Can Americans Handle Shopping for Health Care?
Consumer-driven health (CDH) products [i.e., high-deductible health plans relying on HSAs or Health Reimbursement Arrangements to reimburse for qualified expenses] have been marketed in various forms since the early 2000s. While emerging data is [sic] not entirely conclusive, general directional conclusions can be drawn from the studies published to date. […]
With regard to first-year cost savings, all studies showed a favorable effect on cost in the first year of a CDH plan. CDH plan trends ranged from -4 percent to -15 percent. Coupled with a control population on traditional plans that experienced trends of +8 percent to +9 percent, the total savings generated could be as much as 12 percent to 20 percent in the first year. All studies used some variation of normalization or control groups to account for selection bias.
For savings after the first year, at least two of the studies indicate trend rates lower than traditional PPO plans by approximately 3 percent to 5 percent. If these lower trends can be further validated, it will represent a substantial cost-reduction strategy for employers and employees.
Generally, all of the studies indicated that cost savings did not result from avoidance of appropriate care and that necessary care was received in equal or greater degrees relative to traditional plans. All of the studies reviewed reported a significant increase in preventive services for CDH participants. Three of the studies found that CDH plan participants received recommended care for chronic conditions at the same or higher level than traditional (non-CDH) plan participants. Two studies reported a higher incidence of physicians following evidence-based care protocols.
The authors add that “no data-based study has emerged” to contradict the indication that CDH plans “can produce significant (even substantial) savings without adversely affecting member health status”. H/T to Alex Tabarrok, who adds that the effects of such plans would likely be much more significant if they were adopted more widely.
(Cross-posted.)
Can Americans handle shopping for food?
Hey, what about CDHs plus Care Stamps?
— Kristoffer V. Sargent · Aug 12, 04:01 PM · #
I dunno. Have you ever had to buy a cheeseburger while in a coma under the condition that you would die if you didn’t get it in the next half-hour?
At any rate, this study isn’t particularly informative; it’s well-known that participants in CDH plans achieve greater health outcomes because they’re a self-selected group of people who are already quite healthy. People with significant or chronic health issues simply don’t adopt CDH plans. Other studies have shown that consumers of these plans can’t distinguish between necessary and unnecessary care, because – surprise – they aren’t doctors. Consumer rating and comparison isn’t effective because consumer ratings of care bear little relationship to the actual quality of care – again, because of the lack of medical expertise necessary to assess care quality.
P.S. FTW yourself, John.
— Chet · Aug 12, 04:16 PM · #
Read the paper; selection bias is explicitly taken into account in all the studies that are surveyed.
— John Schwenkler · Aug 12, 04:22 PM · #
“Read the paper; selection bias is explicitly taken into account in all the studies that are surveyed.”
Yeah, but, yeah, but
— mike farmer · Aug 12, 04:39 PM · #
The paper indicates the exact opposite, in fact:
And
So, no, they didn’t substantively control for selection bias; they used a measure that compared the amount you would pay under traditional insurance compared to the amount you would pay under a CDH plan. Indeed under this measure the most “cost effective” improvement would be to drop your insurance altogether and pay nothing.
Interestingly, the four plans they chose to study were all directed and funded by private insurance groups. Maybe you should read this study before you try to hang your hat on it. It’s beginning to look like a pretty flimsy prop.
P.S. I thought you weren’t talking to “pseudonymous trolls” anymore.
— Chet · Aug 12, 05:00 PM · #
Dismissiveness and snark aside, Chet’s comments are apt, and simply because the studies claim to address selection bias doesn’t mean that they’ve actually done so. Many studies claim to address selection bias.
Think about education. In this country, you can send your child to a public school which the state will pay for. Despite what zealots like John will tell you, there is lots of evidence that millions of people who receive their education at public schools are receive excellent educations. But even for people like John, don’t worry, there are alternatives. You can supplement the public education with additional tutoring that you pay for at your own expense. And many do. Or you can avoid the public option altogether and pay for your own, private education. No one’s stopping you.
What you can’t do is take the money that would have gone to the public option and use it to pay for the private option, for the self-same reasons that we don’t let you take money from the public budgets to build your own roads or start your own navy. The state is not an ATM.
Why can’t we have that model for health care? That, in effect, is what they French have, and they have at almost every rung of care a medical system that is the envy of the world. We can’t have that here, though, because as is the case with education, people like John don’t want there to be a public option. They claim to want competition, but they don’t actually want the private insurers to have to compete with a public option— at the same time as they claim that the public couldn’t ever provide a compelling option. (Which, if it were true, would mean that there would be no reason to oppose the public option in the first place.)
Why, it’s almost as if anti-government zealotry and a reactionary distaste for giving people actual, workable options to secure their needs has infected one half of the American political spectrum.
— Freddie · Aug 12, 05:01 PM · #
I’m sorry, not “plans” but studies. Typo.
— Chet · Aug 12, 05:02 PM · #
Man, that post from Chet might be the most damning rebuttal I read all week.
— Freddie · Aug 12, 05:04 PM · #
Interesting. I must confess, I do not take advantage of my employer’s HSA offering, since I find the rules governing it far too baroque.
HSAs make a good deal of sense if we are to view health insurance as insurance. I would contend, however, that despite the moniker, this is not how the general populace views health care. Nor should they. Health care should not be treated as a commodity, but as a facet of public safety.
— Erik Vanderhoff · Aug 12, 05:13 PM · #
What’s funny is, John thinks about these things for a living, supposedly, and I’m just a guy eating Cheetos in my parent’s basement or something.
— Chet · Aug 12, 05:16 PM · #
Freddie: people like John don’t want there to be a public option.
I don’t want a high-quality public option. I want my public option to be barebones and unattractive.
But progressives want healthcare egalitarianism and puppies for always, and conservatives want . . . whatever the hell it is they want, plus Jesus. I become disheartened.
— Kristoffer V. Sargent · Aug 12, 05:52 PM · #
Freddie, you shouldn’t take Chet’s rebuttals without reading the source material. Chet’s engaged in some selective quotation.
