Amy Monahan and Daniel Schwarcz write:
This Essay argues that federal health care reform may induce employers to redesign their health plans to encourage employees who are likely to consume a greater-than-average amount of medical services to opt out of employer-provided coverage and instead acquire coverage on the individual market. Although largely overlooked in public policy debates, this prospect of employer dumping of high-risk employees raises serious concerns about the sustainability of health care reform more generally. In particular, it threatens the viability of individual markets and insurance exchanges by raising the prospect of adverse selection in these markets caused by the entrance of a disproportionately high-risk segment of the population. This risk, in turn, simultaneously threatens to increase the cost to the federal government of subsidizing coverage for qualified individuals and to exempt more individuals from complying with the so-called “individual mandate.” The Essay offers several legislative solutions to the prospect of high-risk employee dumping that can substantially mitigate these risks.
I found the critique section of the paper more convincing than the legal remedies, but in any case it is an important piece. Schwarcz wrote in the MR comments section:
The worry over employers shedding employees onto the exchange is exactly right, but in a different way than almost everyone seems to think. The real risk is NOT that employers will completely drop coverage, leaving their employees to purchase coverage on the exchange. Instead, it is that employers will offer all employees revised plans that are specifically designed to induce ONLY THE LEAST HEALTHY employees to opt for coverage on the exchange. Most seem to ignore this risk because such employees would not be eligible for subsidies. But employers would nonetheless find this an extremely desirable strategy because (i) they would avoid any penalty under the "employer mandate," (ii) their health care costs would decrease substantially by virtue of reducing coverage and shedding high-cost employees, (iii) high-cost employees would not be much worse off, as they could acquire coverage on the exchange with no medical underwriting or preexisting conditions. While coverage for high risk employees would cost more on the exchange than employer coverage, the employer could defray this cost by putting it's normal contribution into a tax free HRA Account, which could be used for coverage. The employer and its employees would be better off, and exchanges would be subjected to the risk of adverse selection from a disproportionately risky pool of policyholders. For much more on this, see: http://ssrn.com/abstract=1651308.
Addendum: Austin Frakt comments.
Dude, we are all bayesians now, and time is limited. Thus we must use such signals as the fact that these two are at a Law School to determine that they are not worth reading. Additionally it is interesting that you yourself devastate their argument (from a signaling perspective.)
I guess you read law professors so the rest of us don't have to.
If you have insurance until you get sick and then you're dumped from the policy, then it isn't insurance.
So what we're talking about is people that employers think would cost more, so when they hire those people they don't offer them health insurance. Like — older job candidates. People who don't require much of a career path, who can be hired cheap only they might get sick more. So if you're thinking about hiring them, but you have to pay a lot of insurance for them, isn't the obvious alternative to not hire them at all? Let them go on Medicaid instead. This does not look to me like a big problem for Obamacare.
So OK, the employer pays insurance for the young healthy people but not for anybody else. Wouldn't it be even cheaper to not pay insurance for anybody and put them all on Obamacare? Well, but the young healthy candidates he *really wants* might go with a competitor who pays insurance. OK, that isn't a whole lot of people. Offer them more money. More than enough to pay for insurance, and what's the problem? Still cheaper than insurance for everybody or even for all the young healthy ones.
So as fewer employers offer health insurance to anybody, Obamacare gets more and more of the business. Not just the people who get sick a lot, but everybody. Employers can pay their share of health insurance through taxes, if the tax structure goes that way. The less of it they pay, the more competitive US businesses are compared to businesses in countries with government-subsidised healthcare.
What's not to like? Well, employees might not like getting stuck in Obamacare along with everybody else instead of getting great health insurance perqs with the job. But that's something they can negotiate with their employers, it's a personal sort of thing and not something required by government. And health insurance companies would be upset to lose their fat profits, but that's something they can negotiate with their customers.
