Reason Magazine - Topics > Health Care

I Love a Man in a Uniform

jwalker@reason.com (Jesse Walker) — Thu, 17 Jul 2008 10:26:00 EDT

A coalition of 400 AIDS and human rights groups are drawing attention to the ways officials around the world have fanned rather than contained the spread of AIDS. For example:

HIV and AIDS services geared toward men who have sex with men and toward sex workers are also hampered by punitive laws and abusive government practices. Officials charged with enforcing prostitution laws routinely extort bribes, confessions, testimony, and sexual "favors" from sex workers.

There's a drug angle, too:

effective measures to reduce HIV infection, such as needle-exchange programs and medication-assisted treatment with methadone, are banned by law in many countries or undermined by abusive police practices. Police abuse, sometimes amounting to torture, keeps people who use drugs away from basic HIV-prevention services, even where government policy supports these services. Police also routinely extort money and confessions from people who use drugs, sometimes using the mere possession of syringes as an excuse to harass or arrest drug users or outreach workers providing services to them.

Similarly, cops in some countries "confiscate condoms from AIDS outreach workers, and use them as evidence of sex work or sodomy." Presumably they don't use them when coercing coitus from actual prostitutes.

What Are You Smiling At?

mriggs@reason.com (Mike Riggs) — Wed, 09 Jul 2008 15:00:00 EDT

Q: What are the eligibility requirements to legally receive dental care from a therapist with a two-year degree?
A: Native American ancestry.

Some 60,000 indigenous Alaskans living in villages accessible only by plane, boat, or snowmobile received little dental care until the Alaskan Native Tribal Health Consortium decided to break a few rules. Following a model that is popular in Canada, England, Australia, New Zealand, and 42 other countries, the consortium sent tribal members to an accredited two-year dental program in New Zealand, where they learned how to fill cavities and clean and pull teeth.

Upon completion of the program, the members returned to their villages as certified dental therapists, capable of providing basic dental services. The therapists have since helped to bring down a rate of tooth decay that is almost three times the national average. But their efforts were nearly undone by the American Dental Association (ADA), which objected to anyone other than a licensed dentist conducting "irreversible dental procedures," such as pulling teeth and filling cavities. By the ADA's standards, a licensed dentist is one that has completed an undergraduate degree, a doctorate of dental medicine, or a doctorate of dental surgery, and has passed a statewide exam.

The consortium spent over a year battling the ADA and the Alaskan Dental Society for the right to send dental therapists into tribal areas. Alaska's Superior Court ruled in favor of the tribes in June 2007, allowing the therapists to continue their work, but only in indigenous communities. In light of the ruling, the ADA altered its strategy and decided to support the tribes' efforts until it could send enough licensed dentists into remote tribal regions to render the therapists unnecessary.

The case received little national attention until the New York Times' Alex Berenson wrote in April that "dentists in private practice consider therapists low-cost competition" because they are only paid "one-half to one-third" as much as licensed dentists. Current ADA President Mark J. Feldman responded a month later in a letter to the Times, denying that the ADA objected to the Consortium's "experiments" out of its own "financial self-interest."

Yet the ADA's actions toward the University of Washington School of Dentistry, which backed the consortium, supports the financial self-interest angle. According to a story in the Seattle Post-Intelligencer, the Washington branch of the ADA "intimidated university officials by threatening to block donations by their members" until the dentistry school withdrew its support for the consortium and abandoned its plans to cosponsor, along with the medical school, a dental therapy track in its physician's assistant program.

This wasn't the only time the ADA has attempted to block a newcomer to the dental market. In December 2007, another New York Times reporter, Ian Urbina, wrote about the work of denturists. Denturists develop and install dentures and replace teeth; their inexpensive services are changing lives for the better in Kentucky, where residents, like indigenous Alaskans, suffer from tooth decay at a rate that is much higher than the national average.

Unlike the Alaskan tribes, however, denturists have had no luck challenging the ADA. The association refuses to recognize denturism, even though denturists can practice legally in a number of states, including Idaho, Montana, Maine, Oregon, and Washington. Additionally, in Arizona and Colorado, denturists can work under the supervision of licensed dentists. The ADA officially "opposes denturism, the denturism movement, and all other similar activities," claiming that denturists are "educationally unqualified to practice dentistry in any form on the public." A 1985 study published in the American Journal of Public Health suggests the animosity stems more from the economic effects of legalizing denturism than anything else. In 1978, the year Oregon became the first state to allow denturism, "The major campaign issue" between those for denturism and those opposed, "was the effect denturism would have on the cost of dentures." Sure enough, the cost of dentures "had a much lower rate of increase after passage of the denturism initiative."

Since then, the ADA has combated denturists by attempting to block their access to supplies. The agency openly discourages manufacturers of dental equipment from selling products to unlicensed dental practitioners, the only exception being dentistry students enrolled in ADA-approved schools.

According to the association and other opponents of alternative dentistry, dental work done by anyone other than a licensed dentist equates to "substandard care," but their argument suffers when international comparisons are taken into account. Canada, for instance, created a regulatory board for dental therapy in 1974. The Australian goverment permits it as well, calling it dental prosthetics. In 1984, the United Kingdom amended its dentistry laws to make room for several types of alternative dentistry, among them the British equivalents to both denturism and dental therapy. And according to the Seattle Post-Intelligencer, some studies have shown that graduates of dental therapy programs "are better trained to provide care to children than dentists are."

Despite the ADA's best efforts at controlling the cost of dental care, the tide may be turning. In May, reports The Charleston Gazette, West Virginia (whose dental problems rival those of its neighbor, Kentucky) passed a bill that will allow dental hygienists—whose services cost a fraction of those of a licensed dentist—to practice outside of a dentist's office and without a dentist being present. Legislators passed the bill—in spite of loud ADA objections—after journalist Eric Eyre wrote a series of articles detailing the state's abysmal dental care.

Bills like the one in West Virginia create new jobs while lowering medical costs. And there is perhaps a bigger benefit: putting smiles on the faces of millions of Americans who, thanks in part to the monopolistic behavior of the ADA, are literally too embarrassed to open their mouths.

Mike Riggs is reason's 2008 Burton C. Gray Memorial intern.

What About Fat Kids With Low Cholesterol?

jsullum@reason.com (Jacob Sullum) — Mon, 07 Jul 2008 14:37:00 EDT

Today the American Academy of Pediatrics issued new guidelines that call for cholesterol screening in children as early as age 2 and no later than age 10. According to the guidelines, treatment with cholesterol-lowering statins should be considered for children as young as 8 with certain risk factors. I don't know enough about the risks and benefits of statins in children to say whether this is a good idea or not, and it sounds like research on the question is meager. But I was struck by the way the New York Times story about the guidelines conflates cholesterol levels with weight:

Proponents [of the guidelines] say there is growing evidence that the first signs of heart disease show up in childhood, and with 30 percent of the nation's children overweight or obese, many doctors fear that a rash of early heart attacks and diabetes is on the horizon as these children grow up....
Previously, the academy had said cholesterol drugs should be considered in children older than 10 if they fail to lose weight after a 6- to 12-month effort.

Shouldn't the decision to treat a patient for high cholesterol hinge on how high his cholesterol is, as opposed to how much he weighs? Even if there's a correlation between weight and cholesterol, doesn't it make sense to focus on the risk factor that's the target of the treatment, instead of simply assuming that all fat kids have high cholesterol and that failing to lose weight is the same as failing to reduce cholesterol?