1) Chet misrepresents his own quote – the studies don’t compare the amount spent by CDH plan participants versus traditional participants, they compare the change over time experienced by CDH participants versus traditional participants.
I’ve emphasized the section Chet left out of his last quote.
2) Basically, you have three people here giving you opinions: (1) Schwenkler; (2) Chet, and (3) the American Academy of Actuaries working group on health care. (Four, if you count me.)
Assuming the AAA aren’t biased hacks, my guess is that they are the most expert of the groups listed above in evaluating studies. Their conclusion is that the studies, while not “entirely conclusive,” are promising. (“While emerging data is not entirely conclusive, general directional conclusions can be drawn from the studies published to date.”)
My interpretation is that Schwenkler is overselling the report by a bit, but Chet is underselling it by a lot.
— J Mann · Aug 12, 05:54 PM · #
I think you are too credulous towards the AAA’s neutrality. What’s more, it’s immaterial. That is not an argument against a public option. Why can’t people decide to use a public option if they exercise their choice and believe the public option to be the best for them and their situation? That question gains added salience in the context of a system where the lack of a public option leaves millions with no option at all.
— Freddie · Aug 12, 05:59 PM · #
Ahem, again. Freddie writes:
Because a public option should never be best for anybody, except in those cases when ‘best option’ means ‘only option.’
— Kristoffer V. Sargent · Aug 12, 06:10 PM · #
Because a public option should never be best for anybody, except in those cases when ‘best option’ means ‘only option.’
Why?
— Freddie · Aug 12, 06:15 PM · #
Freddie,
1) I have never heard of the AAA. I generally consider an actuaries association to be largely impartial, but I would be open to evidence of corruption. What’s your evidence or theory?
2) How did the public option get into this discussion? Based on this study, you might argue that if there is a public option, it should consider including some CDH plans, but I don’t see what the study has to say about the existence of a public option itself.
— J Mann · Aug 12, 06:20 PM · #
Because the existence of CDHs and the assertion of their efficacy and efficiency are taken as evidence against the adoption of government funded coverage.
— Freddie · Aug 12, 06:27 PM · #
Umm, no. I think about philosophy for a living, Chet. And the fact that the studies didn’t take “all of the factors” into account doesn’t mean that they didn’t account for selection bias by considering any of them, which is all that I (correctly) said they did.
P.S. What JMann said about the public option … talk about a red herring.
— John Schwenkler · Aug 12, 06:28 PM · #
You are or are not explicitly opposed to a public option, John? Why are you afraid to talk about it?
— Freddie · Aug 12, 06:29 PM · #
Not true! I am thoroughly in favor of government provision of vouchers and coverage of catastrophic expenses, and have said so countless times. My primary beef is with encouraging consumers to treat health care as if it’s free.
I’m agnostic.
— John Schwenkler · Aug 12, 06:31 PM · #
Sorry, I didn’t mean to say that you say that CDHs are an argument against publicly funded health care, just that some people do. Personally, I think the CDH concept, if presented as an option for coverage in either kind of plan, is fine. The question is whether they will really work to reduce costs while maintaining coverage that consumers consider adequate. But there’s the wonders of competition, again.
— Freddie · Aug 12, 06:34 PM · #
Why?
Because that’s what works, where ‘what works’, the concept, is as logically deep as you please. I can prove this beyond a reasonable doubt.
To be clear, you want a maximin, yes? Why? Because it’s just?
And Schwenkler, whether or not to enact a public option is the key question. The next question is whether it should be a floor or a maximin. (And since you’re a professional philosopher you’re familiar with what’s riding on the second part.)
— Kristoffer V. Sargent · Aug 12, 06:41 PM · #
“My primary beef is with encouraging consumers to treat health care as if it’s free.”
But even single-payer or “socialized” systems don’t do that. The French have co-pays. The Dutch all have private plans, by law. The bottom line is that health care, left to the market, is prohibitively expensive — there is no incentive to cut costs.
Allow me to compare: In 1979, when I was born — in the exact same hospital, under the same ownership, that my son was just born in — my parents were billed about $1,500 of the some $15,000 my fourteen-day stay in the Neo-natal Intensive Care Unit required to save my life. They had excellent insurance through my father’s firm, thus allowing for a small co-pay. To contrast, last month, my son’s four-day stay in the regular recovery unit ended up costing us about $1,500 of the some $20,000 the hospital billed the insurance company. It would have cost me about $2,000, but the hospital gave me a discount for being able to pay in full upon discharge (thus leading me to conclude that there’s at least $500 in charges that aren’t necessary). I, too, have excellent insurance through my employer, and I now pay roughly a third of my take-home pay in order for my wife and child to receive it.
In the span of 30 years, a routine delivery and post-delivery care now costs as much as my abnormal, intensive post-delivery care.
That shit ain’t right.
— Erik Vanderhoff · Aug 12, 06:55 PM · #
No, representative quotation.
Change in what, specifically? Change in cost, like I said. Again, it’s a measure where the best possible trend is to uninsure yourself and stop paying anything for health care, since your change in cost will always be zero. Nobody would consider that adequate care, though.
Quite the assumption, considering that their “authoritative, comprehensive” review looked at only four cherry-picked studies, each produced and paid for by one of their client corporations. Draw your own conclusions, I guess, but I’ve never been impressed when industry groups survey the research and conclude “yup, everything it’s in the best interests of our industry to say was right all along!”
Now, now, John, don’t be dishonest. We can all read, after all. Here’s what you said:
Not “some bias is taken into account”, all the bias is accounted for. You can hardly say you’ve accounted for the bias if you’ve ignored accounting for some of it.
It shows, frankly, in your disingenuous replies.
— Chet · Aug 12, 07:05 PM · #
I’m sorry, but this is pretty much self-evidently false. And your autobiographical example doesn’t support it at all, since in the U.S. over the past 30 years health care hasn’t been “left to the market” in any significant sense!
