Cafe Hayek

Sickness is bad for your health

Evidently, smoking, obesity and diabetes are bad for your health. So is sickness. Death is bad for your life expectancy. So discovers the New York Times:

THROUGHOUT the 20th century, it was an American birthright that each generation would live longer than the last. Year after year, almost without exception, the anticipated life span of the average American rose inexorably, to 78 years in 2005 from 61 years in 1933, when comprehensive data first became available.

But new research shows that those reassuring nationwide gains mask a darker and more complex reality. A pair of reports out this month affirm that the rising tide of American health is not lifting all boats,...

I'm going to stop the quote there for a moment.

Is the reality really "darker and more complex?" Does anyone really think that "the rising tide of American health" lifts all boats?

Does anyone think that rising life expectancy is really a birthright?

If you go sky-diving every week without a parachute or even with one, you don't live as long as the average. If you smoke a lot and eat too much, you might not live as long as the average:

The most startling evidence came last week in a government-sponsored study by Harvard researchers who found that life expectancy actually declined in a substantial number of counties from 1983 to 1999, particularly for women. Most of the counties with declines are in the Deep South, along the Mississippi River, and in Appalachia, as well as in the southern Plains and Texas.

The study, published in the journal PLoS Medicine, concluded that the progress made in reducing deaths from cardiovascular disease, thanks to new drugs, procedures and prevention, began to level off in those years. Those gains, as they shrank, were outpaced by rising mortality from lung cancer, chronic obstructive pulmonary disease and diabetes. Smoking, which peaked for women later than for men, is thought to be a major contributor, along with obesity and hypertension.

Read the rest of the story if you really want to know why this unsurprising absolutely unstartling finding confirms the world view of John Edwards.

Is health care a right?

Is health care a right? I have no idea. What I do know is that treating it like a right can be hazardous to our health. Here's my debate on the issue with a doctor who thinks health care is a right and the government should provide it.

Feedback, knowledge and the division of labor

Arnold Kling over at EconLog tells the poignant story of worrying about his father's health care. Anyone who has had a loved one in the hospital can relate. There are a lot of smart and caring people involved in the treatment, yet no one is overseeing the process and noting the interactions between this specialist and that one. No one is watching the heart rate zealously. The overworked nurse under pressure from another patient fails to note something crucial on the chart. Lots of cooks but no one's in charge. Usually a family member has to play that role, a family member who more often than not doesn't have the time for the full-time assignment and more than often not doesn't have the expertise other than to ask a lot of questions.

Economists talk about the power of specialization and the division of labor. Economists talk about how well things can work when no one's in charge. In the hospital though, it appears not to work as well as it might. Lauren in the comments to Arnold's post asks the right questions:

For which kinds of economic entities does division of labor break down? Why is it that sometimes having no one individual in charge is the economic ideal that is coordinated by the invisible hand, and other times not?

One answer is that maybe it works better in the hospital than it looks. Would we really want our parents in the hospital to be treated by a generalist? There are enormous amounts of knowledge and technology being brought to bear in curing people in a modern hospital.

But it clearly could be so much better than it is. We want the benefits of specialization without the costs, the same way we get them in other areas of our lives. What we want is someone to coordinate the process, someone other than ourselves to look out for the hammer-nail problem. All the specialists I've known are people with a hammer. Everything looks like a nail. The surgeon wants to cut. The oncologist want to give chemo. Beside the interaction problem, you want to make sure you don't have a specialist blinded by too much specific knowledge who fails to see the bigger picture

So why do we need someone in charge in the hospital but not in the graphite industry? In the graphite industry, there are plenty of pencils, tennis rackets and fishing rods and the dozens (thousands?) of products that use graphite. We don't need a graphite czar to make sure there's enough graphite to go around. All the specialists that contribute to those products don't get out of control. Their interactions don't get ignored. As Hayek pointed out, the knowledge gets coordinated without a coordinator. Why does it work there but not in the hospital?

The simple answer is that the price system and profit motive interact in the graphite industry causing the whole thing to work smoothly without it being anyone's intention. The prices and the profit motive lead to feedback and accountability. There are a whole bunch of people with the incentive and the information to make the system work well.

The simple answer is right. But it cannot explain why other organizations work well without prices and profits. Within a firm and within a family, resources and decisions get made without prices and often without profits. The answer (as Coase understood and as Lauren notes in her comment) is that in these organizations, the savings in transaction costs overcomes the loss of feedback and information benefits from using prices. But there are still incentives. There still is a residual claimant who bears the costs of failure and the benefits of success—the boss or the parent. Love motivates the parent. Bonuses and keeping your job motivate the boss.

So why doesn't a hospital work better? The answer I think, is that the level of specialization in medicine has emerged from a process that has very few incentives to make sure that the level of specialization is as productive as it should be. There are very few informational feedback loops. Very little accountability. Sure, if a surgeon leaves a scalpel in your chest cavity and sews you back up, the surgeon bears a cost. And as a result, it doesn't happen very often. But the kind of errors that Arnold worries about, the kind of errors that I've worried about with my Dad in the hospital (and the kind I've seen made) are the ones that have little or no consequence to anyone other than the patient.

These errors are built into the system. When a drug leads to unexpected side effects because the right questions weren't asked, when an opportunity for a safer treatment is missed, when an aggressive treatment for one illness weakens the immune system and leads to other problems, who can you blame? Who bears a cost other than the patient?