Another, apparently related puzzle: By way of justification for more-aggressive use of statins in children, Jatinder Bhatia, a neonatologist who serves on the committee that revised the guidelines, says, "We are in an epidemic." But between 1988 and 2000, according to the guidelines, "triglyceride concentrations [measured by the National Health and Nutrition Examination Survey] decreased approximately 8.8 mg/dL in adolescents aged 12 to 17 years, and total cholesterol, LDL, and HDL concentrations remained relatively stable." Furthermore, a comparison of NHANES data from 1988-1994 with data from 1966-70 found "a decrease in mean total cholesterol concentration of approximately 7 mg/dL" among 4-to-19-year-olds. Evidently, then, Bhatia is not talking about an "epidemic" of high cholesterol levels. Probably he means an "epidemic" of obesity (although recent data indicate that the upward weight trend in children and teenagers seen in the '80s and '90s has leveled off in the last decade or so).

This slippery switching between cholesterol and weight disguises the paucity of evidence that extra weight per se is unhealthy. NHANES data indicate that people in the "overweight" (but not obese) category actually have lower mortality rates than people in the "healthy"/"normal" category. Even for the BMIs that are correlated with shorter life spans, it's not clear how much people should worry about fatness, as opposed to the poor diet and sedentary lifestyle associated with it. This is especially true in the case of heart disease. "As near as I can tell," Barry Glassner reports in his 2007 book The Gospel of Food, "not a single published study demonstrates that heart disease among the overweight and moderately obese results from their heft rather than from other factors that contribute to both obesity and heart disease." Other critics of the conventional wisdom about weight, including Paul Campos, Eric Oliver, and Gina Kolata, make similar points.

Accidents, Murders, Preemies, Fat, and U.S. Life Expectancy

rbailey@reason.com (Ronald Bailey) — Tue, 17 Jun 2008 17:00:00 EDT

Last week, the National Center for Health Statistics announced that the average life expectancy for Americans has risen to an all-time high of 78 years. In addition, record high life expectancy was recorded for both white males and black males (76 years and 70 years, respectively) as well as for white females and black females (81 years and 76.9 years). This is obviously good news. But a question nags—why are people in other countries living longer on average than Americans? After all, we are the country that spends the most money per capita on health care.

For example, according to the World Health Organization, average life expectancy in Japan is 83 years; Australia, 82; Switzerland, 82; Canada, 81; Sweden, 81; Spain, 81; Italy, 81; France, 81; Germany, 80; and the United Kingdom, 79. In all, there are 29 countries whose citizens have longer life expectancies than Americans.

So why do Americans die younger than people living in most other developed democracies? Well, there is the Michael Moore answer delivered in his "documentary" Sicko—it's because we lack a benevolent government funded health care system. But life expectancy is not dependent on just medical care. For example, Texas A&M health economist Robert Ohsfeldt and health economics consultant John Schneider point out that deaths from accidents and homicides in America are much higher than in any other of the developed countries. Taking accidental deaths and homicides between 1980 and 1999 into account, they calculate that instead of being at near the bottom of the list of developed countries, U.S. life expectancy would actually rank at the top.

However as Carl Bialik, the invaluable Wall Street Journal "Numbers Guy" columnist, notes Ohsfeldt and Schneider's analysis does not account for the fact a better health care system would have saved more accident victims and thus would have boosted life expectancy. In fact, in 2002, Harvard researchers argued that the U.S. murder rate is much lower than it would otherwise have been because so many assault victims are being saved by improved medical care. Nevertheless, Ohsfeldt and Schneider are likely right that U.S. life expectancy is being depressed by our higher accident and homicide rates.

America's relatively high infant mortality rate also lowers our life expectancy ranking. A 2007 study done by Baruch College economists June and David O"Neill sheds some light on why U.S. infant mortality rates are higher—more low weight births. In their study, U.S. infant mortality was 6.8 per 1,000 live births, and Canada's was 5.3. Low birth weight significantly increases an infant's chance of dying. Teen mothers are much more likely to bear low birth weight babies and teen motherhood is almost three times higher in the U.S. than it is in Canada. The authors calculate that if Canada had the same the distribution of low-weight births as the U.S., its infant mortality rate would rise above the U.S. rate of 6.8 per 1,000 live births to 7.06. On the other hand, if the U.S. had Canada's distribution of low-weight births, its infant mortality rate would fall to 5.4. In other words, the American health care system is much better than Canada's at saving low birth weight babies —we just have more babies who are likely to die before their first birthdays.

Life expectancy rates also depend on personal habits such as smoking, diet, and physical activity. Interestingly, U.S. smoking rates are lower (17 percent of adults) than for many developed countries with higher life expectancies. For instance, 30 percent of Japanese adults smoke daily. In France, 23 percent of adults smoke; Germany, 25 percent; Switzerland, 25 percent; Spain, 28 percent, and the U.K., 25 percent.

The fact that Americans tend to be a lot fatter than the citizens of other rich developed countries increases their risks of heart disease and diabetes. A recent international survey reported that 31 percent of Americans are obese (body mass index over 30), whereas only 23 percent of Britons, 21 percent of Australians and New Zealanders, 14 percent of Canadians, 13 percent of Germans, 9 percent of the French, and 3 percent of Japanese have body mass index measurements over 30.

Taking all these unhealthy proclivities into consideration, the American health care system is most likely not to blame for our lower life expectancies. Instead, American health care is rescuing enough of us from the consequences of our bad health habits to keep our ranking from being even lower.

Ronald Bailey is reason's science correspondent. His book Liberation Biology: The Scientific and Moral Case for the Biotech Revolution is now available from Prometheus Books.

Back Away From That Teriyaki With Your Hands Up!

matt.welch@reason.com (Matt Welch) — Fri, 13 Jun 2008 10:19:00 EDT

Is your waist size a 36? Better not be Japanese:

Under a national law that came into effect two months ago, companies and local governments must now measure the waistlines of Japanese people between the ages of 40 and 74 as part of their annual checkups. That represents more than 56 million waistlines, or about 44 percent of the entire population.
Those exceeding government limits - 33.5 inches for men and 35.4 inches for women, which are identical to thresholds established in 2005 for Japan by the International Diabetes Federation as an easy guideline for identifying health risks - and having a weight-related ailment will be given dieting guidance if after three months they do not lose weight. If necessary, those people will be steered toward further re-education after six more months.
To reach its goals of shrinking the overweight population by 10 percent over the next four years and 25 percent over the next seven years, the government will impose financial penalties on companies and local governments that fail to meet specific targets. The country's Ministry of Health argues that the campaign will keep the spread of diseases like diabetes and strokes in check.

Whole thing here; hat tip: Veronique de Rugy. Jacob Sullum wrote about "the totalitarian implications of public health" last May.

Card-Carrying Cadaver

kmw@reason.com (Katherine Mangu-Ward) — Tue, 27 May 2008 15:41:00 EDT

File this between your ACLU card and your AAA card.*

Available in "pubs, banks, libraries, GP surgeries, even some churches, the Advanced Decision to Refuse Treatment (ADRT) card sits snugly in a wallet or purse and instructs a doctor to withhold treatment should the carrier lose the capacity to make decisions, because of an accident or illness."

Oddly, these cards are being offered by a U.K. city council, but private groups offer the same service in the U.S.

* OK, that would be a pretty weird wallet, since the card is only available in the U.K. But you get the idea.

Queue Up

rbailey@reason.com (Ronald Bailey) — Tue, 13 May 2008 12:00:00 EDT

Facing lengthening waits at hospitals, the British government has set a targeted turnaround time of four hours from arrival in an emergency room to treatment by a medical professional. Apparently this standard has proven too stringent for the National Health Service.

The Guardian reports that U.K. emergency rooms are meeting the four-hour goal through a simple, quintessentially British expedient: queuing. Thousands of seriously ill patients have been forced to wait outside of emergency departments in ambulances before they can be admitted, thus delaying the start of the four-hour timer. The practice is called “patient stacking,” and various investigations have found people with broken limbs or breathing problems stuck in ambulances for as long as five hours.