— John Schwenkler · Aug 12, 07:05 PM · #
There’s nothing self-evidently false about it. The people who are uninsured – who pay out of pocket in the “free market” pay three times what everybody else pays.
If it’s so self-evidently false, then why is it our system – the closest to a free market in any sense – that is the most expensive of them all? If the free market results in cheaper, more effective care – why have approximately zero nations implemented a totally free market in health care? Surely there must be a “market” in health care systems, since people can move from one country to another; why does the “market of nations” not seem to reward health care markets?
— Chet · Aug 12, 07:10 PM · #
“Because that’s what works, where ‘what works’, the concept, is as logically deep as you please.”
That doesn’t make any sense to me. This seems to rather translate as “I’m opposed to a public option because shut up is why.” Can you be a tad more explicit? It seems that Freddie, Chet, myself, etc. would argue that this most demonstrably does not “work” unless we’re measuring different goals. In which case, there can be no resolution on the basic question.
“I’m sorry, but this is pretty much self-evidently false.”
How so? Why, then, would health care costs be far-outstripping inflation, or wages (which translates as the ability to pay for commodities)? This is pretty basic: If you have a service everyone requires, you can charge whatever people have the physical ability to pay. A physical ability, one might add, that is present only because of easily-available debt in the form of usurious credit?
How has health care NOT been “left to the market?” Of course, since the free-market is a fanciful concoction that doesn’t exist, we may be having an axiomatic problem here, but I’ll assume argument in good faith and look forward to a preponderance of facts behind your assertion.
— Erik Vanderhoff · Aug 12, 07:13 PM · #
Sorry, but no. “Selection bias is taken into account” clearly does not entail “All the selection bias is taken into account”, lest:
* I have money in my pocket. (But do you have all the money in the world in there? Liar!)
* I’ve read Jane Austen. (But have you read everything she ever wrote?! Double liar!!)
* I’ve thought about prime numbers. (But have you thought about 2 to the power of 43112609 minus 1?!?! Triple liar!!!)
Furthermore, failing to account for bias in every possible way is not the same as “ignor[ing] accounting for some of it”; rather, it’s just accounting for the bias (which, again, is all that I promised) in a way that’s unfortunately less than perfect.
— John Schwenkler · Aug 12, 07:19 PM · #
Chet, my man.
You quoted Schwenks as saying, “Read the paper; selection bias is explicitly taken into account in all the studies that are surveyed.”
Then you characterized it: “Not “some bias is taken into account”, all the bias is accounted for.”
In Schwenks quote, ‘all’ qualified ‘studies’, not ‘bias.’ Reading comprehension much?
Oh, and Erik, I’d be happy to elaborate. It’s just that, I didn’t want to over-respond to Freddie’s “Why?” because, well, it’s hard to tell an earnest from a dismissive question on the internet.
First, though, can you expound on what you mean by “That’s just not right?” I assume you are making a truth claim, and not just expressing personal taste. Which means you are making a moral claim about the justice of the situation. Which means you have some conception of justice to which you are appealing.
Which conception of justice are you appealing to?
— Kristoffer V. Sargent · Aug 12, 07:20 PM · #
Tax deductions for employer-provided health insurance. Mandates. Legal obstacles to HSAs and other CDH products. Bans on buying insurance from out-of-state providers. Medicare. Medicaid. Patent laws. Draconian licensing requirements for health-care providers. Need I go on?
— John Schwenkler · Aug 12, 07:23 PM · #
Wait, aren’t the four studies reviewed by the report lacking in real-life data? They’re simulations taking pools of traditional insurance recipients and comparing costs using statistical models.
“Some studies attempt to adjust for one or more of these factors by constructing a statistically similar population from their traditional participants. Others may apply actuarial adjustments to the results before making comparisons and drawing conclusions.”
So, while the results are certainly interesting in the “food for thought” sense, they rely upon the ability of the testers to create accurate models accounting for multivariate inputs. I’m not saying, if I’m reading that correctly, that we should ignore these findings totally, but isn’t that a pretty huge caveat to rest one’s laurels upon?
— Erik Vanderhoff · Aug 12, 07:28 PM · #
Erik, I’m pretty sure that “constructing a statistically similar population” means identifying a population of actual individuals in the traditional plans who are relevantly similar to the people studied in the CDH plans.
I agree that if they were imagining hypothetical people and seeing what their hypothetical costs were, that would be pretty pointless. (Or worse, if they were constructing actual people somehow!)
— J Mann · Aug 12, 07:33 PM · #
No, that’s not right. It’s just that they account for heterogeneity among the populations that the real-life data are drawn from by adjusting the results or constructing models.
— John Schwenkler · Aug 12, 07:36 PM · #
John is right to say that the American system is not a free market system and hasn’t been. The problem is that medicine can’t be both free market and available to any large percentage of the people, let alone all of them. There’s a lot of reasons for that, but the chief one is that medicine is expensive, and gets more expensive as we continue to innovate. We have to find ways to drive those costs down, and any honest commentator on the issue will admit that this involves rationing care. But we already ration care, and people who are denied treatments by insurers are in the same boat as those denied treatment by government. The simple fact of the matter is that business works by having profitable transactions for those in business, and avoiding unprofitable transactions. If you have a real, free market approach to health care, then everyone avoids insuring the chronically ill, the permanently ill, those with a high risk of becoming seriously ill, and the elderly. They avoid insuring them because they are expensive to cover and thus don’t provide an opportunity to profit. Society, however, thinks it’s in our interest to ensure that the sick, or those who may soon become sick, should continue to receive coverage. That’s just not going to happen with a real, free market system.
