The Cost of Defensive Medicine

David Leonhardt reviews research on malpractice and finds what I have been saying. Malpractice does not have the effect on health care costs which many conservatives claim and even the total elimination of malpractice would only have a modest affect on costs. However,  malpractice, primarily due to defensive medicine, does result in unnecessary expenses which we still should try to recover to attempt to pay for the current health care reform measures. Leonhardt writes:

The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.

The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.

At the same time, though, the current system appears to treat actual malpractice too lightly. Trials may get a lot of attention, but they are the exception. Far more common are errors that never lead to any action…

Medical errors happen more frequently here than in other rich countries, as the Robert Wood Johnson Foundation recently found. Only a tiny share of victims receive compensation. Among those who do, the awards vary from the lavish to the minimal. And even though the system treats most victims poorly, notes Michelle Mello of the School of Public Health at Harvard, “the uncertainty leads to defensive behavior by physicians that generates more costs for everyone.”

It should also be noted that often errors are not addressed because medical institutions are afraid that admitting errors will subject them to suits. Reforming our current system would be helpful in reducing true medical errors.

While I agree with Leonhardt’s general findings on malpractice, I would caution the exact amount spent on defensive medicine is very hard to measure. There will be honest disagreement as to what tests are legitimate and which are examples of defensive medicine. Habits also die hard. Studies based upon a reduction in defensive medicine after changes in laws will not be exact as it will take time for physicians to change their habits even if the threat of malpractice is removed. Unfortunately this also means that, while we should pursue such savings, they might not amount to as great a number in the short run as many believe.

The Growth of Extremism

Andrew Sullivan quickly summarizes new data from Public Policy Polling:

More Republicans believe that the president is illegitimate and born in Kenya than those who acknowledge reality. A quarter of Dems believe Bush allowed 9/11 to happen. But at least a big majority – 63 percent – are not insane.

I guess it is a good thing that at least a big majority of Democrats are not insane but this number is still too high for comfort. Finding that a majority of Republicans are insane is also unfortunate but no surprise. Checking the actual data:

Among Republicans there are more voters- 42%- who think he was born somewhere else than there are- 37%- who will say for sure that he was born here.

Upon first reading Sullivan’s post I thought there might be a way to rationalize the Democratic findings. I do not believe that if George Bush had paid attention to the daily intelligence brief which warned of the attack, or if he had any idea as to what to do about it, he would have allowed the attack to happen. I believe that the success of the attack could partially be attributed to Bush’s incompetence, but not to any actual intentions of Bush. Therefore I could see how wording such as “Bush allowed 9/11 to happen” could lead some to say this is true depending upon how they interpreted this. However, reading the actual wording excludes any such interpretation:

Do you think President Bush intentionally allowed the 9/11 attacks to take place because he wanted the United States to go to war in the Middle East?

This does limit the yes answers to the insane, just like those who denied that Barack Obama was not born in the United States, along with the smaller  numbers who consider Obama or Bush to be the Ant-Christ. (Actually I wonder how many people just answered yes to the Ant-Christ questions to screw with the pollster. I might have been tempted to do so).

Republican Congressman Sees Gay Marriage As Socialist Concept

Demonizing gay marriage becomes more difficult when we consider the individuals involved. Republicans have no problems with generalized attacks. Think Progress quotes Republican Congressman Steve King as resorting to the usual right wing name calling on same sex marriage: “And not only is it a radical social idea, it is a purely socialist concept in the final analysis.”

Republicans, in a throwback to McCarthyism, love to throw around claims of socialism. They also like to use gay marriage and homophobia to motivate the right wing base and bring in more votes. After all, despite their success with the Southern Strategy, they cannot always rely upon racism and xenophobia to win elections.

Republicans often forget that they are dealing with people. Therefore we see this contradiction between a personal viewpoint and Republican policy in Bush speechwriter Matt Latimer’s new book:

For a commencement address at Furman University in spring 2008, Ed Gillespie wanted to insert a few lines condemning gay marriage. Bush called the speech too “condemnatory” and said, “I’m not going to tell some gay kid in the audience that he can’t get married.” (Of course, Bush ran his 2004 campaign telling that kid just that.)