In U.S. emergency rooms, the average length of time it takes a patient to see a doctor has increased from 22 minutes to 30 minutes during the last decade. In nonurban hospitals, the wait averages just 15 minutes. And there’s no extra waiting in the ambulances outside.

Kidneys for Sale

khowley@reason.com (Kerry Howley) — Tue, 13 May 2008 12:00:00 EDT

“What can Iran teach us about good governance?” is not a question often posed in Washington. But according to Benjamin Hippen, a transplant nephrologist in North Carolina, the Iranians have managed to do something American policy makers have long thought impossible: They’ve found kidneys for every single citizen in need.

As Hippen explains in a March report for the Cato Institute, the Iranian government has been paying kidney donors since 1988. To avoid potential conflicts of interest, donors and recipients work through an independent organization known as the Dialysis and Transplant Patient Association. Donors approach the association on their own; they cannot be recruited by physicians or referred by brokers with financial incentives. They receive $1,200 and limited health coverage from the government, in addition to direct remuneration from the recipient—or, if the recipient is impoverished, from one of several charitable organizations. The combination of charitable and governmental payments ensures that poor recipients are treated as well as wealthy ones.

Critics of organ markets often claim that where payments are permitted, altruistic donation will drop off. Hippen found this is not the case in Iran. The country’s deceased donor program, started in 2000, has grown steadily alongside paid donation. (Posthumous donations are not remunerated.) During the last eight years, deceased donations have increased tenfold.

Data on the long-term health of Iranian kidney doors is mixed and inconclusive, so Hippen recommends that any U.S. system closely track donors and provide them with lifelong health care. Since many potential kidney recipients are currently surviving on vastly more expensive dialysis treatment (paid for by Medicare), providing donors with long-term health care is probably more cost-effective than the status quo.

American critics continue to lament that Iran failed to adopt the U.S. policy of banning payment for organs in the mid-1980s. “Carrying this reasoning to its conclusion,” writes Hippen, “would entail admitting that in so doing, Iran would have also incurred our current shortage of organs, our waiting list mortality, and our consequent moral complicity in generating a state of affairs that sustains an international market in illegal organ trafficking.” No other country has managed to eliminate its kidney waiting list; the U.S. has a list 73,000 patients long. Who should be advising whom?

Putting Our Entitlements in Order

info@reason.com (Paul Wilner) — Wed, 07 May 2008 15:00:00 EDT

Over the course of his career, George Shultz served as Secretary of Labor and Secretary of Treasury to Richard Nixon and Secretary of State to Ronald Reagan. Shultz's reputation for independence survived the Reagan era, in which he famously opposed the Iran-Contra adventure while maintaining credibility as a committed Cold Warrior. And as a strong critic of the war on drugs conducted by his former bosses (and every other recent American president): In a widely discussed 1989 Wall Street Journal op-ed, Shultz wrote, "We need at least to consider and examine forms of controlled legalization of drugs."

More recently, he retained influence as the senior member of the "Vulcans,'' a group of policy advisors, including his protégée Secretary of State Condoleeza Rice, who helped identify George W. Bush as a rising political star who could lead the Republicans back to electoral victory in the post-Clinton era. He is still respected within the Bush 43 administration, even if one senses that, as a veteran internationalist, he might have preferred a less Lone Ranger-style of foreign policy.

An ex-Marine, Shultz is discreet about differences he may have with the Bush administration and was incensed at the group of generals and ex-generals who broke ranks not long ago to openly criticize former Defense Secretary Donald Rumsfeld. (One wonders what his reaction will be to the book Rumsfeld is reportedly writing about his experiences in the administration.)

These days, the 87-year-old Shultz hangs his hat at Stanford University's Hoover Institution as the Thomas W. and Susan B. Ford Distinguished Fellow. As befits an elder stateman, he is turning his attention to some of the unsolved problems of our society, especially the looming wreck of federal entitlement spending. In a new book, Putting Our House In Order: A Guide to Social Security & Health Care Reform (W.W. Norton), co-written with fellow Stanford economics professor John B. Shoven, Shultz, outlines potential solutions to the Social Security and health-care messes.

Specific reforms Shultz and Shoven propose include changes in the indexing system of Social Security benefits, so that "the rate of increase over and above inflation is either eliminated or moderated," raising the age at which benefits would start, and creating individual accounts "with the possibility of an additional deduction on a mandatory or voluntary basis.'' They argue that a "Personal Saving Account plan would transfer a significant part of Social Security payments to a Personal Security Account system in which the amount of benefits would directly reflect the amount of contributions. This plan would likely increase national saving, which in turn would increase national income in the future.''

"Reform of these programs will not come easily,'' Shultz and Shoven write in their introduction. "To touch them, many politicians worry, is to touch a third rail. But well-documented projections of the costs of current programs show that inaction is simply not an option. Progress will be promoted by widespread realization of the depth of the problem and of the fact that workable options exist. In fact, the rigidity and stability of the programs are major parts of the problem. Everything about the U.S. economy is dynamic except its major entitlement programs. To serve their fundamental purposes, these programs must be modernized so that they are suitable for the twenty-first century.''

West Coast writer Paul Wilner, whose work has appeared in The San Francisco Chronicle, The Los Angeles Times, barnesandnoblereview.com, and many other publications, talked to Shultz at the Hoover Institution in April. Comments can be sent to letters@reason.com.

reason: Some people go to Washington and get addicted to life there. But you've chosen to divide your time between San Francisco and Stanford. I guess staying back East was not for you?

George Shultz: When I'm in Washington, I like to be in the action. If I'm not in the action, I'd rather be somewhere else.

reason: You're still very much in the action, even from this remove. It was down here at Stanford, wasn't it, that you and others identified the political potential of the current occupant of the White House?

Shultz: He came here, and we had a nice day.

reason: It was more than a nice day, You helped identify him as a candidate who could successfully carry the Republican torch forward in the 2000 election...

Shultz: (Pause). He won.

reason: Twice. With the help of your protégée, Condoleezza Rice.

Shultz: My other protégé was Ronald Reagan. And Condi's a very good friend.

reason: What's your view of recent history, especially in Iraq? Do you think the current arrangement, with Rice, Defense Secretary Robert Gates and Gen. David Petraeus, is more workable, even just from a purely managerial standpoint, than what came before?

Shultz: They had good arrangements before....

reason: What do you think of the prospect of a McCain-Rice ticket?

Shultz: Well, she's kind of ruled it out.

reason: But if she were to call you for advice on the subject, what would you say?

Shultz: She's very capable and can do just about anything. But she's expressed some interest in returning to Stanford, and that's our expectation.

reason: You were identified in The New York Times recently as part of the foreign policy debate for the heart and soul of McCain.

Shultz: I didn't know I was going to be in that story, but I'm a supporter of his.

reason: Have you had a chance to discuss any of the ideas set forth in this book on health care and entitlement programs with him?

Shultz: I think he thinks of me as a foreign policy person. I saw him recently and gave him a copy of the book, so he may look at it.

reason: The subjects you discuss in it couldn't be more timely. But how do we get these programs under control. How would you rate the positions of the candidates?

Shultz: Clinton's plan, apparently, is to force people to pay for health insurance. Obama says that he thinks the reason many people don't have health insurance isn't that they don't want it, but that they can't afford it. So I tend to agree more with that. Anybody, Republican or Democrat, can adopt some of the solutions we propose. We believe that the Social Security issue can be resolved more readily and that health care will require intermediate steps.

reason: One of the specific suggestions you make is to remove health-care tax exemptions for businesses.