You can blame the hospital of course, whatever that means, but the costs to the human beings who work in the hospital are small. There are no feedback loops within the hospital to reward generalists who look for the costs of specializations. And the reason there are not is because the patient is not the customer. The patient is not paying the bill. The financial incentives that do exist are coming from Medicare and Medicaid and the insurance companies. The normal feedback loops that protect the customer from error and greed and simple stupidity are missing. In a way, it's amazing it works as well as it does. It works as well as it does presumably because most doctors and nurses do care about the lives in their hands. But it's imperfect and could be much better.

And because there isn't a residual claimant within the hospital, it is left to the wife or the husband or the parent or the child of the patient to represent the patient's interests in the face of the decentralized incentives presented by the hospital and its specialists. Ironically, the monitoring and feedback comes from the family, another organization that is usually not using monetary incentives to improve performance. But the love works pretty well.

But the patient who is unrepresented for whatever reason, who must rely on the system itself to keep an eye on the treatment regimen is at a greater risk than the patient whose wife is a doctor or better yet, a loving doctor or better yet, a loving doctor who is at her husband's side 24/7 until he comes home safely.

It's a flawed system that will stay that way until the incentives change. In the meanwhile, my heart and prayers go out to Arnold and his Dad and to anyone with a loved one at a distance going through a medical challenge.

Affordable Health Care

Are many Americans really unable to afford health care?  No.  Or, more precisely, the question is flawed -- as I argued in this column a few years ago.  Here are some key paragraphs:

But health care, like most things in life, is not like pregnancy. It comes in an enormous range of degrees. At one extreme is the amount and quality of health care that Bill Gates might purchase -- personal physicians and pharmacists, each devoted exclusively to Gates; monthly physicals conducted with the most advanced technology; immediate transportation in a private jet to the world's finest hospitals for treatment by the world's most acclaimed physicians; and recuperation at luxurious Swiss resorts attended round-the-clock by a staff of doctors, nurses and dieticians of unparalleled excellence.

Now imagine the opposite extreme -- the case of someone who can afford no health care at all. This horribly unfortunate person would not only be unable to visit a physician to check out that runny nose or that blurry vision, he could not afford even to buy over-the-counter antihistamines, aspirin, cough drops, rubbing alcohol, hydrogen peroxide, reading glasses, Band Aids, athlete's-foot spray, vitamins, toothpaste, condoms, or any of the many other health care and personal hygiene products for sale in every supermarket.

Almost all Americans, of course, consume an amount and quality of health care somewhere between the amount consumed by billionaires and the amount consumed by homeless paupers.

Continuing Assaults

At a family gathering this weekend in New Orleans -- as I enjoyed a rich, very yummy, and sodium-laden bowl of okra gumbo -- I complained to a cousin about the recent calls to have the government force food-preparers to use less sodium.  Karol -- sitting nearby and enjoying her own sodium-enriched Cajun dish -- lamented with me the fact that our freedoms are increasingly under assault (pun intended).  But, she pointed out, the alleged justification for such intrusions isn't so much a simple nanny-state itch to treat us as children but, rather, the need to control health-care costs.

Of course Karol is correct.  This "stop each of us from imposing costs on others" justification is typically used to support motorcycle-helmet regulations, smoking bans, and, now, eat-less-salt commands.  And as more and more of Americans' health care is provided collectively, the ring of validity to such justifications increases in volume.  As Russ points out, if you're paying, I'm ordering the expensive menu items.

If you are obliged to subsidize the costs of my behavior, then you clearly have an interest in restricting any of my behaviors that might potentially raise the costs you bear as my subsidizer.

But a question: if the proponents of greater collectivization of health-care provision not only recognize this fact but cite it as a justification for restricting personal freedoms that would otherwise be no one else's business, it seems to follow that these proponents of collectivization of health-care provision would recognize also that the problem is so general that it indicts the very idea of collectivization of health-care provision.

Because such collectivization creates a giant tragedy of the commons – because such collectivization enables each of us at each moment of making health-care choices to impose most of the costs of our choices on others – such collectivization will require not only that government restrict our access to fun but unhealthy life choices (such as eating lots of Cajun food), but also restrict our access to medical-care.

So the idea that a young mother whose child has a runny nose will be able to skip off to the pediatrician pronto for a diagnosis and treatment is chimerical.  Just as collectivization of health-care provision will encourage people to eat too much sodium and too much bacon, it will also encourage people to seek medical treatment too frequently and too frivolously.  And in both cases, these attempts to free-ride on the largess of the collective will oblige the protectors of the collective to restrict personal freedoms and personal choices lest the collective be utterly ruined.

Bonus podcast on health care costs

Here's a midweek bonus podcast on the issue of health care costs that came up recently at EconTalk and here at Cafe Hayek. It's an interview with Henry Aaron of the Brookings Institutions about the challenges of measuring administrative costs and how much they might fall if we had government-funded health care.

His fault

I get it. All along, I thought it was her fault. But it wasn't. Turns out it was his fault. I'm talking about Hillary's health care plan, her one serious life experience of government action, that didn't turn out so well. But it wasn't her fault that it failed. It was Bill's fault. Why? Well, he didn't provide enough budgetary slack for her. So of course it failed. It had nothing to do with the goal of creating a top-down, expertly designed from scratch, bureaucratic monstrosity. Nope. His fault:

"She has taken the rap for some of the problems we had with health care the last time that were far more my fault than hers," the former president said.

He said part of the problem was a lack of money to finance the health care expansion. Money could be available this time to pay for expanded health care, such as the universal health care plan Hillary Clinton has proposed.