Kristoffer wants to talk about whether the public option will provide a minimum of care or maximin. Where the lines that are drawn for “adequate” care is a complicated question. (It’s complicated, incidentally, for private insurers too.) But I think that the most pragmatic and useful option is one that preserves the element of choice and private insurers that can act as supplements or substitutes to a robust public option. Yes, the affluent will receive better care, or at least, better coverage. But they already do. That’s life, I’m afraid. What we want and need to change is the inefficiency in the current hodge-podge system and the practical and moral problem of those without coverage. The beauty of it is that a public option will only be as large as the number of people who think it’s in their best interest to use it. That should help assuage the people who think that the public option simply can’t be a good one because of government incompetence. And absent the objection that government won’t run a medical option well, the only argument I’ve heard about having one is that it’s unAmerican, or “not our culture,” neither of which is an actual argument.
— Freddie · Aug 12, 07:38 PM · #
Erik wrote:
It’s hard to believe that was actually a serious question. But here’s your answer in 2 words: Medicare, Medicaid. And then there’s the rest of the answer: our insurance coverage is not really free-market. It’s just more free-market than Medicare, Medicaid and those systems used in every other country in the free world. It’s enough free-market to give us far and away the best health care in the free world, but not enough free-market to keep costs down.
Anyone who believes government health care will ultimately keep costs down is either ignorant or dishonest. But you would be in good company (I guess) because Ezra Klein agrees with you.
— jd · Aug 12, 07:42 PM · #
This is true, but it’s also true that there are ways to achieve this goal – such as providing means-tested vouchers and/or guaranteeing catastrophic insurance – that more closely approximate the free market than, e.g., a public option would, and that work to keep costs down through demand-side measures rather than supply-side ones. It is largely an empirical question which approach is best.
— John Schwenkler · Aug 12, 07:42 PM · #
In John’s quote “bias” is not qualified at all, which is where I got the implicit “all”. I wasn’t referring to the literal word “all” that appears in his remarks. Contrast this to the study, where the bias is qualified – it’s qualified by “some”. Which means “not all.” Which means that the review has some bias, which means that it is biased. In particular, the studies were biased in precisely the way I described and precisely the way John denied.
I find this needling, nit-picking logic-chopping style of argumentation distasteful, frankly, and characteristic of philosophers. And like the field of philosophy itself it does absolutely nothing to further understanding of any practical issue.
No, that’s exactly what it means, because:
* “The milk has spoiled” means that none of the milk in the container can be consumed, because it is all spoiled;
* “The wine is poisoned” means that none of that wine is fit to drink, because it is all poisoned;
* “We weren’t able to control for all the bias” means that the study is biased, because the bias in the study has not been eliminated.
And so on. Words really have meanings, John. Is there something about being a philosopher that teaches you to avoid plain meaning in English?
— Chet · Aug 12, 07:47 PM · #
And I never said that it was eliminated, but only that it was taken into account. Which it was, albeit imperfectly.
Words have meanings, indeed.
— John Schwenkler · Aug 12, 07:50 PM · #
Kristoffer,
I don’t mean to be obtuse, but I genuinely find most queries, when couched in philosophical language like yours, to be totally incomprehensible. I feel like we’re arguing on different levels here. I’m trained in public policy administration and analysis, not philosophy. I don’t really care about expounding upon some sort of Rawlsian theory of justice. But since you’re being kind and willing to engage, I don’t want to shrug off your questions, even if I view philosophy as mental masturbation — enjoyable from time to time, but dulling to the senses if indulged in too frequently.
I’d rather say it was both an expression of taste and of moral outrage. I’m a procedural equality kind of guy. I view health care in much the same conception as I view national defense or public safety: a necessary, common good, that should be equally available to all and, as it is necessary in this day and age to survive, it should be available at the same relative cost. I fundamentally disagree with the conception that health care can be treated as a commodity. I also work in the field of developmental disabilities, where I see private insurers refuse to cover things like speech therapy or even eye glasses for children because their underlying condition cannot ever be “cured,” leaving families with limited discretionary income to cover huge costs, unto bankruptcy. So that kind of injustice pisses me off. I have no faith in the “market” because it is profit-driven, and profits do not encourage fair treatment.
John,
Aside from Massachusetts, what state has insurance mandates? Weren’t tax deductions to employers created as an incentive for employers to assist employees in obtaining health insurance precisely because the individual market was so cost-prohibitive? “Draconian” licensing requirements such as what, precisely? Medicare is a single-payer health insurance that no medical care provider is required to accept. The same with Medicaid. (I deal with both in the course of my job.) Patent laws, as originally constructed, are supposed to provide incentive for innovation and creation; I will grant that they have been abused by corporations and changed by legislators to benefit said corporations. How would buying out-of-state insurances benefit anyone; it doesn’t seem to have worked so well for the credit industry.
But I think we’ll ultimately have a problem even agreeing on the basics here, since your responses indicate a certain axiomatic bent that I vociferously disagree with.
“No, that’s not right.”
Thanks for the correction. It didn’t seem right.
JD,
“Anyone who believes government health care will ultimately keep costs down is either ignorant or dishonest”
This flies in the face of all other developed countries’ results. We have the “best” health care for those who can afford it.
— Erik Vanderhoff · Aug 12, 07:53 PM · #
Except that it wasn’t, John. They stated exactly that in the study – there was positive bias that they could not take into account. They absolutely could not be clearer on that point. It’s akin to shooting an arrow at the bullseye, missing widely, and then stating “I hit the target, albeit imperfectly.”
I can only assume these absurd defenses of the most minor point mean you’ve completely abandoned your position on CDH plans and the use of this review in their defense.
— Chet · Aug 12, 07:56 PM · #
But I think that the most pragmatic and useful option is one that preserves the element of choice and private insurers that can act as supplements or substitutes to a robust public option.
Okay. So basically you want the public option to be the core solution, with the market choices orbiting on the periphery. Kind of the same situation we have with primary and secondary public education.
I want the inverse. I want the government to maintain the periphery, while inhabiting the core with a market of consumer-friendly choices. The former means a floor, and the latter takes some tweaking.
What’s so wrong with the latter that it’s not worth trying first?
— Kristoffer V. Sargent · Aug 12, 07:56 PM · #
Many of them; see here. In Maryland, for example, it’s been estimated that mandates for coverage of certain conditions increase the cost of health care by over 60%.