Shultz: We didn't suggest that—President Bush suggested that. We mentioned various suggestions, including that idea, Milton Friedman's plan, and (Democratic Congressman) Rahm Emanuel's plan. Many of the proposals are interesting, but they're quite radical, and we didn't think a radical plan would likely succeed. Social Security is a problem that can be solved. There are various ways to do it. But it ought to get done. Nevertheless, the health of the system depends on other factors. The bigger the economic pie, the easier it is to cut a slice from it.

reason: The argument being made by Elizabeth Edwards and other critics of Obama and McCain's plan is that if everyone isn't covered, the costs will just be passed on to consumers.

Shultz: We have a lot of history that if you order people to do something, it doesn't work out very well. Remember Prohibition?

reason: Yes, but there's also the history of the creation of Social Security and of Medicare, where people can't opt out of paying into the system.

Shultz: When Franklin Roosevelt created Social Security, in his wisdom, he said that the one thing it should not be is a welfare program and that we couldn't afford such an approach. We keep borrowing from the Social Security trust fund—the politicians can't seem to keep their hands off it.

We favor subsidizing existing spending, providing benefits for people 65 years old and older regardless of sex or prior medical conditions. But that's different from saying to you, if you're a healthy 25-year-old, that you have to buy insurance for everything. They want insurance against a catastrophic event—they don't want to cover acupuncture, or wigs, or all kinds of things that make it more expensive. So how do you bring that about? Provide an insurance policy for the 25-year-old that makes sense. I'm 87 years old. I don't want the same policy as a young man; I'm in a different position.

reason: So as a free-market advocate, you think competition would get costs down?

Shultz: If you're mandating things to people, you won't get lower costs.

reason: You and Shoven are at some pains to say you want to preserve the safety net by taking incremental steps.

Shultz: It's incremental, but it's bold—we have a lot of suggestions.

reason: You mentioned President Bush's efforts in this regard, but his attempts at reform came up against a stone wall of resistance.

Shultz: As did President Clinton's. There's a bipartisan recognition that this is a problem that needs to be solved, and a bipartisan recognition of the resistance to solving it.

reason: If the federal government won't do it, what about local communities? What do you think of Gov. Schwarzenegger's and Mayor Newsom's health-care proposals?

Shultz: We know and like them both. The governor's proposal hasn't gone anywhere, so there's no need for me to talk about that. What's interesting about Newsom's proposal is the idea of clinics where ordinary health care needs can be addressed inexpensively.

reason: As you watch the deficit increase—along with the costs of funding the war—is your feeling one of, "A plague on both their houses?"

Shultz: I haven't seen any lack of appetite for more domestic spending programs. The last time anything substantive got accomplished [on Medicare reform] was when two Irishmen [Reagan and Speaker of the House Tip O'Neill], who didn't agree on much else but knew this was a big problem, could get together over drinks and work to help fix it and get the changes through Congress.

reason: You mentioned Prohibition—I know you've taken a somewhat controversial stand for the legalization of recreational drugs.

Shultz: I don't think of them as "recreational.'' They do enormous harm, and we should do everything we can to prevent people from taking them. But the current system isn't working.

reason: You write in Putting Our House in Order about the successes of our economic system. As you point out: "Over the last 150 years, the U.S. economy has become increasingly stable. The economy was in recession nearly 45 percent of the time during the last half of the nineteenth century, 33 percent in the first half of the twentieth century and 16 percent in the last half of the twentieth century. In the post-World War II period, the occurrence of down quarters has diminished sixteen in the years between 1946 to 1965 to fifteen from 1966 to 1985 to just five since then. Meanwhile, even as the economy has grown to Herculean size, its rate of growth has continued to be robust.''

Despite the threats of terrorism, entitlement costs and the current downturn in the economy, are we better off today than we were 20 years ago?

Shultz: The economy has been very successful, but there are other problems, so we have to work on them.

reason: Are entitlements a bigger problem than terrorism?

Shultz: I don't see how you get very far by comparing them. Terrorism is a gigantic problem.

reason: Which is a greater threat to our way of life, though?

Shultz: Well....Entitlement spending is something we have to face up to.

The Wal-Mart Prescription Drug Benefit

mmoynihan@reason.com (Michael C. Moynihan) — Mon, 05 May 2008 15:23:00 EDT

I've spent a fair amount of time shilling for Wal-Mart's prescription drug plan on this blog, so don't think for a second that I would miss today's news that the Corporate Monster from Bentonville is greatly expanding the program to include a whole slate of new drugs, including, according to AP, "several women's medications."

Wal-Mart Stores Inc., the world's largest retailer, announced Monday it would expand its discounted prescription drug program to offer 90-day supplies for $10 and add several women's medications at a discount. It also said it would lower the price of more than 1,000 over-the-counter drugs.
The move marks the third phase of a company program that began in 2006 to provide a 30-day supply of generic prescription drugs for $4. The Bentonville-based company said the program has saved customers more than $1 billion.
With the expansion, the company began filling prescriptions Monday for up to 350 generic medications at $10 for a 90-day supply at Wal-Mart, Neighborhood Market and Sam's Club pharmacies in the U.S. Almost all the prescription generics in the company's $4 program were included in the expanded $10 offer, said Wal-Mart senior vice president John Agwunobi.
In addition, the company will add several women's medications to its list of prescriptions available for $9, including drugs to treat breast cancer and hormone deficiency.
For instance, alendronate, the generic version of osteoporosis medication Fosamax, will be added to the list. Company pharmacies will fill 30-day prescriptions of alendronate for $9 and a 90-day supply for $24 at a comparison of $54 and $102, respectively, that women previously paid for the same amounts, the company said.
Tamoxifen, used to treat breast cancer, will be offered for $9 for a 30-day supply, as well as combination estrogen/methyltestosterone tablets, prescribed for menopause and hormone deficiency.
Wal-Mart also will lower the prices of more than 1,000 over-the-counter medications to $4 or less in its pharmacies, company officials said. The company has sold over-the-counter medicines in the past at discounted prices, but revised and expanded its offerings specifically to include commonly used drugs that usually sell for $7 or more, said company spokesman Deisha Galberth.

My previous paeans to the Wal-Mart plan can be read here and here. My pooh-poohing of the "big box panic"—with the requisite Wal-Mart mentions—can be found in this month's Utne Reader.

Aussie Doc Proposes $47,000 per Donated Kidney to Relieve Chronic Shortages

gillespie@reason.com (Nick Gillespie) — Mon, 05 May 2008 07:37:00 EDT

An Australian doctor has proposed that the government pay up to $47,000 for kidney donations to overcome a chronic shortage.
The suggestion has touched off debate around the country on the idea, which critics say will end in the poor selling their organs to the rich.
Kidney specialist Gavin Carney says allowing the sale of organs would save thousands of lives and billions of dollars in care for patients on transplant waiting lists.
He also says it would stop people from buying organs on the black market in developing countries, where they pursue risky, unregulated surgeries.

And the predictable response from the Aussie medical establishment, despite the country's low rate of donation? Don't even think about it: "The idea was dismissed by Health Minister Nicola Roxon, who said Australians would not be allowed to market their organs.

A few weeks ago, reason.tv host Drew Carey looked at how open markets in human organs would make everybody involved much better off.

Check it—and a ton of relevant resources—here.

Opening Up the Dental Market Is Like Pulling Teeth

jsullum@reason.com (Jacob Sullum) — Fri, 02 May 2008 11:44:00 EDT

Years ago I wrote an article for reason (not available online) that explored the cost-controlling potential of allowing nurse practitioners, physician assistants, and other non-M.D.s to offer services traditionally performed by doctors. Not surprisingly, organized medicine tends to resist these inroads, especially when it comes to operating independently and prescribing drugs. But judging from a recent New York Times story, dentists have been even more effective at fighting off competition from people who have less than the conventional seven or eight years of post-secondary education. The Times reports that "dental therapists," who undergo two years of intensive training after high school, can do basic dental work such as filling cavities and extracting teeth, serving people who otherwise might not get dental care at all. If you've never heard of dental therapists, that's not surprising: Although research indicates their work is just as competent as the average dentist's, they are permitted to operate only in Alaska, under a federally funded program serving people in sparsely populated areas.