"This time, when you let the tax cuts for upper-income people expire, it'll create a pool of money that wasn't there last time," Bill Clinton said. "We told her she had to get to universal coverage and there would be no new money. She had to figure out how to do it."

Poor Hillary. She had to figure out the money problem. That was the problem and that problem was his fault. How could she be expected to get blood from a stone? His fault.  Not her fault.

How dumb do these people think we are? (That's a rhetorical question.)

Pass the doughnuts

Remember that obesity epidemic? Remember how it can spread unknowingly from friend to friend? What do you call an epidemic that causes you to live longer? Any minute now, public health officials will be clamoring for subsidies for McDonald's and Krispy Kreme.

Cut those costs!

If the government paid for everybody's health care, some argue that we'd save money by cutting out administrative costs. The logic is that we'll save on all those bureaucratic duplications caused by multiple insurance providers. The empirical evidence is that in countries where government pays for health care, they spend less for health care than we do in America.

But as Arnold Kling points out, they spend less not because they're more efficient but because they provide fewer services. Charlie Quidnunc makes an even deeper point in the comments on this earlier post:

If profits and administrative costs are so terrible, why stop at eliminating them in the health industry? Why not get rid of those pesky elements in other industries? How about creating a single provider Information Technology industry? Think about how much better computers would be without all that complex and expensive competition between companies. Or single provider Automobile industry. Or single provider food companies. Why not have the government decide what a wholesome and nutritious meal should look like and eliminate all that expensive experimentation in fancy restaurants?

Here is additional wisdom on the issue from Tyler (HT: Whatever).

The big impact of pharmaceutical industry profits

Proponents of a single-payer system in health care argue that it would save costs because of lower industry profits and lower administrative costs. Arnold Kling argues that the impact would be minimal. Is he right?

According to Public Citizen, a source not particularly friendly to corporate interests, pharmaceutical industry profits in 2002 (the year I happened to stumble on) were 36 billion. If all pharmaceutical companies were forced to serve the public at zero profit, that would lower US health care expenditures from 1.3 trillion to 1.3 trillion.

That's a pretty small change

I'll carry it out to a few more decimal places. In 2002, total health care expenditurea in the US were $1.342 trillion. So taking out ALL pharmaceutical profits lowers that number to 1.306 trillion. I don't think there's any way you can argue that the profitability of the pharmaceutical industry is a large factor in the size of US health care costs or that moving to a system where government could exploit its power as a large buyer of drugs would lower total expenditures.

Does anyone have data on administrative costs in the current system?

Growth in health care expenditures

This week's EconTalk is with Arnold Kling talking about health care. it's a very nice introduction  to the incentives affecting our health care decisions both privately and publicly. One issue that came up is the change in the proportion of health care costs paid out of pocket vs. third party payments. Here are some data, taken from an HHS publication, "Health, United States, 2005":

In 1960, 55 cents of every dollar of health care was out-of-pocket. In 2003, it was down to 16 cents.

In the Teeth of the State

CNN reports on a new study that finds that Brits are pulling their own teeth and otherwise providing self-dentistry because of their difficulty of finding affordable dentists -- yet further evidence that government-supplied health care is unhealthy.  Here are the opening paragraphs:

Some English people have resorted to pulling out their own teeth because they cannot find -- or cannot afford -- a dentist, a major study has revealed.

Six percent of those questioned in a survey of 5,000 patients admitted they had resorted to self-treatment using pliers and glue, the UK's Press Association reported.

England has a two-tier dental care system with some dentists offering publicly subsidized treatment through the National Health Service and others performing more expensive private work.

But more than three-quarters of those polled said they had been forced to pay for private treatment because they had been unable to find an NHS dentist. Almost a fifth said they had refused dental treatment because of the cost.

One respondent in Lancashire, northern England, claimed to have extracted 14 of their own teeth with a pair of pliers. In Liverpool, one of those collecting data for the survey interviewed three people who had pulled out their own teeth in one morning.

"I took most of my teeth out in the shed with pliers. I have one to go," another respondent wrote.

Others said they had fixed broken crowns using glue to avoid costly dental work.

(HT Brian Summers.)

Reality Is Not Optional

The web-only edition of today's New York Times published this letter of mine on health care.

Who cares what modern health care-delivery methods are called? The elemental problem is that more and more people feel entitled to vast quantities of high-quality health care paid for by someone else.

And politicians, ever lusting for office, are only too happy to conjure the ridiculous illusion that A will get top-flight service from B when C is forced by G to pay the bills.

Donald J. Boudreaux
Fairfax, Va., Sept. 28, 2007
The writer is chairman of the economics department, George Mason University.

The author of the letter published along with mine is like so many others: he forgets that -- to steal Thomas Sowell's phrase -- reality is not optional.  Calling health care "a necessity" does nothing to make it universally available in quantities and qualities sufficient to satisfy all demands that would be expressed for it by individuals each of whom is not required personally to pay for the care he or she receives (or seeks to receive).

Stossel on Moore

John Stossel of ABC News is a seasoned reporter with a keen nose for the facts.  In this op-ed in today's Wall Street Journal, Stossel reveals some important facts that Michael Moore missed in the docu-ganda movie "Sicko."