Whoops! HRAs can be used with other plans. My previous statement applies to HSAs.
http://www.nationmaster.com/graph/hea_tot_exp_on_…
We should do what Iraq is doing. They only spend 1.5% GDP on health.
Because health benefits are still untaxed, it still works out best if the employer offers at least some health benefit to the employee.
That problem is trivially solved.
Oh, but that would be socialsim, and we all know, *socialism doesn't work*. So I guess the fact that the French and Germans spend HALF AS MUCH on healthcare as we do means that they *must* be suffering under horrible systems.
Once again, I am reminded of the injunction provided on the last day of my last graduate (advanced managerial) accounting.
Beware of people who know the cost of everything, but the value of nothing.
Funny how we are told that cheaper healthcare is better-can you imagine that argument in any other product?
The whole thing seems to be designed to create a smooth transition to single payer while pretending to keep private insurance, but do to things like signaling it may not ever get there.
In other words, it's the well-worn government ratchet effect. It is built around aspects of voter helplessness.
Yeah, somebody explain to me why it's a good thing for employers to pay for healthcare in the first place. Even just for their healthy employees. Because the way I see it, if I can save money by ditching 10% of my employees off my insurance rolls why would I, my accountant, or my business partners be happy that I stopped there? Next year there's going to be the next 10% most-expensive employees, and I really don't see any reason to keep *them* on my books until the savings fail to offset the accounting cost of rooting them out.
As has been amply demonstrated elsewhere the whole idea arose out of arbitrage on regulatory inefficiency (to bypass a war-economy wage freeze.) Most of what we're talking about when we say "reform" is metastasis of that original "sin." I mean, seriously, if you were to re-run that tape we might have rational healthcare but a giant crisis over the escalating cost of employer-provided home electrification or K-12 education. But ideally if we were to re-run that tape we wouldn't have employer-provided anything at all, except maybe wages, bonuses, and maybe a holiday ham. Instead we'd have what we actually do have in almost all cases: some combination of individual consumers and/or aggregate voters providing home electrification, schools, *and* healthcare at optimal economies of scale.
In both today's and yesterday's posts nobody talked about the obvious issue of *paying* for all this. There doesn't seem to be a huge amount of systemic anxiety over "the most expensive" sewer-using households or even expelling the most expensive to educate children. Businesses do participate in funding public utilities but typically they do so the same way citizens do: through general user fees and taxes rather than outright footing of bills. Either that or they pay their employees enough that said employees can pay their utility bills.
What's broken about the current "dump their employees into public coverage" conversation, at least so far, is that it's assumed employers will retain 100% of the savings as profit and/or reduce 100% of the savings from the price of their goods. There's been approximately zero assumption that they will instead pass any portion of the savings at all either to their employees in the form of wages or to voters in the form of taxes. Employers dumping employee coverage is an issue if and only if voters and those they deputize to advocate in their interests decide they want to subsidize employer's share of the cost.
Voters have been allowing business to create huge public burdens. Originally in terms of untreated cadmium, fly ash, horse carcasses, and injured child employees, for instance, and more recently in terms of waste oxides of carbon, sulfur, and nitrogen and of bankrupted payday-loan and/or credit-card debtors. And they may choose to similarly provide healthcare welfare for plan-dumping employers as well. But one shouldn't assume that at some point voters will balk at the uncompensated imposition.
figleaf
Employers actually have relatively little control over healthcare policies, providers do. They have real incentives to keep high cost individuals in high cost plans and not drive them into lower cost plans since they will likely be covering them in either case. Not much of an issue.
"Should we be paying what others are paying" is a question, not a conclusion. The answer isn't even "if we are doing the same things they are doing." It's only answered 'yes' if everything costs the same and we are doing the same things, which they don't and we aren't. So, you are assuming Obamacare will make this cost the same and make us do the same things, which it won't even if we wanted it to. All Obamacare definitely does is make sure more money is going into the system and fewer people can opt-out.