Even this limited experiment has drawn fierce opposition from the Alaska Dental Society and the American Dental Association, which say dental therapists threaten ~~dentists'~~ ~~income~~ patients' welfare:

The opposition to therapists follows decades of efforts by state dental boards, which are dominated by dentists, to block hygienists from providing care without being supervised by dentists.
The dental associations say they simply want to be sure that patients do not receive substandard care. But some dentists in public health programs contend that dentists in private practice consider therapists low-cost competition. In Alaska, the federally financed program that supplies care to Alaska Natives pays therapists about $60,000 a year, one-half to one-third of what dentists typically earn....
The American Dental Association...says it does not fear lower-cost competition but instead wants to protect patients from inadequately trained therapists, who may not be able to handle the emergencies, like uncontrolled bleeding, that sometimes occur during routine procedures.

So it's better for someone with a bad cavity to suffer constant pain or yank his own tooth than it is to run the risk of "uncontrolled bleeding" during a visit to a dental therapist. The other argument against dental therapists is even more blatantly paternalistic:

In the long run, the only way to improve dental health is encourage people to take better care of their teeth, Dr. [Amid] Ismail [an ADA consultant] said.
"I'm not in favor of training just to fill teeth, because a solution of filling teeth is not going to reduce disease," he said. "The patients will go home, and they will drink six cans of soda a day, and they will come back with more cavities."

But if the government forces them to suffer with unfilled cavities by blocking access to low-cost dental care, maybe they'll learn to lay off the soda and brush and floss regularly. They'll be better off in the long run!

John McCain's Plan to Keep Employer-Provided Health Insurance While Moving Away From It

jsullum@reason.com (Jacob Sullum) — Wed, 30 Apr 2008 18:11:00 EDT

Severing the government-supported, market-distorting connection between health insurance and employment would promote choice, allowing people to select the medical plans that best suit their circumstances, and security, addressing one of the main anxieties about health care by making coverage portable. This is one of the few areas where the Bush administration was on the right track, and I'm glad to see John McCain picking up the idea. But I wish his talk were a little straighter on this subject. Here is how he describes the current system, in which most Americans with health insurance get it through their employers, and the change he'd make:

Under current law, the federal government gives a tax benefit when employers provide health-insurance coverage to American workers and their families. This benefit doesn't cover the total cost of the health plan, and in reality each worker and family absorbs the rest of the cost in lower wages and diminished benefits. But it provides essential support for insurance coverage. Many workers are perfectly content with this arrangement, and under my reform plan they would be able to keep that coverage. Their employer-provided health plans would be largely untouched and unchanged.
But for every American who wanted it, another option would be available: Every year, they would receive a tax credit directly, with the same cash value of the credits for employees in big companies, in a small business, or self-employed. You simply choose the insurance provider that suits you best. By mail or online, you would then inform the government of your selection. And the money to help pay for your health care would be sent straight to that insurance provider. The health plan you chose would be as good as any that an employer could choose for you. It would be yours and your family's health-care plan, and yours to keep.
The value of that credit—$2,500 for individuals, $5,000 for families—would also be enhanced by the greater competition this reform would help create among insurance companies. Millions of Americans would be making their own health-care choices again. Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs. It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.

Although you might not guess it from McCain's gloss, the "tax benefit" in question goes to employees, not employers. Companies can deduct money spent on employee compensation as a business expense whether it takes the form of wages or health benefits. But since the government does not treat employer-provided health insurance as taxable income, there's an artificial incentive for employees to prefer compensation in that form, rather than the cash equivalent. If both kinds of compensation were treated the same, most employees presumably would prefer the money; employers would respond by ditching health benefits and offering higher wages instead. Equal tax treatment could be accomplished either by taxing the health benefits as income or, as McCain seems to be proposing, making the money an employee independently spends on health insurance tax-free as well.

Although the policy change has to do with taxes paid by employees, The New York Times has McCain "eliminating the tax breaks that currently encourage employers to provide health insurance for their workers," which makes it sound as if employers are the ones getting the breaks. And the McCain campaign seems to be downplaying the impact that equalizing the tax treatment of health benefits and wages would have on the prevalence of employer-provided medical coverage. According to the Times, McCain's domestic policy adviser "said he believed that many employers would still offer health insurance to try to attract the best workers." McCain himself says "employer-provided health plans would be largely untouched and unchanged" for the "many workers" who "are perfectly content" with the status quo. Maybe this is just his way of reassuring people that changes in the compensation mix would be driven by employee preferences. But the main economic rationale for eliminating the health-benefit tax preference is to make employer-provided medical coverage the exception rather than the rule; otherwise we would still have a system in which medical coverage is both artificially expensive, since patients have little opportunity or incentive to economize, and insecure, since losing a job often means losing health insurance.

Both Sides Now—and We Hate That

jsullum@reason.com (Jacob Sullum) — Mon, 14 Apr 2008 11:19:00 EDT

Over at The Huffington Post, reason contributor Maia Szalavitz notes that Kansas physician Stephen Schneider and his wife, Linda, who are accused of drug trafficking through improper painkiller prescriptions, have managed to get their side of the story out with the help of the Pain Relief Network. The usual practice in cases like this is to convict the defendant in the press, which typically depicts his practice as nothing but a "pill mill" and rarely covers patients who are grateful for desperately needed pain relief. In the Schneiders' case, Szalavitz writes, "The AP has covered the story as one with two sides—including the legitimate need for access to pain relief, not just focusing on the prosecution's storyline of evil doctors pushing patients into addiction." Federal prosecutors have responded by seeking a gag order that would not only prevent the Schneiders and their lawyers from publicly discussing the case but silence Pain Relief Network President Siobhan Reynolds as well. Shouldn't they also have asked the judge to prevent people from talking about the gag order?

Szalavitz on pain doctor prosecutions here. More reason coverage of the subject here.

Free the Kidneys!

matt.welch@reason.com (Matt Welch) — Fri, 21 Mar 2008 08:45:00 EDT

Former reason editor Virgina Postrel talks about her star turn in Drew Carey's latest reason.tv production on creating a market for organ transplants:

The video is excellent, even though all of us look pretty awful. The only thing I'd fault it for is not making the point that--I cannot say this often enough--EVEN IF EVERY SINGLE ELIGIBLE CADAVER KIDNEY WERE DONATED, THERE WOULD NOT BE ENOUGH. This shortage cannot be fixed by changing the law to override families' wishes and turning everyone who hasn't explicitly said no into a deceased donor. All that would do is sow further mistrust of the organ transplant system, particularly among (calling Barack Obama) already-suspicious African Americans.

Whole thing, well worth reading, here.

Senior Editor Kerry Howley asked "Who Owns Your Organs?" in 2006. Contributing Editor Julian Sanchez explored the morality of organ transplants in 2003. Science Correspondent Ronald Bailey made the case for selling human organs in 2001. James DeLong decried the federal government's mishandling of transplants in 1998. (UPDATE: Cato has also published a recent study on the subject.) And by popular demand, once again, here's Drew Carey:

Now Playing at Reason.tv: Drew Carey on Human Organ Markets

Tue, 18 Mar 2008 07:00:00 EDT

In his most controversial segment yet, reason.tv host Drew Carey offers a startling solution to the critical shortage in kidneys available for transplant: Pay people to donate their kidneys.

Featuring former reason editor—and organ donor—Virginia Postrel.

Click on the image below to watch "Organ Transplants: Kidneys for Sale."