It is one thing to run a political campaign or to make bizarre generalizations comparing gay marriage with socialism. Even George Bush was bothered when he actually considered individuals. Similarly Dick Cheney’s views varied from the Republican mainstream when he considered his own daughter.

It is harder to accept Republican bigotry when considering how it actually does affect individuals. Andrew Sullivan recently discussed the personal problems he faces due to American laws regarding both gay marriage and immigration:

I’ve been in the US for a quarter of a century, have paid taxes when I was working, am married to an American and have never asked for a dime of public help. But the US – alone among developed nations – still persecutes non-Americans for having HIV and regards my civil marriage as null and void and my husband as a total stranger to me.

Britain doesn’t persecute people with HIV and never has; moreover, Britain would allow my husband and I to relocate together to England at any point. I’m not sure people fully understand what it’s like to build a life with someone and to do all you can to contribute to a society – and yet be vulnerable at any moment to having your family torn apart by the government. But it’s a strain that eventually becomes crippling: you have no security, no stability, no guarantee that you have a future you can count on. And that affects an American citizen, my husband, as well.

Why has America become such a callous outlier on these matters? Why is the government forcing more and more able, qualified, productive and talented citizens into a diaspora to protect their families? And why, even after a big victory for Obama and a Democratic Congress, is there not the slightest chance of any progress for the foreseeable future?

Because it’s about gays. And we are still, in the eyes of the federal government, sub-human.

Hopefully Sullivan is wrong about there not being the slightest chance of any progress on these issues.

Placing the Individual Mandate in Perspective

While philosophically I object to a mandate to purchase health insurances, it is also necessary to look at the issue pragmatically. Compromise is often necessary to pass legislation and the reality of the situation is that we might face a choice of health care reform with mandates or no health care reform at all. As I’ve often said in discussing health care legislation, the details are essential.

While I would prefer not to have mandates at all, the manner in which mandates are enforced is an important point. The most hysterical conservatives sometimes talk of people being dragged off to reeducation camps for refusing to comply with ObamaCare. More realistically, there will be ways to opt out and, especially with Obama’s initial opposition to mandates, I suspect that enforcement will not be a major priority. The details of any legislation are especially important on this point. The Wall Street Journal places this somewhat in perspective with a description on the penalties now under discussion:

Mr. Baucus said his reduced penalties would ease the burden on those who refuse to carry insurance. The top fee of $1,900 would apply to families with incomes between three and four times the federal poverty line, which currently stands at about $22,000 a year for a family of four. The penalty for individuals who earn three to four times the poverty level was also halved, to $750 from $1,500.

Looking at these numbers makes an individual mandate appear less of an intrusion on individual liberty. The fact does remain that having people without insurance will result in some public spending when those who believe they are invincible wind up utilizing health care resources. Paying an amount into the system which is far less than the cost of actually purchasing health insurance may be a reasonable compromise. While I would still prefer that health care legislation went down a different pathway without mandates, having mandates is not necessarily a deal killer.

Mandates Are Once Again An Issue

Whether or not to have an individual mandate to purchase health insurance was a controversial issue during the 2008 battle for the Democratic nomination but is now only beginning to be raised during this year’s health care debate. Soon after Obama became president many in the insurance industry began to make statements that they would accept health care reform with the elimination of pre-existing conditions if there was an individual mandate and universal coverage. This was initially seen as both a worthwhile sign of cooperation and a pragmatic move on the part of the insurance industry to increase the size of their market. In realty this was a way for insurance companies to limit the down side if health care reform passed while continuing to fight it.

The political effect of this was to suspend any meaningful political opposition to mandates. The Republican Party, being in the pocket of the insurance industry, would only oppose their wishes as a last resort. Having both major elements of the Democratic Party as well as the Republicans backing mandates, Obama surrendered to pragmatism in the hopes of passing health care reform and gave up his opposition.

There is suddenly opposition to mandates coming from both the left and the right. As the public option got into trouble, many liberals had second thoughts about forcing people to buy health insurance from insurance companies they have legitimate reasons to distrust. Suddenly Republicans are showing signs of changing their view on the subject. In reporting recent objections to mandates being expressed by some Republicans, Sam Stein notes how they backed mandates until recently:

Indeed, for months it was presumed that a relatively ironclad deal was in place: in exchange for the government mandating coverage, private insurance companies would agree to cover individuals with pre-existing conditions. The arrangement was all but blessed by prominent figures from within the GOP ranks. In mid-August, the ranking member of the finance committee, Sen. Chuck Grassley (R-Iowa), announced that the way to get universal coverage is “through an individual mandate.”