Here are some key passages from Stossel's excellent essay:

Mr. Moore claims that because private insurance companies are driven by profit, they will always deny care to deserving patients. For this reason, he argues, profit-making health-insurance companies should be abolished, our health- care dollars turned over to the government, and the U.S. should institute a health-care system like the ones in Canada, Britain or France. But does Mr. Moore think, even for a second, that any of the government systems he touts in his movie would have provided a bone-marrow transplant to Ms. Pierce's husband? Fat chance.

When government is in charge of health care, the result is not that everyone gets access to experimental treatments, but that people get less of the care that is absolutely necessary. At any given time, just under a million Canadians are on waiting lists to receive care, and one in eight British patients must wait more than a year for hospital treatment. Canadian Karen Jepp, who gave birth to quadruplets last month, had to fly to Montana for the delivery: neonatal units in her own country had no room.

Rationing in Britain is so severe that one hospital recently tried saving money by not changing bed-sheets between patients. Instead of washing sheets, the staff was encouraged to just turn them over, British papers report. The wait for an appointment with a dentist is so long that people are using pliers to pull out their own rotting teeth.

Patients in countries with government-run health care can't get timely access to many basic medical treatments, never mind experimental treatments. That's why, if you suffer from cancer, you're better off in the U.S., which is home to the newest treatments and where patients have access to the best diagnostic equipment. People diagnosed with cancer in America have a better chance of living a full life than people in countries with socialized systems. Among women diagnosed with breast cancer, only one-quarter die in the U.S., compared to one-third in France and nearly half in the United Kingdom.

Mr. Moore thinks that profit is the enemy and government is the answer. The opposite is true. Profit is what has created the amazing scientific innovations that the U.S. offers to the world. If government takes over, innovation slows, health care is rationed, and spending is controlled by politicians more influenced by the sob story of the moment than by medical science.

And be sure to watch Stossel's special on health care, to be aired this Friday on ABC, at 10:00pm EDT.

Rank Ranking

John Stossel of ABC News writes a regular column.  Every one is worth reading.  His most recent column exposes some of the flaws in those now-celebrated rankings that purport to find that medical care in the U.S. is inferior to that in countries such as France, Morocco, and Cyprus.

Here's a chunk of Stossel's column:

So what's wrong with the WHO and Commonwealth Fund studies? Let me count the ways.

The WHO judged a country's quality of health on life expectancy. But that's a lousy measure of a health-care system. Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That's not a health-care problem.

Similarly, our homicide rate is 10 times higher than in the U.K., eight times higher than in France, and five times greater than in Canada.

When you adjust for these "fatal injury" rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation.

Diet and lack of exercise also bring down average life expectancy.

Another reason the U.S. didn't score high in the WHO rankings is that we are less socialistic than other nations. What has that got to do with the quality of health care? For the authors of the study, it's crucial. The WHO judged countries not on the absolute quality of health care, but on how "fairly" health care of any quality is "distributed." The problem here is obvious. By that criterion, a country with high-quality care overall but "unequal distribution" would rank below a country with lower quality care but equal distribution.

It's when this so-called "fairness," a highly subjective standard, is factored in that the U.S. scores go south.

The U.S. ranking is influenced heavily by the number of people — 45 million — without medical insurance. As I reported in previous columns, our government aggravates that problem by making insurance artificially expensive with, for example, mandates for coverage that many people would not choose and forbidding us to buy policies from companies in another state.

Even with these interventions, the 45 million figure is misleading. Thirty-seven percent of that group live in households making more than $50,000 a year, says the U.S. Census Bureau. Nineteen percent are in households making more than $75,000 a year; 20 percent are not citizens, and 33 percent are eligible for existing government programs but are not enrolled.

(HT Sandy Baillie)

A Lesson from Passport Control

Late Friday evening, Karol and I flew, on Delta Airlines, from Bucharest to New York's JFK airport.  We had two hours to connect to our Delta flight to Washington's Dulles airport.  We missed our flight.  And herein lies a lesson.

The reason we missed our flight is that nearly 50 minutes of our time after landing was consumed by waiting in a long and slow-moving line to clear passport control.  At that terminal on Friday evening, the TSA had only three agents to service the line of U.S. citizens returning from abroad.  Three.  That's it.  Most of the passport-control-agent booths stood empty.

So as we silently fumed and inched forward in line, I couldn't help but wonder why so many people want the same agency that cannot adequately staff one of the country's busiest international airports (during the height of international-travel season) to run Americans' health-care.  If government were to take over more completely the supply of medical services in the U.S., the same sorts of under-staffing (i.e., shortages of service) would occur.

In light of my recent experience -- which isn't unusual -- at JFK, can anyone give me a plausible reason why I should be optimistic that government would adequately staff (and maintain - remember Walter Reed!) its hospitals and medical clinics?  With the same general set of incentives facing bureaucrats who now supply "passport control" facing bureaucrats who would supply medical care, it's a childish fantasy to imagine that people needing medical care would not encounter unnecessarily long queues when seeking government-supplied medical care.

Those persons who think me cynical, or who think that I draw a mistaken lesson from my experience at passport control, should ask themselves as seriously as they can just why they suppose that government-supplied medical care will not be characterized by the kinds of frustrations that travelers and post-office patrons routinely suffer.

Like a Virus

Gina Kolata writes on the front page of the New York Times:

Obesity can spread from person to person, much like a virus, researchers are reporting today. When one person gains weight, close friends tend to gain weight, too.