Whatever they were created for, the fact is that they’re not a free-market measure, and they vastly distort prices upwards.
Like forbidding people who don’t have AMA certification from offering basic medical services; see here.
By allowing them to escape statewide mandates, for one thing, and generally by making available a wider range of options. Maybe you don’t think this would be beneficial, but the fact is that the current restriction is clearly not market-freeing.
— John Schwenkler · Aug 12, 08:03 PM · #
I’ll just drop in to add the following:
1. Man, it sure would be great if there were less vitriol and accusations of dishonesty in the world
2. on Schwenkler v. Chet on selection bias, Chet is wrong and Scwhenkler is right. The AAA report does try to account for selection bias, and is fairly upfront about the ways in which this is difficult
3. Chet’s claim that the four studies in the AAA report are ‘cherry-picked’ is unsubstantiated. It could be true, it could be false. I don’t know the set of studies that could have been used, but the AAA report describes selection criteria and explicitly calls out that these studies on which the analysis is based have not been published in peer-reviewed journals.
— Ben A · Aug 12, 08:10 PM · #
I’m sorry, I thought you meant mandates for obtaining coverage.
It seems, at the base, two types of axioms are at work here: those who view government with a legitimate regulatory and public health-ensuring role to play, and those who do not believe government has, or should have, any such role. As I said, axiomatic, and irreconcilable. What is one’s priority: that everyone receive affordable care appropriate to their needs, or that the “market” be “free?” Those two goalss work directly contrary to one another.
“Like forbidding people who don’t have AMA certification from offering basic medical services…”
Wait, weren’t you the one arguing against physicians’ assistants? Or was that one of your colleagues here?
— Erik Vanderhoff · Aug 12, 08:17 PM · #
Look, John’s point is about the validity of a particular study. Chet disagrees about the study’s ability to account for selection bias. That’s a matter for debate. I don’t find this study the silver bullet that it is made out to be. What is unfair is the notion that Chet is somehow uniquely disqualified from adult conversation for disagreeing about the validity of a study, when that question is at least debatable.
— Freddie · Aug 12, 08:32 PM · #
Must’ve been one of my colleagues. And it seems to me that your “two types of axioms” formulation is far too simplistic; there are all sorts of people – like me! – who lie in between.
Who ever said that? I think the implication was that he’s disqualified from adult conversation for, well, failing to act like an adult.
— John Schwenkler · Aug 12, 08:40 PM · #
Erik,
It usually is. But it can help to clarify a term, or show how its use is problematic. This is particularly true when morally-weighty terms are used to justify policy prescriptions.
So healthcare should be a positive right? (Seriously. I’m not sure what you mean here.)
Also, national defense is a public good because you can’t provide it to someone without giving it to everyone. The same is true for public safety. Healthcare, on the other hand, is consumed in discrete units by discrete individuals. Therefore, even if it is a right it would be the right to consume a commodity.
And even if we assume it’s a right, in what way is that meaningful when the government is allowed to use cost projections to decide how much of this right you get? Does the right to healthcare include the right to expensive services? Is there a ceiling on how many times I may exercise this right? On how often? If the government provides my care and denies me a new cancer treatment, do I have redress in the courts for this substantive violation of my rights. (Answer: no). How is it not a commodity?
Or are we talking about fairness? If so, are we sure that fairness demands so much? Mightn’t fairness only require a floor — a plan-B for our least lucky — rather than a robust, attractive public option that substitutes for quality private insurance, and thereby undermines it?
I think the government has a legitimate role to play, I just think the role is much narrower than eliminating frowns altogether. The government should only eliminate the worst frowns, and resign itself to the rest.
— Kristoffer V. Sargent · Aug 12, 08:55 PM · #
Not “is difficult”, but “weren’t able to do so.” I mean that’s a direct admission that there’s uncontrolled bias in these studies – which, gosh, was my contention all along. No, I’m not wrong; John is.
Then why on Earth are we even talking about this review? Not being based even on peer-reviewed research (!) makes it trash, case closed.
— Chet · Aug 12, 08:56 PM · #
John now:
John in the last thread:
— Chet · Aug 12, 09:33 PM · #
In all this its worth noting that some progressive types like HSA’s as a method of cost control. Specifically, Brad de Long and Matt Yglesias
They both seem to think that an HSA could be a vital component of a good public option system.
Even the Brookings Institute thinks that there is good evidence that sharing the cost of insurance helps to control the costs of that insurance (even though they don’t like HSA’s)
On a more “meta” level its worth keeping in mind Belloc’s formulation from The Servile State. People desire three things, freedom, sufficiency, and security. They usually get two. Under the current health care system, we have (some) freedom and sufficiency. The public option promises to provide sufficiency and security at the cost of freedom. HSA’s, in addition to helping to control costs, also inject a lot of individual choice back into the system. And, that’s a pretty good thing.
— Johnny A · Aug 12, 09:59 PM · #
Chet, you’re too eager to rubbish this report. It’s not proof positive of anything but it appears to be a reasonable and good faith attempt to work with the data available.
1. On selection bias. What the AAA report says is that a) all the studies contain attempts to account for selection bias and b) that “the most straightforward” way for trying to avoid the problem is to look at trend rates. Other methods employed in the selected studies are described on page 10. For example, several of the studies followed continuously enrolled patients so as to compare the difference in expenditures pre- and post-CRH enrollment. Nowhere does the study claim that all bias was eliminated, nor do I read John as making that claim. The claim is rather that multiple methodologies were used to correct for selection bias, and that the results were robust after the correction methodologies were applied.
2. It would of course be preferable to work from peer-reviewed data. But if none are available, that does not make an analysis of non-peer reviewed studies ‘trash’, or render analysis worthless. Here let me just quote from the report (page 3-4):
Numerous multiyear studies of experience that include hundreds of thousands of health plan members have been performed. While the data may not be entirely conclusive or complete, directional or general conclusions can still be drawn. Most of the available reports have been developed by companies directly participating in the market for these plans and have not been published in peer-reviewed journals. However, neither has much of the actuarial literature for traditional plans. Skilled actuaries are accustomed to evaluating emerging data and drawing conclusions from partially credible or incomplete data sets.
