A Question For Megan McArdle

Megan McArdle responds to my last post:

“Surely the point of worry is that many millions of people will be forced into the public system, because its existence will encourage their employers to dump their health care plans. Since private systems have so far found it virtually impossible to deny many treatments for long, this will mean that millions of budget constrained people will find themselves with less available treatment than before. (…)

This is not a crazy worry. What America is best at is delivering a lot of complicated care in extremis, and “quality of life” treatments. What European countries are best at is delivering a lot of ordinary care for the sorts of things that afflict people from 0-50, which is why most of the Europhile journalists writing about Europe genuinely have very good experiences to report. I’d rather be here to have a hip replacement, but I might rather be in the Netherlands to have a baby. Doing something moderately ordinary here is a hassle. Doing something extraordinary there is often not possible for the overwhelming majority of citizens, though that depends on what, and in what system.”

The main point I wanted to make in my last post was this: if by ‘rationing’ you mean making it impossible for people to get certain kinds of care, even if they’re willing to pay for it themselves or buy supplemental insurance, then no one is proposing rationing. If, on the other hand, you mean ‘making people have to buy it themselves or pay for supplemental insurance’, then you have to count our current system as rationing care in such a way that 47 million people, plus all those who discover that their health insurance doesn’t actually cover the care they need, are ‘deprived’ of care.

What you don’t get to do is act as though the fate that would befall a 99 year old who needs a pacemaker (in the imaginary world in which no one has Medicare) is a horrible new scourge that Obama’s plan would introduce into the world. Or, in short: you don’t get to ignore the existence of the uninsured. (Or the underinsured, or those whose private plans deny them care.)

With that in mind, consider this sentence from McArdle’s piece:

“I’d rather be here to have a hip replacement, but I might rather be in the Netherlands to have a baby.”

A question for Megan: would you really rather be here for a hip replacement, given that you’d have about a one in six chance of being uninsured? If you say ‘yes’, does your answer rely on the fact that most people who need hip replacements are covered by Medicare? Would you also say ‘yes’ for some treatment that people your age are more likely to need?

If not, you’re relying on the assumption that the people you’re imagining actually have health insurance. In this context, that’s not a valid assumption.


UPDATE: Kevin Drum questions Megan’s assumption that we do, in fact, do better at managing serious diseases:

“If by “extraordinary” Megan means the most extreme 0.001% of procedures, then maybe she’s right. Maybe. But nothing I’ve read about Western European healthcare systems makes me believe that there’s any substantial difference between the way they treat severe illnesses and the way we do it. And no systematic difference in success rates for such treatment either. Nor should this come as a surprise, since most extreme medicine is practiced on older patients, who are covered by a public plan both here and in Europe.”

He’s right. But even if we pretend, for the sake of argument, that there is such a difference, we’d still need to bear in mind the possibility of being uninsured here when asking: where would I rather be if I needed medical care?

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