It's much like a virus, you see. It's not a virus. We know what a virus is. Obesity is not a virus. But it's like a virus. It's much like a virus. You see, the more it's LIKE a virus, the more increasing obesity is like an epidemic rather than a failure of personal responsibility or merely a pleasant experience, say, of eating more ice cream and being a little less trim. The more it is like a virus, the less it is a personal choice, the more justified is government involvement on "public health" grounds. And in case you didn't get the drift, check out the headline of the article:

Find Yourself Packing It On? Blame Friends

So blame your friends. Don't blame yourself. Never blame yourself. After all, you're standing in the path of a tsunami (scroll to the bottom.) There's nothing you can do. But if we can just get more regulation to protect you from your friends, we can save you. We'll start by saving your friends, first, of course. That will save you, eventually.

Here's the summary of the study:

Their study, published in The New England Journal of Medicine, involved a detailed analysis of a large social network of 12,067 people who had been closely followed for 32 years, from 1971 to 2003.

The investigators knew who was friends with whom as well as who was a spouse or sibling or neighbor, and they knew how much each person weighed at various times over three decades. That let them reconstruct what happened over the years as individuals became obese. Did their friends also become obese? Did family members? Or neighbors?

The answer, the researchers report, was that people were most likely to become obese when a friend became obese. That increased a person’s chances of becoming obese by 57 percent. There was no effect when a neighbor gained or lost weight, however, and family members had less influence than friends.

It did not even matter if the friend was hundreds of miles away, the influence remained. And the greatest influence of all was between close mutual friends. There, if one became obese, the other had a 171 percent increased chance of becoming obese, too.

You see it's even worse than a real virus. It can spread over the phone or across the country covering hundreds of miles!

The real lesson here is that if you see your best friend gaining weight, stop being friends with your best friend. Dump your fat friends. You don't want to catch the obesity "virus." In fact, make friends with people who are thinner than you. What a great study. All those people who judge people on their looks were right after all! It turns out that looking for thin, fashionable friends is actually good for you.

And it turns out the researchers actually have thought of this, though as you might expect, it isn't a pleasant thought to have. The article in the Times continues:

If the new research is correct, it may say that something in the environment seeded what some call an obesity epidemic, making a few people gain weight. Then social networks let the obesity spread rapidly.

It may also mean that the way to avoid becoming fat is to avoid having fat friends.

That is not the message they mean to convey, say the study investigators, Dr. Christakis and his colleague, James H. Fowler, an associate professor of political science at the University of California, San Diego.

You do not want to lose a friend who becomes obese, Dr. Christakis said. Friends are good for your overall health, he explained. So why not make friends with a thin person, he suggested, and let the thin person’s behavior influence you and your obese friend?

Beautiful isn't it? If you have a fat friend, the two of you need to befriend a thin one. Or maybe two thin ones. After all, you risk exposing the new thin friend to the "virus." Obviously this is too risky. We need to quarantine fat people to protect the rest of us from the "epidemic."

At the bottom of the first page on the web version of the story, the author gives us a little more info about the magnitude of the changes we can expect from "exposure." Turns out it's not quite as dramatic as it sounds:

On average, the investigators said, their rough calculations show that a person who became obese gained 17 pounds and the newly obese person’s friend gained five. But some gained less or did not gain weight at all, while others gained much more. Those extra pounds were added onto the natural increases in weight that occur when people get older.

What usually happened was that peoples’ weights got high enough to push them over the boundary, a body mass index of 30, that divides overweight and obese. (For example, a 6-foot-tall man who went from 220 pounds to 225 would go from being overweight to obese.)

And the last part of the article talks about how the study can never be replicated because it's based on a one-in-a-lifetime data set, the Framingham Study. It turns out that the conclusions are based on the residents of a single town, Framingham, Massachusetts. I wonder if they controlled for time trends and economic factors correctly.

An Anecdote on Health Care

My family and I are in France.  Yesterday we visited, near Arles, the parents of some friends.  These lovely people have a newly acquired dog, Tor.  They came to own Tor because of the unfortunate death of their 60-year-old neighbor, whose dog Tor was.

Conversation at lunch revealed that the neighbor, who had a history of heart trouble, suffered severe chest pains a few weeks ago.  He wisely went to the hospital seeking treatment.  He was told that there was no space available for him.  He was advised to go home and call back later to see if a room might have become available.  He did so, but was told repeatedly that the hospital remained full to capacity.  Several days later this man died at home, never having received hospital treatment.

This incident, while true, is also an anecdote.  It doesn't prove anything about the merits or demerits of France's universal-health-care system compared to those of the (still somewhat) private system in the U.S.  But this sad event does reveal that merely declaring, statutorily, that every citizen has a right to health care, or that health care is "free" to every citizen, does not make health care available to all or "free."

Secular priests performing ceremonies, beneath marble domes, in which health-care is declared "a universal right" do not, in fact, perform the miracle of making health-care universally available.

Kidney show a hoax

Turns out that Dutch show was never going to save a life. But some education probably happened anyway. The last paragraph of this excerpt from the AP story says it all for me. We have the same situation in America:

AMSTERDAM, Netherlands - A television show in which a woman would donate a kidney to a contestants was revealed as a hoax Friday, with presenters saying they were trying to pressure the government into reforming organ donation laws.

Shortly before the controversial program was to air, Patrick Lodiers of the "Big Donor Show" said the woman was not actually dying of a brain tumor and the entire exercise was intended to put pressure on the government and raise awareness of the need for organs.

The three prospective recipients were real patients in need of transplants and had been in on the hoax, the show said.

The program concept had received widespread criticism for being tasteless and unethical.