This seems like a reasonable and appropriately qualified description of the data set. Again, not proof positive, but interesting, and worthy of discussion and consideration.
— Ben A · Aug 12, 10:47 PM · #
It’s rather rich, the anti-intellectual/anti-philosophy nonsense in this thread. I thought conservatives had cornered the market on teh stupid.
— Kate Marie · Aug 12, 11:04 PM · #
“So healthcare should be a positive right? (Seriously. I’m not sure what you mean here.)”
Perhaps “commodity” is not the correct term here. Much like, say, electricity, health care is required to adequately function in the modern world. This makes it an inelastic product at some basic level. I certainly don’t believe that everyone is entitled to Cadillac plans with free nose jobs and unlimited colonoscopies for all. But I do believe they are entitled to what they need to survive, and for some people, that’s simply more than others. Fairness is each receiving what they need, not each receiving the same; its availability shouldn’t be predicated on ability to pay — the amount one pays for the necessary treatment should be predicated on one’s ability to do so. Health care is a public service that we’ve been conditioned to view as privatized. As a public service, it should be treated as any other social service.
It’s like Eric Hoffer said (to paraphrase): A social safety net encourages entrepreneurship and creativity. More people would take bigger risks to create businesses, new industries, and innovations of existing systems, if they knew that they wouldn’t suffer and possibly die if the venture failed. A basic safety net benefits society as a whole. Useful arguments are what that should look like, and how it is funded. The collective experience of the developed world is a telling example that our system is not it. The idea that a “free” market would do anything is a myth; the market can NEVER be free because it is always influenced by people and their interactions — an insight Smith himself noted lo these centuries ago. A “free” market can never be truly tried because it can never truly exist.
Kate,
Do tell. I expressed a personal distaste for much of philosophy, but that’s more a language thing — philosophy devolves into semanticism and wankery for the most part. I remain agnostic on the report cited by John. People I respect stand by high-deductible plans coupled with HSAs. People I respect do not. My own experience, working in public administration of social services, seems to indicate that there is much that private insurance does not care to provide, as it is not profitable to do so. I do not see much in the way of anti-intellectualism here, but I’m sure you’ll enlighten me.
— Erik Vanderhoff · Aug 12, 11:17 PM · #
A social safety net encourages entrepreneurship and creativity.
I agree here – ‘safety net’ is the proper frame. But a safety net is by definition a device to keep one from hitting rock bottom. It’s not supposed to be anybody’s Plan A.
So to be clear: I want a public option for the least fortunate. But it should be closer to Baby’s First Policy rather than Daddy’s Preferred Alternative.
Now what does that look like? I really don’t know, but it’s probably going to be closer to the ‘necessary’ end of the spectrum rather than the ‘sufficient’. And while I haven’t taken the time to define ‘necessary’, I think it could be negotiated without much gnashing of teeth.
Is that historically correct? I don’t think so: I think it might be the reverse.
— Kristoffer V. Sargent · Aug 13, 12:58 AM · #
Erik,
I remain agnostic on the report, too.
The anti-intellectualism that I detected was separate from any discussion of the the report or the health care issue.
A casual dismissal of philosophy as a discipline because it devolves into “wankery” or automatically renders one’s discourse suspect and “disingenuous” (as Chet suggested) is a species of anti-intellectualism.
I can certainly imagine that any similar dismissal on the part of a conservative would be met with howls of derision in certain quarters. How is Don’t trust what he says; he’s a philosopher different from Don’t trust what he says; he’s a pointy-headed elite?
You’re certainly welcome to your personal distaste for philosophy, but what is the point of expressing that distaste except to subtly denigrate the philosopher’s mode of discourse or argumentation?
— Kate Marie · Aug 13, 01:44 AM · #
They both seem to think that an HSA could be a vital component of a good public option system.
I think it could be. I’m unsure, at this point, although I’m interested and hopeful.
— Freddie · Aug 13, 02:43 AM · #
Then you, and supposedly John, would seem to agree with my point – since the study does not succeed in eliminating positive selection bias, the study is tainted by positive selection bias. Obviously.
“We’re the experts; just trust us when we arrive at conclusions based on insufficient, incomplete, or untrustworthy data.” Wow, can they walk on water as well? That the American Association of Actuaries has a pretty high opinion of actuaries comes as little surprise, really, but I see no reason to take their assurances of “skill” particularly seriously.
John, for all intents and purposes, stopped defending this study almost immediately. I don’t see why you feel you have to, and the study as presented is basically indefensible. The idea of a “comprehensive” metasurvey based on four sources – non peer-reviewed – would be laughed out of any science. Does it just work differently among actuaries? Not a good indication for the rigor of their field, frankly.
A quick search of scholar.google.com returns about 7,000 peer-reviewed articles on the subject of the costs and outcomes of consumer-driven health plans, and a quick look at some of the articles shows that very many of them meet or exceed all of the metareview’s criteria for inclusion – but were not included. What’s the explanation for this? Cherry-picking seems most likely; the unincluded studies are largely the production of public health institutions and research universities, not private insurance corporations.
— Chet · Aug 13, 02:47 AM · #
Did John’s absurd dictionary game add to, or detract from, discussion of this review in your opinion? (Try to separate your opinion on this issue from your opinion of me and John as people.)
— Chet · Aug 13, 02:50 AM · #
My absurd dictionary game?! Ha!
(And at least I was right, or so the consensus seems to indicate.)
— John Schwenkler · Aug 13, 03:39 AM · #
Oh, so we’re doing consensus dick-waving, now? How mature. Regardless, you can have your “comments from your peanut gallery” consensus, I’ll take the “results of the 2008 Presidential election” consensus.
