I cannot disagree with Uwe Reinhardt's response to me. But his response bears clarification and emphasis.

Improving "population health" generally means "helping people live longer."

To paraphrase, Uwe then writes:

If helping people live longer were our objective in health reform, we could do better than universal coverage. But health reform is not (solely or primarily) about helping people live longer. It is (also or primarily) about other things, like relieving the anxiety of the uninsured.

I applaud Uwe for acknowledging a reality that most advocates of universal coverage avoid: that universal coverage is not solely or primarily about improving health.

Will Uwe go farther and acknowledge that, since universal coverage is largely about some other X-factor(s), that necessarily means that advocates of universal coverage are willing to let some people die sooner in order to serve that X-factor?

This is an anecdote I have at my blog. It’s what they call “universal coverage” in Massachusetts:

I get my health care through MassHealth [Medicaid in Massachusetts] and I went through 20 names before I finally found a doctor who would see me. I wasn’t going through the Yellow Pages. I was going down a list that MassHealth gave me!

Michael Cannon invites us to reflect on his throught-provoking statement, and so I shall.

It has been known for many years that, at the aggregate level, the use of health care as we define it is only one of numerous factors that drive the average health status of populations (what we call "population health"). In fact, in health-production-function work or other research on the drivers of population health status, health care per say is only a minor player. Education, nutrition and environment rank higher.

So it is true that if "population health" were our objective in health reform, we would could do better than merely to finance more spending on health care per se. For example, the blasphemous thought occcurs that more could be done for the health status of particular the lower-income and less well educated strata of the population if the Catholic church reallocated real resources drastically away from hopitals systems and towards parochial schools in inner cities.

Even so, these insights are not that helpful when an axious person visits a physicians, looking for a diagnosis and treatment for whatever ails him or her. Telling someone stricken with cancer to forego health care and read a book is not really a staisfactory solution to the problem the uninsured face.

Furthermore, in this country one must contend with the Betsy McCaughey's, Sarah Palin's, Rush Limbaugh's of this world, along with large sections in the Congress, where Cost Effectiveness Analysis evokes talk of Adolf Hitler and death panels.

So Helen Levy's and David Meltzer's message is interesting among people who can and will think, but unfortunately it is a hard sell in this country.

Collapse

Let me state how touched I am by John Goodman's candor and modesty.

All of us, I am sure, will from time to time encounter situations or statement that push uas beyond our intellectual capacity. Usually, at meetings, we remain quiet about it, lest someone discover our intellectual limitations.

How refreshing then that John openly admits them, for all of us to see.

Uwe

The more important question is: should Congress even try to achieve universal coverage?

If the goal is to improve health, then the answer is clearly no.

Ironically, even though universal coverage is presumably about helping the sick, the Democrats’ pursuit of universal coverage demonstrates not how much, but how little they care about their neighbors’ health.

Economists Helen Levy and David Meltzer explain, in a book published by the Urban Institute, “There is no evidence at this time that money aimed at improving health would be better spent on expanding insurance coverage than on…other possibilities,” such as clinics, hypertension screening, nutrition campaigns, or even education. In the Annual Review of Public Health, they explain further: “The central question of how health insurance affects health, for whom it matters, and how much, remains largely unanswered at the level of detail needed to inform policy decisions…Understanding the magnitude of health benefits associated with insurance is not just an academic exercise…it is crucial to ensuring that the benefits of a given amount of public spending on health are maximized.”

If Democrats were serious about improving health, they would first gather evidence about which of those strategies produces the most health per dollar spent. (As I recommend elsewhere, the $1.1 billion Congress allocated for comparative-effectiveness research should just about do the trick.) Democrats would then fund the most cost-effective strategies, which may or may not include broader insurance coverage.

But the fact that Democrats are pursuing universal coverage without any such evidence necessarily means that they are willing to sacrifice potentially greater health improvements to achieve…whatever else they hope universal coverage will achieve.

Universal coverage is not about improving public health. It is about subordinating health to some X-factor that supporters value even more.

Which leads to an even more intriguing question: what is that X-factor?

Financial security? (If so, would universal coverage achieve that? Or are there better strategies?) Political power? Dependence on government? Industry subsidies? The appearance of compassion?

I’d like to see that question put to the group.

(Cross-posted at Cato@Liberty.)

Collapse

We should make every effort to secure health coverage for all Americans. However, instead of playing a numbers game of what percentage of the American public needs to have health insurance for it to be considered universal health coverage, we should focus on the key measures that need to be taken by Congress to move us towards the universal goal. At least two sets of improvements to the pending bills should receive top-priority attention.

First, we need to ensure that the Medicaid expansions for America's lowest-income people and families -- currently proposed under all pending bills to rise to 133 percent of the federal poverty level (approximately $29,300 in annual income for a family of four) -- truly reach everyone who qualifies for the program. The Urban Institute estimates that, under this improved standard, more than 22.7 million people will become newly eligible for Medicaid coverage. However, the Congressional Budget Office projects that only half of these people will actually be reached and get enrolled. Improving this enrollment will go a long way towards universal coverage. To achieve optimal enrollment will require rigorous outreach as well as an enrollment system that is user-friendly. New applicants should be enrolled through many portals, including points of health care service; they should be able to sign up without face-to-face interviews (which would cause them to lose a day of work); and they should be able to sign up for coverage when they apply for other means-tested programs. Additionally, since states will continue to administer the program, Congress should eliminate fiscal disincentives to undertake rigorous enrollment by providing full federal funding for the uninsured people newly covered by Medicaid. Second, Congress needs to improve the affordability of health coverage for people who can receive health coverage through the new exchanges. The sliding-scale tax credit subsidies need to be adequate so that health coverage is truly within the financial reach of currently uninsured people. Improving such affordability will make the individual mandate more realistic and, more importantly, will add many uninsured people to health care coverage.

Collapse

I've read Uve's comment several times and cannot make sense of it.

But then the question we are answering is sort of nonsensical. Universal coverage has not been the goal since the Democratic Primary contest ended -- some time last August.

Now there is only one goal: pass a bill.

It's funny how we all talk about it as if we knew what it was; but operationalizing it is quite a challenge.

The definition has at least two distinct dimensions: (a) the benefit package that is considered minimally adequate and (b) the fraction of discretionary income (disposable income minus estimated minima spending on food, housing, utilities, etc.) that is absorbed by health spending on that minimum package (out-of-pocket spending on it plus premiums paid).

So we would count as "uninsured" anyone who has less than that minimum package or spends mor than the normative percentage of discretionary inome on it or is characterized by both..

People who spend less than the normative percentage of their income on the benefit package (perhaps zero) but could afford it within that limit (perhaps with the help of subsies) would be called "self-insured).