But Lodiers said that it was "reality that was shocking" because around 200 people die annually in the Netherlands while waiting for a kidney, and the average waiting time is more than four years. Under Dutch rules, donors must be friends, or preferably, family of the recipient. Meeting on a TV show wouldn't qualify.

The Big Donor Show

The BBC reports on the outcry over a reality show where a terminally ill patient will decide who gets one of her kidneys:

A Dutch TV station says it will go ahead with a programme in which a terminally ill woman selects one of three patients to receive her kidneys.

Political parties have called for The Big Donor Show to be scrapped, but broadcaster BNN says it will highlight the country's shortage of organ donors.

"It's a crazy idea," said Joop Atsma, of the ruling Christian Democrat Party.

"It can't be possible that, in the Netherlands, people vote about who's getting a kidney," he told the BBC.

Sounds like a sure ratings winner. But the broadcasting station, BNN, has a political and educational motive as well:

The former director of TV station BNN, Bart de Graaff, died from kidney failure aged 35 after spending years on a transplant waiting list.

"The chance for a kidney for the contestants is 33%," said the station's current chairman, Laurens Drillich. "This is much higher than that for people on a waiting list."

"We think that is disastrous, so we are acting in a shocking way to bring attention to this problem."

"For years and years we have had problems in the Netherlands with organ donations and especially kidney donations," agreed Alexander Pechtold of D-66, the Dutch social liberal party.

"You can have a discussion about if this is distasteful, but finally we have a public debate," he told BBC Radio 4's Today programme.

As you might expect, the kidney establishment isn't too keen on the spotlight:

The Dutch donor authority has condemned the show, as have kidney specialists in the UK.

"The scenario portrayed in this programme is ethically totally unacceptable," said Professor John Feehally, who has just ended his term as president of the UK's Renal Association.

"The show will not further understanding of  transplants," he added. "Instead it will cause confusion and anxiety."

As a writer at the British Guardian puts it:

"My first reaction, probably everyone's reaction, is that this is as dangerously near as we've got to a TV programme playing God," said Julia Raeside of the Guardian newspaper.

And how is the decision made now in the UK? The answer is earlier in the article from Professor Feehally, the outgoing head of the UK Renal Association.

"The set up of the programme bears no relationship to the way decisions are made about transplants in the real world," he said.

"Living donors can choose altruistically to give one of their kidneys - usually to a family member.

"If organs become available after someone dies, health professionals with access to detailed information about those waiting for a transplant make objective decisions about who should receive those particular kidneys."

Health professionals with detailed information making objective decisions. Sounds so scientific. Objective decisions? Impossible. A better word would be arbitrary. Or maybe random. Or maybe selfish. With people dying because there aren't enough kidneys for transplant, how would you describe someone who gives the current system a patina of objectivity?

Hanson on Health

This week's EconTalk podcast is with Robin Hanson. Robin offers a rather ambitious and all-encompassing explanation for why, in his words, "health care is different." His argument is that we are hard-wired via the evolution of our brains to prefer communal and sacrificial expenditures even when such methods are costly.

I challenge the explanation and we go back and forth. And while I remain unconvinced, Robin sure made me think. What I've found striking since completing the interview is how it forced me to realize just how differently people do feel about health care. Otherwise wise and intelligent people make arguments in favor of government provision that I don't think they would make in other areas.

So go listen to Robin and if you agree or disagree with his arguments, enter a comment over at EconTalk. Robin will be checking in now and then to respond.

Kling on Medical Care; Or, How Americans are Screwing Themselves

Arnold Kling has just published one of the most insightful and entertaining and instructive essays I've ever read on how Americans pay for their medical care.  Don't miss it!

(HT Andy Morriss.)

Satel's Kidney

Last year, Sally Satel received a kidney from Virginia Postrel. She writes in the Washington Post:

It is a sad time for the 96,000 patients waiting for kidneys, livers, hearts and lungs: The chasm between supply and demand grows wider each year. By this time tomorrow, 18 people in need of an organ will be dead because they did not get one soon enough.

Kidneys are in highest demand; currently, 71,000 people need a renal transplant. They will spend, on average, five years on dialysis while waiting for an organ from a deceased donor. At least half will die or become too sick to undergo a transplant before their name is called.

She argues for allowing people to receive compensation for donating their kidneys. Here is the podcast with Richard Epstein on this issue. Here is the podcast with Virginia Postrel, the donor of the kidney. The discussion of her decision to donate a kidney to Sally Satel begins around 35 minutes into the podcast.

Cancer Is Not the Killer That it Once Was

I was born in 1958.  I am fortunate that my parents were very young at the time (mom just turned 20; dad was 23).  Both of my parents are still alive and I knew and loved all four of my grandparents.

The first of my grandparents to die was my paternal grandmother, who died in 1967 at the age of 62.  Her life was taken by colon cancer.  My paternal grandfather died eight years later of a stroke.  He was 75.  While one must be careful in making inferences from personal recollections (especially from recollections drawn from one's childhood), my very clear memory is that both of these grandparents were old.  Even before being struck with their fatal illnesses, both looked old; both acted old; both were regarded as old.

My parents (now in their late 60s and early 70s) now are suffering health problems (stemming largely from their many years of working in a shipyard) -- but even with these problems, they aren't old in the way that my paternal grandparents were old.  My in-laws, who are each in their mid-70s, have also had health problems (including a serious bout in 2002 with lung cancer), but they remain in excellent shape.  Both my parents and my in-laws today travel and pursue hobbies in ways and with a normalcy that I cannot imagine my own grandparents ever having done 30 and 40 years ago.

