dithering over the entity doing it is worse than trivial.
— Victor Morton · Jul 23, 09:23 PM · #
Much the same could be said for rent. Actually, that would make a rather interesting comparison to study, but as I recall efforts to manage the cost of rent politically has seen some disasters.
What alternative do you have in mind, then, for dealing with scarcity?
— Blar · Jul 23, 11:18 PM · #
“Much the same could be said for rent.” Actually, no it can’t. People can and do move around with little market friction, can and do comparison shop, and can meaningfully make do with less.
“What alternative do you have in mind, then, for dealing with scarcity?” On the one hand that has absolutely has no relevance whatever to whether a particular act is immoral in itself (and thus should not be done, period). But the very fact you respond in such a positivistic, programmatic way is exactly why Q-o-L measures are immoral — they impose that mindset.
— Victor Morton · Jul 23, 11:55 PM · #
Blar, you’re right. There are some resource-deprived societies that are unable to provide treatment for people even with the most easily preventable or curable ailments. The point is that we don’t want to be one of those places where the rich spend millions on cosmetic surgeries while the poor fight for clean water. Even if that’s what the market wants to do with our resources.
You may accept brutality as part of reality. But can’t we agree that some societies are less brutal than others? Maybe the market would work things out in the end, but I’m not willing to pay the immediate price for that uncertain efficiency. In the mean time, I have no argumentative recourse for convincing you that we should show solidarity with people who can’t afford healthcare, today.
— wfrost · Jul 24, 12:19 AM · #
<p>Blar wrote:</p>
<p><cite>I believe you misstate the choice. It’s not one HMO bureaucrat versus another in Washington; it’s a system of several HMO’s and other providers in competition versus a system of one federal agency making all the decisions.</cite></p>
<p><cite>You can wax Pollyanahish all you like, and it won’t change the fact that healthcare is a scarce good, or a “commodity” as you put it, and as such some people who need it aren’t going to get it. I would rather that determination be made in the marketplace, in as decentralized a fashion as possible, <strong>rather than give a sole political entity the power of life and death.</strong></cite></p>
<p>I believe YOU misstate the choice. It is quite easy to conceive of a system that would provide everybody with some level of medical insurance, while simultaneously allowing everyone to buy supplementary medical insurance</p>
<p>Such systems exist already in many countries, and the employers often offer supplementary insurance as just another perk that comes with the contract (like bonuses, company car, etc).</p>
— Marko · Jul 24, 12:28 AM · #
Sorry for the unsuccessful formatting. Clearly the note “all HTML will be removed from your post, but with the Textile markup syntax you can do whatever you need. Links, images, formatting, it’s all there.” is not really true.
— Marko · Jul 24, 12:29 AM · #
A year of life is priceless.
— Julana · Jul 24, 01:30 AM · #
Gimongus comment alert.
@Victor: Rent is relatively inelastic (gotta live somewhere), it is difficult to switch brands (leases, moving expenses, and the time it takes to move make moving prohibitive for many), and while you can shop around, there are a host of informational asymmetries that make it more difficult to know you are getting the best deal until you are locked into a lease (“what do you mean, you can’t do anything about the plumbing?”). It’s not a perfect comparison, but I believe that covers everything you said about healthcare. And yet few are clamoring these days against the unfair power of landlords, which was my point in making the comparison.
Also, I see you dodged my question about what to do about healthcare and scarcity.
@wfrost:
I never said I had no solidarity with people who can’t afford healthcare, or that I didn’t want some kind of reform. But remember that my principle beef is with those who are arguing that Singer’s political QALY is indistinct from the QALY measurements we see in the marketplace. Since I think (like Peter, I believe) that some sort of QALY protocol is necessary to deal with the scarcity of healthcare, I would rather see such decisions made through diverse actors in the market than in the hands of a monolithic healthcare juggernaut.
Also, showing solidarity with the uninsured does not logically imply supporting government-run healthcare.
@Marko
I agree, but that wasn’t part of the framework that I was addressing. It was “one HMO bureaucrat making QALY decisions” vs. “one Washington bureaucrat making QALY decisions.” Of course there are other options between our current system and a political monopoly on healthcare, but I didn’t believe that our current system was accurately represented in that framework.
In other words, I wasn’t trying to present the only healthcare choices available to us; I was making a narrower point in addressing whether our current system at all resembles what Singer is advocating about the need to centralize QALY decisions.
(Though come to think of it, if the government is providing everyone with a baseline of insurance, that already centralizes QALY decisions quite a bit, even if purchasing supplemental insurance from private providers is possible.)
— Blar · Jul 24, 01:43 PM · #
Let’s take it to real life situations:
-You have persistent sciatica. You’ve gotten your MRI and it shows a disc pinching the nerves in your lower back. You doctor has recommended disc surgery. Is it “worth it”? Well according to this evidence-based review (http://www.cochrane.org/reviews/en/ab001350.html) you’ll probably get faster resolution of your pain (by maybe 12 – 18 months). But by 18 months you’ll likely be at the same place if you didn’t have the surgery. How much is avoiding 12 months of severe low back pain worth to you? Your employer? Your government? (A few additional bits of info: The average cost of the surgery itself was $12,754 ; over a quarter million such surgeries are done every year in the US. You can do the rest of the math)
-You have Stage IV non-small cell lung cancer (that’s bad). Your doctor has suggested Tarceva. Overall it will give you at least two maybe 6 or if you’re fortunate 12 more months of life (side effects may occur). How much is that worth to you? Your employer? Your government? (PS monthly cost of tarceva is about $2500) (PPS, the very agency we’ve excoriated has recommended it use. Who’d thunk it! See here http://www.nice.org.uk/nicemedia/pdf/Lungcancer_erlotinib_ERGreport.pdf or quick link here http://www.nice.org.uk/nicemedia/pdf/TA162QRGFINAL.PDF)
— C3 · Jul 25, 05:05 PM · #
@ blar
“Though come to think of it, if the government is providing everyone with a baseline of insurance, that already centralizes QALY decisions quite a bit, even if purchasing supplemental insurance from private providers is possible.”
Well, does it really? In the end, if everyone is allowed to purchase extra insurance then for all those people QALY decisions would not be centralized. They would be centralized only for those without any other insurance. And if those have no insurance now, that would still be an improvement.
Also, another thing. I might be naive, but I’d rather have such decisions in the hands of a government bureaucrat (even if he/she is acting under general intent to curb costs), than made by the companies who are operating under zero-sum conditions, in which any such expenditures take away directly from their profits. It is easy to imagine who would be less charitable.
— Marko · Jul 25, 08:56 PM · #