The Great Healthcare Robbery

khowley@reason.com (Kerry Howley) — Thu, 06 Mar 2008 12:00:00 EST

Is Ephraim Dagadu stolen goods? The Ghana-born and trained physician, who runs a successful family practice in Maryland, does not speak like a man who has been ripped from his rightful home and forced to toil in the Baltimore suburbs. His visage appears on no milk cartons; no cross-continental Amber Alert calls for his return. But according to a recent piece [registration required] in a prominent British medical journal, a caring U.S. would have done more to keep Dagadu from encountering opportunity abroad. He, goes the argument, belongs to Ghana.

Read the entire article at the Los Angeles Times.

Still Stuck on Castro

mmoynihan@reason.com (Michael C. Moynihan) — Fri, 22 Feb 2008 12:00:00 EST

In a country where major news developments rarely precipitate anything but deeper misery, Cuba awoke Tuesday to the news that el jefe maximo, Fidel Castro, had formally ceded power to his younger brother Raul. Cuba has grown accustomed to a seemingly endless and ageless set of images of the revolutionary father delivering a stultifying oration on Yanqui this-or-that, reposing in a monogrammed track suit, mumbling incoherently about his days in the Sierra Maestra. But to Cuba watchers and exiles, his official ceding of power was unexpected.

The 81-year-old Castro tendered his resignation in column form, carried in Cuba's national newspaper (there is, excluding a flimsy "youth publication," just one). Lifting language from Lyndon Johnson (one of the many presidents that, the deeply serious pundit is required to mention, he has "outlived"), Fidel declared, "I will neither aspire to nor accept—I repeat, I will neither aspire to nor accept—the positions of President of the State Council and Commander in Chief." Delusional until the end, Castro presumes that his indentured subjects demand eternal revolution, forcing him to repeat that, no, it will be little Raul, 76, who will guide the Cuban people towards a classless and cashless utopia. MSNBC's Chris Matthews apparently believes this too, asking Rep. Dan Burton (R-Ind.), co-sponsor of the monumentally stupid, embargo-expanding Helms-Burton Act, why "Cubans on the island still support the Castro brothers."

The preceding days have demonstrated that information peddled by Castro's legion of academic and celebrity apologists has deeply penetrated the mainstream media consciousness, with credulous reporting sundry revolutionary "successes" of the regime: not so good on free speech, but oh-so-enviable on health care and education.

In an email to staffers, with the nudging subject line "Castro guidance," CNN producer Allison Flexner advised reporters to be fair and not to focus solely on the regime's repressiveness. "Please note Fidel did bring social reforms to Cuba," writes Flexner, "namely free education and universal health care, and racial integration in addition to being criticized for oppressing human rights and freedom of speech."

Well, wrong on all three counts, but more on that later. That evening, CNN's ubiquitous foreign correspondent Christiane Amanpour appeared on a panel to hail the end of Castro's rule while managing to mention that he was "a leader in many things such as education, health care." Message received, Atlanta!

In Europe, The Guardian's Latin American correspondent Rory Carroll admonished Cuba for its human rights violations while praising "the government's success in offering all its citizens free access to education and healthcare, resulting in western levels of literacy and life expectancy." That's at best a dubious achievement, considering that Cuba is situated in the West. "Compared with other Latin American countries," Carroll gushed, "Cuba is notable for its absence of beggars, violent crime and extreme inequality," because everyone is equally poor. The average monthly salary in Cuba is 330 pesos—about $13.75.

Thirteen measly bucks and there aren't any beggars in Cuba? Well, not really. As one Miami Herald reporter observed in December 2006, "Anyone strolling through Cuba's tourist spots like Old Havana is likely to encounter a number of panhandlers, from the disabled like Avila and the elderly like Cecilia in the Plaza de Armas, to those struggling with mental illness such as Irma Castillo at the Parque Central." The British left-wing magazine The New Internationalist reported, "On the streets of Havana there are two relatively common sights that wouldn't have been seen 20 years ago: cellphones and beggars." (Cell phone use is, naturally, heavily regulated by the government, ensuring that Cuba ranks second to last in a recent United Nations table of cell phones per person. For those scoring at home, only Papua New Guinea ranks lower.)

The British news agency Reuters tells us that Castro came to power by overthrowing "U.S.-backed dictator Fulgencio Batista." And Batista was a dictator—one alternately supported, tolerated, and disliked by Washington. As historian Hugh Thomas, author the magisterial book Cuba or the Pursuit of Freedom, wrote, "American assistance to Batista was never explicitly forthcoming." By 1958, a year before Castro's seizure of power, the U.S. had instituted an arms embargo against Batista, and elements within the CIA and State Department were actively agitating for a Castro victory. Indeed, it was the British government that agreed to sell Batista military hardware—15 fighter planes—when the Eisenhower administration refused.

And how does Reuters describe Castro? After 50 years of brutal one-party rule, to apply the appellation "dictator" seems a rather contentious issue: "Vilified by opponents as a totalitarian dictator, Castro is admired in many Third World nations for standing up to the United States and providing free education and health care." And again, we return to education and health care.

The AP, retracing the history of modern Cuba, explains that Castro's "revolutionaries opened 10,000 new schools, erased illiteracy, and built a universal health care system." And what kind of schools, what kind of education system, did they inaugurate? As Georgetown University professor Eusebio Mujal-Leon has observed, "The [rewritten Cuban] Constitution made the furtherance of Marxism-Leninism the purpose of education, and through its Article 38 made the latter a function of the state." What good is universal literacy if one can be arrested for possession of an Orwell book? What good is "free" education if honest academic inquiry is forbidden?

In fairness to fourth-estaters, it wasn't just journalists that cribbed from the party script. The ridiculous Rep. Jose Serrano (D-N.Y.) was the only American politician to debase himself by issuing a Granma-worthy press release actually praising Castro. This week's events prove, Serrano wrote, "that Castro sees clearly the long-term interests of the Cuban people," including the selfless decision to hand power to his brother, thus saving the Cuban people from the indignity of electoral choice. "I would like to congratulate both Fidel Castro and the Cuban people for this smooth transition of power," continued, "Few leaders, having been on the front lines of history so long, would be able to voluntarily step aside in favor of a new, younger generation." The absurdities of that sentence are too many to catalog, though note that the "younger generation" is represented by Fidel's septuagenarian brother Raul.

Writing in The New Statesman, British parliamentarian John McDonnell, the Right Honorable Gentleman from 1968, offers high praise for Cuban communism and demonstrates a level of credulity not seen since John Reed vacationed in Moscow. But don't mention Moscow, because, as McDonnell bizarrely writes, "unlike Stalin's Russia there have never been any Cuban gulags." What's not to like, he asks, about a country that provides "free prescriptions, free care for the elderly, free university education."

So again, the health and education canard returns. What all of these pols and pundits lazily presume is that if the state of Cuban health care and education have markedly improved on Castro's watch, surely the situation was dire during the final years of the Batista dictatorship.

Well, not exactly. In 1959 Cuba had 128.6 doctors and dentists per 100,000 inhabitants, placing it 22nd globally—that is, ahead of France, the United Kingdom, the Netherlands, and Finland. In infant mortality tables, Cuba ranked one of the best in the world, with 5.8 deaths per 100,000 babies, compared to 9.5 per 100,000 in the United States. In 1958 Cuba's adult literacy rate was 80 percent, higher than that of its colonial grandfather in Spain, and the country possessed one of the most highly-regarded university systems in the Western hemisphere.

Cuba improved, as have most countries, on some of these indices in the years since the revolution. As reason Contributing Editor Glenn Garvin points out, "countries like Costa Rica, Panama, and Brazil have posted equal gains in literacy during the same time period without resorting to totalitarian governments." (For more reason coverage over the years on Cuba and Castro, go here.)