When I was a boy, persons in their 60s were regarded as old; they were old.  Not so today.  One important reason is that cancer is not the killer that it once was.  As Gina Kolata reports in today's New York Times

News about cancer, it seems, is everywhere. But, as statisticians readily explain, impressions can be misleading. While cancer remains the second-leading killer of Americans, behind heart disease, and while no one would make light of the toll from the disease, cancer deaths are on the wane.

This decline in the death rate from cancer is yet another few drops of well-being added to our prosperity pool.

More on Interpreting Statistics

Here's more, now from The Economist.com, on the need to be careful when interpreting statistics -- such as that infant-mortality rates in the United States are higher than in many countries much poorer than America.  A snippet:

Comparing infant mortality rates between countries is fraught with uncertainty—after all, it's hard to argue that every country's figures are reliable. But it's still worth asking what more we can do to stop babies from dying. Defined as death before one year of age, infant mortality frequently gets framed in the United States as a problem of insufficient health-care funding. In December, for example, a New York Times column blamed it on the lack of a single-payer health insurer. However, a closer look reveals the counterintuitive possibility that high infant mortality in the United States might be the unintended side effect of increased spending on medical care.

Read the whole Economist.com post.

(HT: Liberty Alone)

Walter Reed and Government-Provided Universal Health Care

The New York Post today published this letter of mine:

Conditions at Walter Reed Army Medical Center truly are deplorable ("Sick Army Hosps," March 6).

This "flagship" institution is at the heart of Uncle Sam's system of socialized medical care for military personnel.

So, why are many politicians and pundits clamoring for socialized medical care for all Americans?

A GMU graduate student in economics, Ms. Meredith Jones, makes this additional point in an e-mail to me:

Walter Reed Army Medical Center is set to close (in 2010, I think) and most of its work is being moved to either Ft Belvoir or Bethesda, so naturally any incentive to maintain the facilities was further muted after that decision was made. Of course, such lengthy closings are typical of inefficient social programs, and not of privately operated businesses.

Income and Health

Alert, alert. Do not miss this. Best thing I've seen in a long time. Three people told me about in the last two days. And I'm pretty sure someone else told me about it before that and I just missed it. Don't miss it.

So go here. It is a spectacular presentation on how international measures of life expectancy and other measures of health are getting better over time and the relationship to income. It's also has some spectacular examples of how averages can be misleading. But equally compelling is the way the data are presented. This is so cool.

When you're done, more info here.

HT: Avi Hoffman, Ville (in the comments at EconTalk on the Easterbrook podcast) and Ben Parizek.

Kidney Gymnastics

It is against federal law to receive anything of value in return for donating a kidney. The result is the following kind of absurd kidney gymnastics reported by Forbes:

It took 12 surgeons, six operating rooms and five donors to pull it off, but five desperate strangers simultaneously received new organs in what hospital officials Monday described as the first-ever quintuple kidney transplant.
....

Four of the sick patients had approached Johns Hopkins with a relative who was willing to donate a kidney but was an incompatible donor. The fifth had been on a waiting list for a kidney from a dead person.

Together, those nine people and an "altruistic donor" had enough matched kidneys among them to pull off a five-way swap.

The altruistic donor, Honore Rothstein, decided to donate a kidney after losing her husband and daughter to accidents and illness, Vohr said. She did not know any of the donors or recipients.

...

In a live-donor practice used increasingly in the U.S. over the past few years, a patient who needs a kidney is matched up with a compatible stranger if the patient lines up a friend or relative willing to donate an organ to a stranger, too.

Dr. Robert Montgomery, director of Hopkins' transplant center and head of the transplant team, called Monday for a national kidney-swap program, saying it could help ease the nation's shortage of transplant organs and cut costs by getting people off dialysis.

He noted, however, that live-donor kidney swaps present ethical problems for some institutions since federal law prohibits receiving something of value in exchange for an organ. Some institutions feel multiple arrangements come uncomfortably close to quid pro quo, Montgomery said. He called for a clarification of the law.

What a bizarre definition of ethics. Try and explain that one to your kids. I can't.

Here is my podcast with Richard Epstein on the topic.

Beware Pols Bearing Health-Care Fixes

In today's Washington Post, Alberto Mingardi of the Istituto Bruno Leoni in Italy draws lessons from his country's experience to warn Americans against increasing Uncle Sam's role in providing medical care.  Here's his concluding paragraph:

So by attempting to hold down drug prices, the Italian government has deprived its citizens of the best care without reducing health-care spending. And it has deprived the country of what could be a vibrant sector of the economy. In their rush to revamp Medicare, U.S. policy leaders should be careful not to make the same mistake.

Bruno Leoni (1913-1967), by the way, wrote a wonderfully deep and profound book on the nature of law, entitled Freedom and the Law.

Wrong Right

Treating health-care as a right is wrong.  I explain why in today's Christian Science Monitor.

The Ethics of Rationing

Sharon Begley in today's WSJ raises the issue of rationing in a life or death situation:

You have 100 doses of a vaccine against a deadly strain of influenza that is sweeping the country, with no prospect of obtaining more. Standing in line are 100 schoolchildren and 100 elderly people.

The elderly are more likely to die if they catch the flu. But they also have fewer years left to live and don't get out enough to easily spread or catch the disease. The kids are more likely to act like little Typhoid Marys, sneezing virus over anyone they encounter, and have almost their whole life ahead of them. But they're also less likely to die if they get sick.