— Chet · Aug 13, 03:55 AM · #
Things to not see: a consensus dick-wave.
— Kristoffer V. Sargent · Aug 13, 04:29 AM · #
You mean the one where I opposed McCain tooth and nail? Go take that consensus for a nice, long non-sequitur of a run, pal.
And on matters of grammar, by the way, consensus trumps.
— John Schwenkler · Aug 13, 04:31 AM · #
No, I was thinking the one where Barack Obama ran on a platform of health care reform and expanding access to affordable care, not the one where we “solve” the problem of unaffordable health insurance premiums and recission by simply uninsuring people.
You know, that election. How often do the American people have to vote against conservativism before it, you know, takes?
Your attitude keeps getting more and more adult! Why, at this point you might actually convince me you’re older than 12.
— Chet · Aug 13, 05:20 AM · #
It [John’s career in philosophy] shows, frankly, in your disingenuous replies.
That’s you, Chet — way before John’s “absurd dictionary game.” The “absurd dictionary game” was merely a correct rebuttal of your claim that the statement “selection bias was taken into account” implies that all selection bias was taken into account.
So let me ask you this. Did your resort to the I’ve looked in my interlocutor’s heart (and found him, alas, “disingenuous”) fallacy add to, or detract from, the discussion?
P.S. I actually don’t find it that difficult to separate my opinion on this issue from my opinion of you and John as people. I don’t know you as people. The only thing I know about either of you is how you choose to present yourselves here.
— Kate Marie · Aug 13, 06:12 AM · #
False. Here’s John’s comment to which my remarks about his philosophy vocation were a reply:
Did you even read this thread, Kate? Or did you just pop in to troll when you saw 60+ posts?
As a rebuttal to my claim that “the study is flawed by positive selection bias”, it does imply that all selection bias was taken into account. If John has now retreated from that attempted rebuttal, then he’s been forced to conclude that my claim was substantively correct. Positive selection bias is present in the study. Nobody’s been able to successfully contest this; do you?
— Chet · Aug 13, 06:44 AM · #
Let me get this straight, Chet. You’re defending the anti-intellectual and typically ungenerous swipe at the discipline of philosophy and at John’s intellectual honesty, because . . . John’s a lying liar and a no-good, dirty, rotten, lowdown scoundrel of a philosopher?
You read the thread again. The “dictionary game” wasn’t a rebuttal to your claim that the study is flawed by positive selection bias. It was a rebuttal to your claim that the phrase “selection bias was taken into account” means all selection bias was taken into account. You started the semantics game:
Now, now, John, don’t be dishonest. We can all read, after all. Here’s what you said:
“Read the paper; selection bias is explicitly taken into account in all the studies that are surveyed.”
Not “some bias is taken into account”, all the bias is accounted for. You can hardly say you’ve accounted for the bias if you’ve ignored accounting for some of it.
You quoted John. You presumed to tell everyone exactly what the direct quotation meant. You were wrong, and John pointed it out. And it’s not just little old moronic me who thinks so.
And here’s the thing, Chet. You might have had a point to make on this thread, especially for people (like me) who are “agnostic” on the issue of the report. But any point you make seems to have to be accompanied by another point — that your interlocutor is stupid and/or dishonest. Since that is demonstrably not true, everything you say becomes suspect. Instead of thinking to myself, “Hmmm, interesting point, Chet, I’ll think about it,” I say to myself “What an a**hole.”
I think you’re probably clever enough to understand how that works, which leads me to wonder whether you’re really interested in honest debate. And remind me again . . . what is it that they call people who constantly make bad faith arguments on blogs?
— Kate Marie · Aug 13, 08:01 AM · #
That seems implausible to me. 7,000 peer reviewed articles about CDH plans?
— J Mann · Aug 13, 12:16 PM · #
Supra shoes should be hired by the New Yorker to reject submissions. Shoes would phrase the rejection so that you actually felt better, if befuddled, for receiving it.
— turnbuckle · Aug 13, 02:14 PM · #
As it should. The actual number’s a bit over 500, and many of those will be duplicates or are not directly relevant to the present issues. That said, I think the question of why the AAA paper included only the studies it did is a legitimate one, though I’m not especially inclined to think that they’re any more biased than is, say, Chet.
— John Schwenkler · Aug 13, 02:18 PM · #
Is everything on Google scholar peer reviewed? I couldn’t figure out how Chet restricted his search to only return peer reviewed results.
— J Mann · Aug 13, 02:35 PM · #
Not at all.
— John Schwenkler · Aug 13, 02:52 PM · #
Sounds about right. Surely these remarks are justified by the fact that they’re true? Or can a spade not be called a spade? John’s remarks that I’m a child get a pass? Your remarks that I’m an asshole get a pass? How does that work, in your view? Conservatives get to say whatever they like?
As a rebuttal to “the study is flawed by the presence of positive selection bias”, that’s exactly what it must mean. Otherwise, how is it a rebuttal? How does it contradict my point at all?
Are you saying that John was agreeing with me, all this time? That he was agreeing that uncontrolled positive selection bias was present in the study, all along? Because he doesn’t seem to be. Fine, fine. John’s told me what he didn’t mean (he didn’t mean “all”.) You’ve told me what he didn’t mean.
Why won’t either of you be honest and forthcoming about what he did mean? Specifically – what he meant in the context of rebutting my statement than positive selection bias taints the study. How is it any kind of rebuttal to say that they “account” for it unless you mean to say that they account for all of it? If they don’t account for all of it, isn’t that my point? That the study contains unaccounted-for positive selection bias?
I feel like I’ve made this point several times. Why do you and John refuse to address it?
If you can’t separate your opinion of me from your opinion of my argument, as you now admit, doesn’t that make you the liar? I mean, isn’t that exactly what you said you “didn’t find all that difficult”, above?
— Chet · Aug 13, 05:03 PM · #
Your remarks that I’m an asshole get a pass?