This is precisely the point: Punctual trains and spiffy highway networks hardly mitigate the horror of dictatorship. Such "advances," like the illusory gains of the Cuban Revolution, are best achieved through policies that promote economic and political freedom. You would think, almost 20 yeas after the fall of the Berlin Wall, that journalists would understand that.

Michael C. Moynihan is an associate editor of reason.

The Egalitarian Cruelty of the NHS

jsullum@reason.com (Jacob Sullum) — Thu, 21 Feb 2008 17:25:00 EST

Even if you're accustomed to hearing horror stories about Britain's National Health Service, this one is really appalling. Debbie Hirst, a woman with metastasized breast cancer, wanted to take Avastin, a drug that, per The New York Times, is "widely used in the United States and Europe to keep such cancers at bay." The NHS refused to pay for it, saying it was too expensive. That much is par for the course in a system that holds down costs by rationing care according to standards set by a single central authority. But then Hirst, with the support of her oncologist, decided to raise the $120,000 she'd need to pay for the drug on her own, mainly by selling her house. The NHS said she was perfectly free to do that, but then she would have to pay for all of her care out of pocket, a financial burden that was far beyond her means. The Times does its best to explain the rationale for this position:

Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.
Patients "cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs," the health secretary, Alan Johnson, told Parliament.
"That way lies the end of the founding principles of the N.H.S.," Mr. Johnson said.

Yet if you are wealthy enough to pay for all of your health care out of pocket, you are allowed to do so. Doesn't that also give richer patients an unfair advantage over poorer ones? Why isn't that equally offensive to the egalitarian sensibilities of NHS bureaucrats? The fact is, it's better to be rich than poor for many reasons, and fairness doesn't really enter into it (assuming the absence of force or fraud), unless you view all resources as the government's to distribute as it sees fit. And even a collectivist would have to admit that the NHS policy that Hirst ran into makes little sense:

In fact, patients, doctors and officials across the health care system widely acknowledge that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free.
"Of course it's going on in the N.H.S. all the time, but a lot of it is hidden—it's not explicit," said Dr. Paul Charlson, a general practitioner in Yorkshire and a member of Doctors for Reform, a group that is highly critical of the health service. Last year, he was a co-author of a paper laying out examples of how patients with the initiative and the money dip in and out of the system, in effect buying upgrades to their basic free medical care.
"People swap from public to private sector all the time, and they're topping up for virtually everything," Dr. Charlson said in an interview. For instance, he said, a patient put on a five-month waiting list to see an orthopedic surgeon may pay $250 for a private consultation, and then switch back to the health service for the actual operation from the same doctor.
"Or they'll buy an M.R.I. scan because the wait is so long, and then take the results back to the N.H.S.," Dr. Charlson said.
In his paper, he also wrote about a 46-year-old woman with breast cancer who paid $250 for a second opinion when the health service refused to provide her with one; an elderly man who spent thousands of dollars on a new hearing aid instead of enduring a yearlong wait on the health service; and a 29-year-old woman who, with her doctor's blessing, bought a three-month supply of Tarceva, a drug to treat pancreatic cancer, for more than $6,000 on the Internet because she could not get it through the N.H.S.

In the end, after Hirst's cancer spread even further, the NHS decided the balance of costs and benefits had shifted, and it agreed to pay for her Avastin:

Mrs. Hirst is pleased, but up to a point. Avastin is not a cure, but a way to extend her life, perhaps only by several months, and she has missed valuable time. "It may be too bloody late," she said.
"I'm a person who left school at 15 and I've worked all my life and I've paid into the system, and I'm not going to live long enough to get my old-age pension from this government," she added.
She also knows that the drug can have grave side effects. "I have campaigned for this drug, and if it goes wrong and kills me, c'est la vie," she said. But, she said, speaking of the government, "If the drug doesn't have a fair chance because the cancer has advanced so much, then they should be raked over the coals for it."

Hirst had no choice about paying the taxes that support the NHS, and when she tried to supplement the limited coverage it provided out of her own pocket, it reneged on its promise to take care of her. The Michael Moores of the world surely would see injustice in a decision by an HMO or insurer not to cover a cancer patient's Avastin. Why don't they see injustice in a case like this?

Michael Moynihan on Michael Moore and the NHS here, here, and here, among other places.

The Burden of Healthy Living

jsullum@reason.com (Jacob Sullum) — Tue, 05 Feb 2008 18:14:00 EST

A Dutch study reported yesterday in the online journal PLoS Medicine undermines the fiscal argument for a government-led War on Fat, which says how much you weigh is everyone else's business because other people have to pick up the tab via taxpayer-funded health care programs. The researchers found that eliminating obesity would, over the long term, increase medical spending instead of reducing it:

Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures....
Obesity prevention, just like smoking prevention, will not stem the tide of increasing health-care expenditures. The underlying mechanism is that there is a substitution of inexpensive, lethal diseases toward less lethal, and therefore more costly, diseases.

The researchers compared the medical expenses of three hypothetical cohorts: obese people, smokers, and thin nonsmokers. They found that annual costs were highest among obese people until age 56, after which smokers were the most expensive group. But because both groups had lower life expectancies (80 and 77, respectively) than the "healthy-living" cohort (84), they had lower lifetime health care costs as well. Taking the long view, the thin nonsmokers cost the most, followed by obese people and smokers, in that order:

At discount rates of, respectively, 3% and 4% successful smoking prevention would result in additional health-care costs of €7.1 and €3.4 million (assuming costless intervention). For obesity prevention these figures would amount to €1.8 and €1.0 million. Only for discount rates above 4.7% would costless obesity prevention be cost saving. For smoking prevention to be cost saving, the discount rate for costs should be at least 5.7%.

The authors note that they considered only health care costs, leaving out "other potentially substantial costs and consequences" of obesity, such as reduced productivity and "the reduced well-being of family members due to morbidity and premature death." But the former cost would be borne mainly by obese people themselves through reduced earnings, and the latter should be internalized to the extent that obese people care about their family members. (If the government did not force some people to pay for other people's health care, medical costs would be internalized as well.) Notably, the study also left out taxpayer-funded pensions, which increase the burden that healthy-living people impose on the rest of society.

In my 2004 reason article about the War on Fat, I noted that research might find that obesity, like smoking, saves taxpayers money.

[via The Freedom Files]

Saying No to CoerciveCare

info@reason.com (Shikha Dalmia) — Mon, 04 Feb 2008 14:58:00 EST

One week ago, California Gov. Arnold Schwarzenegger's "universal" health-care plan was shot down by a committee in the state's Senate, 7-1. The most vociferous opponents were not fiscal conservatives, but labor unions that launched a last-minute revolt against its most crucial feature: an individual mandate that would have forced everyone to buy coverage.

This defeat has national political implications. Hillary Clinton, for example, has denounced Barack Obama for refusing to include an individual mandate in his health-care plan. Yet many California unions argued that a mandate would force uninsured, middle-income working families to divert money from more pressing needs toward coverage whose price and quality they cannot control.

The unions are correct: This is exactly what is happening in Massachusetts, where Mitt Romney enacted a similar plan two years ago as governor. (And Mr. Romney's plan is the inspiration for both the Schwarzenegger and Clinton plans.) The experience in the Bay State deserves a lot more scrutiny than it has been getting.

Massachusetts uses a sliding income scale to subsidize coverage for everyone up to 300 percent of the poverty level—or a family of four making around $60,000. Everyone over that limit is required to pay for their own coverage if their employers don't provide it. All this has inflated demand, which, combined with onerous regulations on insurance suppliers, has triggered premium increases of 12 percent for this year—double last year's national average.