Whom do you vaccinate?

This dilemma is haunting experts concerned that avian influenza might start spreading from person to person instead of (as far as we know) mainly from birds to people. But it also applies to regular old flu, which always has the potential to reach pandemic proportions. In response, studies now are shedding light on the ethical issues and the most effective strategy for reducing illness and death if vaccine must be rationed. Sadly, they make a pretty good case that current U.S. policies leave a lot to be desired.

But how could we possibly find ourselves in this situation. We never ask, if there's not enough shoes to go around, should young or old people get the shoes. Or the oranges. Or the houses. Or cars. We don't even have to ask these questions about the rich and the poor, let alone, the young and the old. It certainly is a tough question, once you only have 100 vaccines or some number less than people would like. But how could that possibly happen?

But it has been happening. In the winter of 2004 there were serious shortages with the President reduced to begging healthy people to forego flu vaccination to leave enough for those at risk. So it could easily happen again.

Why?

Part of the answer is that in the name of making sure that everyone has equal access to vaccine, we have taken the profit out of making vaccines. In addition, Attorneys General threaten anyone who charges what the market will bear in a time of shortage. So we have protected the poor and elderly and the children and made sure that they will not be outbid by the rich and the relatively healthy. And through that protection we have created a situation where increasing numbers of Americans cannot be sure of getting medicine. As a result, a political mechanism, rather than a market mechanism, must be used. Some form of rationing becomes inevitable. And inevitably, that rationing will be subject to political rather than truly ethical influences.

But even if politicians stepped aside (something they are genetically and psychologically incapable of) the most benevolent philosopher cannot answer the question of who should live or die when there is a vast shortage.

But if we let markets work, there would be fewer people at risk of death.

In every other market, innovation, driven by the profit motive, improves access to life-giving, life-enhancing devices, products and services.

People often say that medicine or some other good is too important to be left to the marketplace.

The opposite is true. Medicine is too important to be left outside the marketplace.

I Demand the Right to be Free of Economic Ignorance

Today's New York Times has several letters-to-the-editor expressing inanely quixotic notions about health care.  For example, Professor of Psychology Marcus Tye writes that

We should stop thinking of health care as a benefit to be earned from work and bought through middlemen (private insurers), and start treating it as a human right and a universal entitlement.

Sounds nice.  Rights are good, right?  So if some rights are good, more rights are better.

Wrong.  Bart Hinkle, columnist at the Richmond Times-Dispatch, very admirably summarizes (at the TimesDispatch.com blog) the reasons why health care is not, and cannot be made to be, a right.

Bastiat vs. Krugman

Last December, Paul Krugman was admirably forthright about his disdain for the competence of ordinary men and women.  Writing in the New York Times about health-care decisions, Krugman rhetorically asked:

is giving individuals responsibility for their own health spending really the answer to rising costs? No.

....it's neither fair nor realistic to expect ordinary citizens to have enough medical expertise to make life-or-death decisions about their own treatment. A well-known experiment with alternative health insurance schemes, carried out by the RAND Corporation, found that when individuals pay a higher share of medical costs out of pocket, they cut back on necessary as well as unnecessary health spending.

Krugman dismisses without comment the likelihood that the vast majority of people will seek the advice of experts -- MDs -- when making deisions about health care, just as ordinarly people seek the advice of experts -- say, electricians -- when seeking advice about how to repair electrical wiring in their houses.

I recalled Krugman's distrust for ordinary people's decision-making capacities when I read this passage in Chapter 10 of Frederic Bastiat's book Economic Harmonies.  It's interesting -- and, I  believe, proper -- that Bastiat saw freedom of choice as intimately connected with competition:

After all, what is competition? Is it something that exists and has a life of its own, like cholera? No. Competition is merely the absence of oppression. In things that concern me, I want to make my own choice, and I do not want another to make it for me without regard for my wishes; that is all. And if someone proposes to substitute his judgment for mine in matters that concern me, I shall demand to substitute my judgment for his in matters that concern him. What guarantee is there that this will make things go any better? It is evident that competition is freedom. To destroy freedom of action is to destroy the possibility, and consequently the power, of choosing, of judging, of comparing; it amounts to destroying reason, to destroying thought, to destroying man himself. Whatever their starting point, this is the ultimate conclusion our modern reformers always reach; for the sake of improving society they begin by destroying the individual, on the pretext that all evils come from him, as if all good things did not likewise come from him [emphasis added].

Fat Folks

In the latest podcast EconTalk, Darius Lakdawalla and I discuss just how much fatter Americans are than they once were and why. Turns out, it's not McDonald's fault. We also discuss the role of norms, the changing nature of the workforce, the technology of barbecue potato chips. He has a very nice insight that in the past, we were paid to exercise on the job and now we pay for the opportunity to exercise. Listen to it here.

A Good Weekend for Pesticides

The spinach e-coli outbreak comes from organic spinach. The Washington Post reports:

Federal health officials last night linked a deadly E. coli outbreak in bagged spinach products to a California farm company that sells organic produce in 74 percent of the country's grocery stores.

My memory is that un-natural produce, the produce that is grown with pesticides has a lower chance of carrying e-coli. Is this true? Please post some evidence on this issue in the comments.

And on the opposite page comes this pro-pesticide story:

The World Health Organization reversed a 30-year-old policy yesterday and declared its support for indoor use of the pesticide DDT to control mosquitoes in regions where malaria