“That’s individual responsibility,” the senator told Nightly Business Report. “And even Republicans believe in individual responsibility.”

Months earlier, Grassley told Fox News that there wasn’t “anything wrong” with mandates even if some may view them “as an infringement upon individual freedom.”

“But when it comes to states requiring it for automobile insurance the principle then ought to lie the same way for health insurance,” Grassley added. “Because everybody has some health insurance cost and if you aren’t insured there aren’t free lunches.”

Grassley wasn’t alone. His fellow Republican Senator John Thune (R-S.D.) recently told reporters that while he was conflicted on a mandate, it was “something I guess that I would take a look at. There — there are good arguments on behalf of getting everybody in the — in the pool,” he said. Former Massachusetts Governor Mitt Romney made an individual mandate a staple of the health care overhaul he pursued for his state. “For the uninsured who can afford insurance but expect to be given free care at the hospital, require them to either pay for their own care or buy insurance,” he wrote in Newsweek.

Former Senate Majority Leader Bill Frist, himself a doctor, told Fox Business Network that consumers should “be responsible to paying for” their insurance. If they can’t afford it, he added, “there are going to be taxes, excise taxes, user taxes on companies like Aetna, on individuals.”

Meanwhile, six current Republican Senators – Lamar Alexander (Tenn.), Bob Bennett (Utah), Mike Crapo (Idaho), Lindsey Graham (S.C.) and Judd Gregg (R-N.H.) – all have sponsored legislation (Sen. Ron Wyden’s 2009 “Healthy Americans Act”) that includes an individual mandate.

Steve Benen notes the change in view among Republicans and concludes:

Congressional Republicans could probably save themselves a lot of trouble by simply saying, “Whatever Democrats are for, we’re against,” in response to every question.

The answer is slightly more complicated than this. The top priority for Republicans is to block health care reform not because of ideology or objection to any specifics but because they do not want to see the Democrats have a legislative victory of this magnitude. They see opposing health care reform as improving their chances for picking up House seats in 2010. They are even willing to risk crossing the health insurance industry on mandates if they find it necessary to raise a new objection, probably figuring that the insurance industry will continue to contribute to Republicans, especially if they are successful in blocking health care reform.

James Joyner has linked to one of many posts I have written in opposition to mandates. I agree with him that, despite the questions of hypocrisy raised above, this is controversial and is a legitimate objection to Obama’s current policies.  I disagree with him in citing this one reasonable objection to the current health care reforms as evidence that the general opposition to health care reform has been reasonable. Not only have most (but not all) conservatives been silent about this objection until now, but the vast majority of objections have been absurd. Having some valid objections such as opposition to mandates does not make false claims of “death panel,” “a government take over of health care” and other Republican distortions of what is being proposed any more justifiable.

(As an aside, Big Tent Democrat also linked to my post via Joyner. The manner in which I sometimes distinguish between progressivism and liberalism as well as any views on taxation would be a needless distraction from the main points of this post. Therefore for the moment I’ll just note that for Big Tent Democrat–especially considering his track record–to call views of mine he has no knowledge of “rather absurd” is like Sarah Palin calling views she has no knowledge of too intellectual. I do share some of his concerns about the Baucus plan.)

I fear that the new found objection to mandates is too little too late. I can imagine a scenario in which Republicans objected to this at the start, leading Obama to stick to his initial opposition to mandates in hopes of achieving a bipartisan compromise. In such a scenario Congressional Democrats might have continued to write legislation which included mandates, largely because, regardless of my philosophical objections, including mandates is much simpler. Perhaps health care reform might have been written differently based more upon voluntarily providing assistance to those who require assistance with coverage, as well as eliminating many of the unsavory practices of the health insurance industry.

At this point it is doubtful that they will start from scratch and go about writing health care reform in a different manner. Besides, even a voluntary approach would still result in GOP opposition, as they also attacked John Kerry’s voluntary 2004 plan as “a government take over of health care.” As Steve Benen noted, having the Democrats propose a plan is enough to have Republicans oppose it.

Update: Placing The Individual Mandate in Perspective