No one is escaping the financial sting. The state health-care bill for fiscal 2008-2009 is expected to be $400 million more than originally projected—an 85 percent increase. Still the state won't be able to full shield those it subsidizes from the premium increases. But uninsured folks who don't qualify for government help really get pounded. Before the hike, the cheapest plan for uninsured couples in their 50s cost $8,200 annually. Now, unless government bureaucrats hand them an exemption, they might well find it cheaper to pay the penalty—up to half the price of a standard policy—than purchase insurance. That is, pay to remain uninsured. This is legalized extortion: TonySopranoCare.

The government response to rising premiums is, unsurprisingly, price controls. The Commonwealth Health Insurance Connector Authority—the bureaucracy created to oversee RomneyCare—is considering prohibiting underwriters from raising premiums more than 5 percent for unsubsidized plans, meanwhile requiring them to cover 40-odd benefits from hair prostheses to chiropractic services. If companies can't scale back coverage, they'll have to compromise care; and the Connector is perfectly willing to assist.

As reported in the Boston Globe, the Connector is encouraging insurance companies to include only a limited network of cheaper physicians and facilities in some plans to hold down premiums. Patients who wish to see more expensive providers will have to dig into their own pockets. Dr. Steffie Wollhandler, a professor of medicine at Harvard University, worries that the Connector will revive Gov.
Romney's original idea of enrolling poor people in plans that only offer access to neighborhood health centers ill-equipped to treat anything beyond routine ailments. Forcing people to buy substandard care they cannot afford is not universal care, she says. "It is a hoax." And so Massachusetts is marching toward a system of two-tiered medicine—the alleged market inequity that universal care is supposed to cure.

How about enforcing the mandate? In Massachusetts, non-compliers lose their personal tax exemption—about $220—the first year, followed by fines in subsequent years.California was planning to garnish the wages or impose liens on the mortgages of the uninsured to pay for coverage. "This bill was like telling someone who is in need of help, 'I'm going to give you food, but I'm going to take away your clothes," Leland Yee, a Democratic senator from San Francisco, told the California Chronicle.

The problems with RomneyCare have prompted Mr. Romney himself to abandon it. And Mr. Obama is surely correct that part of the reason 45 million Americans are uninsured is not that no one is forcing them to buy it, but that they can't afford it. It may be too much to hope that Mr. Obama would embrace market-oriented measures—such as deregulating insurance markets, giving patients more control over their health care dollars, and fixing the federal tax code to let individuals, like employers, buy health coverage with pre-tax dollars—to bring down insurance costs. But unlike Mrs. Clinton, he at least seems to understand the perverse side effects of an individual mandate.

Should Hillary Clinton ever be in a position to bully people into buying coverage, a coalition of labor and fiscal conservatives might well do to HillaryCare what it just did to GovernatorCare.

Shikha Dalmia is a senior analyst at the Reason Foundation. This article originally appeared in the Wall Street Journal.

ArnoldCare: On the Brink of Termination?

bdoherty@reason.com (Brian Doherty) — Thu, 24 Jan 2008 11:33:00 EST

Ron Bailey warned us last January about some of the problems with California Gov. Arnold Schwarzenegger's proposed health-care reforms, which instead of empowering consumers of health insurance to make their own choices, makes those who can't afford to buy the health insurance the plan will mandate that all Californians own into wards of the state by enrolling them in expensive state programs such as MediCal.

Now the LA Times tells us, despite passage by the state Assembly, that the plan seems set to die in the charnel fields of the state's Senate. Why?

A report by the nonpartisan legislative analyst's office released Tuesday evening questioned some of the Schwarzenegger-Nuñez plan's fiscal assumptions as too optimistic and estimated that by the fifth year of operation, the plan would be spending $300 million more than it was raising.

Even before the report's release, many Senate Democrats expressed concerns about a grand expansion of healthcare at a time when the state is facing a $14.5-billion budget shortfall that may require large cuts in existing healthcare.

Schwarzenegger and [Assembly Speaker Fabian] Nuñez have insisted that their plan will have no effect on the state budget. But the legislative analyst noted that the state's general fund "would be the ultimate backstop," and if the healthcare plan gets out of balance "it could create pressure on the general fund."

..........Even if the bill passed the Senate, it would not go into effect unless a companion ballot measure is approved in the November election. That measure contains the financing for the plan: $2.5 billion in hospital taxes, an increase in tobacco taxes of $1.75 a pack and a requirement that employers spend the equivalent of up to 6.5% of their payroll costs on healthcare or pay into a state fund that would provide those workers with coverage.

George Passantino of the Reason Foundation has more on what's wrong with ArnoldCare. The key: the real problem with health care is cost, not insurance coverage, and Arnold's plan is apt to exacerbate the cost problem.

The headline is, I believe, my very first cutesy reference to the fact that the governor of California is a former actor who starred in a series of action flicks called The Terminator. I hope that will be noted as a mitigating circumstance in any eventual blog-headline show trial come the revolution.

And Don't Get Me Started About Doctors...

jsullum@reason.com (Jacob Sullum) — Fri, 11 Jan 2008 11:50:00 EST

On Wednesday the Massachusetts Public Health Council approved plans by CVS to open 25 to 30 "MinuteClinics" at stores in the Boston area. The limited-service clinics are aimed at providing quick, convenient treatment for minor illnesses. Boston Mayor Thomas Menino was outraged:

In a statement, the mayor said the decision yesterday by the state Public Health Council "jeopardizes patient safety. Limited service medical clinics run by merchants in for-profits corporations will seriously compromise quality of care and hygiene. Allowing retailers to make money off of sick people is wrong."

Evidently Menino not only wants to prevent the clinics from opening; he wants to abolish CVS and every other pharmacy.

[Thanks to an anonymous reader for the tip.]

The Care and Feeding of Soldiers: Any Larger Implications?

bdoherty@reason.com (Brian Doherty) — Thu, 03 Jan 2008 14:04:00 EST

Tyler Cowen wonders whether we can leap to any conclusions about the economy writ large from the starting point of how well the Army takes care of Vets health care--or food.

Cowen's reason contributions.

DIY NHS

mmoynihan@reason.com (Michael C. Moynihan) — Wed, 02 Jan 2008 14:33:00 EST

This year Britain's National Health Service (NHS), a single payer system worthy of emulation, say its American boosters, will celebrate 60 years of queues and DIY dentistry by introducing a new "patient constitution" that, according to reports, will refuse treatment to those who smoke or spend inordinate amounts of time on the couch time eating fried Mars bars and watching Eastenders. The Telegraph editorializes:

The inadequacy of our healthcare model has led us to a senseless (and heartless) contradictory position: the Department of Health states categorically that "co-payment" is unacceptable because it would result in an unequal system in which better-off patients would have advantages that poorer ones do not. But it now plans to refuse care to people whose unhealthy lifestyles are usually associated with poverty and deprivation. The extraordinary high-handedness of these proposals is symptomatic of all that is wrong with a tax-funded monopoly health system run by central government: ordinary people are encouraged to think of healthcare as a gift of the state.

The Telegraph also uncovers an internal Department of Health memo advising doctors to steer some patients towards self-treatment, thus avoiding doctor and emergency room visits and saving the NHS billions in overhead costs

Millions of people with arthritis, asthma and even heart failure will be urged to treat themselves as part of a Government plan to save billions of pounds from the NHS budget. Instead of going to hospital or consulting a doctor, patients will be encouraged to carry out "self care" as the Department of Health (DoH) tries to meet Treasury targets to curb spending.
[...]
The Prime Minister claimed the self-care agenda was about increasing patient choice and "personalised" services. But an internal Government document seen by The Daily Telegraph makes clear that the policy is a money-saving measure, a key plank of DoH plans to cut costs.

Full story. In other NHS news, Tory leader David Cameron has pledged that the conservatives will replace Labour as "the party of the NHS."