Just calling a spade a spade, Chet. ;)
What’s interesting is that you’re willing to take the anti-intellectual line when it suits you. Them egghead philosophers are trying to manipulate all us straightforward Joes with their Jedi mind tricks and dictionary games. Guess you have more in common with those conservatives knuckle-draggers than you thought.
Once again, Chet, try to concentrate here, because I’m going to throw some of that tricky academic stuff at you . . . I don’t know you as a person. I don’t even know your name. I know you as the commenter “Chet” who makes an obnoxious ass of himself in his written comments at TAS. I don’t know you as that fun-loving guy eating Cheetos in his parents’ basement. I know you as “text,” and “Chet” the text is an a**hole. “Chet” has been an a**hole every since I have been reading comments here at TAS. What’s more, you yourself have admitted that you can be “assholish,” and you have implied that it’s just the freewheeling, raucous nature of the internet that makes you so. So you yourself seem to understand or imply that your character as “text” is distinct from your “real life” character. Now, we could have a philosophical discussion about whether character is static and inflexible or always in flux, but you know how all of us Joe Cheetos feel about those absurd dictionary games, right? ;)
— Kate Marie · Aug 13, 05:46 PM · #
Chet,
Can you provide a link to the search on scholars.google.com that produced “about 7,000 peer-reviewed articles on the subject of the costs and outcomes of consumer-driven health plans”? Also, how do you restrict your search to only turning up peer reviewed plans? I clicked around for a while, but I can’t figure out how you are doing it.
Thanks!
— J Mann · Aug 13, 05:55 PM · #
Okay, you know what? Any comments on this thread that concern the character of commenters (or authors) rather than health care policy are going to be deleted from here on out. And I apologize, of course, for my role in letting things get to this point.
— John Schwenkler · Aug 13, 07:24 PM · #
I’m sorry, too, John. I’m still angry, but I’m sorry.
— Kate Marie · Aug 13, 07:32 PM · #
I have a suspicion these Google scholar searches are turning up a great many brief squibs and articles in business magazines. I went spelunking about in EconLit, which I would imagine would be the primary utility for literature reviews undertaken by economists, and find fewer than thirty articles with references to ‘consumer driven health plan’ or ‘health savings account’ in their text, abstract, or subject heading. Much the same was the case with searches of MEDLINE. I have been through Academic Search Premier and Business Source Premier and discover perhaps 130-odd articles in academic and professional journals tangential to the subject. “Health Affairs”, “Benefits Quarterly”, and “Health Services Research” have all published multiple articles quite proximate to the topic.
— Art Deco · Aug 13, 11:41 PM · #
Ok, ok. Jesus. Why don’t we continue the policy debate then with one of the other points I raised in my very first post? You pick.
— Chet · Aug 14, 03:56 PM · #
Chet, do you plan to answer my question about your google scholar search? I would find it very helpful. Can you provide a link to your search, and also tell me how to restrict google scholar searches to peer-reviewed articles?
— J Mann · Aug 14, 06:03 PM · #
I don’t understand your question. Google Scholar is a scholarly-literature specific search engine. “Restrict” it to “peer-reviewed plans”? Help me make sense of that.
— Chet · Aug 14, 06:38 PM · #
A quick search of scholar.google.com returns about 7,000 peer-reviewed articles on the subject of the costs and outcomes of consumer-driven health plans
Chet, I believe J Mann is asking you to provide a link to the google scholar search that brought up 7,000 peer-reviewed aricles about consumer-driven health plans. In other words, could you please back up the claim you made about 7,000 peer-reviewed articles?
I don’t want to misinterpret your comment just above, but is your point that Google Scholar only provides links to peer-reviewed articles? I really don’t know; I’m not very familiar with Google Scholar. I’m asking sincerely.
Thanks!
— Kate Marie · Aug 14, 07:20 PM · #
Chet – Kate stated my question precisely.
Part 1 is could you please provide a link to th search that produced about 7,000 peer-reviewed articles on the subject of the costs and outcomes of consumer-driven health plans.
Part 2 is whether google scholar only produces links to peer reviewed articles or whether you used a restriction on your search to limit the results to peer reviewed articles, and if so, how you did it.
Thanks!
— J Mann · Aug 14, 08:19 PM · #
And believe me, J Mann, I’ve tried to respond several times now, but John keeps deleting the posts. It’s clear that he doesn’t want me to address your question.
— Chet · Aug 14, 08:48 PM · #
I should note that specialized databases will often index articles from publications pitched to the general reader and presumably Google Scholar does as well. My own efforts in “Academic Search Premier” and “Business Source Premier” generated many an article from ‘Workforce Management’, a trade magazine for personnel office staff.
As far as I can see, Google Scholar does not have a feature to restrict your search to publication type. My searches looking for articles with ‘consumer driven health plan’ and ‘health savings account’ somewhere in the text return some 1,278 articles, but I have no ready way to excise duplicates from the list.— Art Deco · Aug 14, 09:35 PM · #
Uhh, no, I haven’t deleted any of your comments on that subject. If you want to respond to JMann’s question, Chet, rather than continuing to advance strange theories about the meanings of words, please do.
And P.S. Google Scholar frequently turns up non-peer-reviewed (and indeed not even published) articles, and there’s no way to avoid this.
— John Schwenkler · Aug 14, 09:41 PM · #
Thanks, John. That’s helpful.
— Kate Marie · Aug 14, 09:52 PM · #
[Comment removed due to policy articulated earlier - John S.]
— jd · Aug 15, 03:16 PM · #
An easy claim for you to make, since only the two of us have seen the comments in question. The fact is that I have addressed the question in comments you’ve suppressed, comments that included no “strange theories about the meanings of words” but were nonetheless deleted. Of course, if I were simply lying, you could easily restore my comments and prove it, but I doubt you will. (You might simply restore comments that don’t address the question, or redacted comments with that material taken out, or any number of other tactics.) This is, frankly, the can of worms you open when you delete comments for no good reason.
— Chet · Aug 17, 06:28 AM · #