Medicare and Medicaid already impose cost controls on their systems, yet they aren't any cheaper compared to the corresponding services in France, Germany, et al. than the non-Medicare/Medicaid system is compared to corresponding services.
That is not entirely accurate. Medicare prices are much closer to European levels.
Further, Medicare has to compete for providers with private insurers, and has to meet providers' income expectations. In France and Germany, the price-controlled system is all there is.
figleaf: "Yeah, somebody explain to me why it's a good thing for employers to pay for healthcare in the first place."
Absenteeism is a huge burden for most employers. Many employers believe that health insurance encourages employees to get regular checkups and to seek routine health care before conditions get serious. This may seem somewhat paternalistic on the part of the employer. But recognize that employers invest huge sums in getting employees trained to high levels of productivity. It is in the employers best interest to keep employees on the job.
Group health insurance has for many decades been cheaper on a per capita basis than has individual insurance. The group buying power employers offer is a benefit the corporation can use to attract talent. As a former small business owner, I know firsthand how difficult it is to compete with large employers who can offer much better benefit packages due to economies of scale.
Jules, the French and Germans *ARE* suffering from "horrible" systems, if you judge them by U.S. standards.
Countries with socialized medicine invest in family planning, pre-natal and early childhood care, infectious disease control… things with a very low cost that produce a huge benefit when it comes to overall life expectancy and health.
The U.S. invests in technology that keeps old people, and people with serious life-threatening diseases, alive. Advanced cancer treatments, advanced heart surgery… and the U.S. has the resources committed to treat large numbers of people with very expensive treatments at the end of life.
Now, which system is "good", or "bad", is subjective. However, it is clear that most Americans favor the second approach. If most Americans saw how quick doctors in socialized system are to "pull the plug on grandma" as they say, Americans would be horrified. If their insurance companies refused to purchase advanced cancer drugs that are unavailable in the public systems of Europe, people would be outraged. If American seniors had to wait years to get hip surgeries, the party responsible would meet the wrath of the AARP and would pretty much be finished. Can you imagine the venom if a government system in the U.S. decided to cut funding for arthritis treatment, in order to fund hepatitis vaccinations for junkies (arthritis does not effect life expectancy and is expensive to treat… infectious disease is cheap to prevent and has a huge effect on life expectancy… from a public health perspective you would almost always go after the latter)?
If the United States magically replaced its system of health care with the healthcare system of Canada, or France, or Germany, overnight, most Americans would consider it a disaster. European systems are "good", because Europeans have entirely different values and expectation about what health care is supposed to provide.
And the solution is?
If most Americans saw how quick doctors in socialized system are to "pull the plug on grandma" as they say, Americans would be horrified.
It is true that extreme end-of-life "care" for patients that are evidently barely conscious, suffering and dying is more widespread in the US. I'm not sure there are any benefits, including for the patients themselves.
If their insurance companies refused to purchase advanced cancer drugs that are unavailable in the public systems of Europe, people would be outraged
Advanced cancer drugs are very much available in most of Europe, and universally covered. It is true that new drugs come to the European market later than the US one, but that is mostly due to extra caution in authorizing them (i.e. benefit and safety criteria) in Europe vs. the US.
If American seniors had to wait years to get hip surgeries, the party responsible would meet the wrath of the AARP and would pretty much be finished
I've never seen as much people on scooters as in the US. Trust me, hip replacements are nowhere more rationed than here. My wife used to work as a nurse in a unit doing hip surgery in France. There, if you need one, you get one. Here, you have to convince the insurance first.
Can you imagine the venom if a government system in the U.S. decided to cut funding for arthritis treatment, in order to fund hepatitis vaccinations for junkies
Tell me where that happened ?…..
Except maybe for the first point above, the rationing of care in socialized systems is a myth and a lie. Period.
"We die sooner"
There is no "we die" or "we pay." There are statistics. It would be interesting if all these folks who think they know how to fix everything would perform an experiment that didn't involve the entire country at once.
What Jim said….the idea that they respond exactly to the incentives that were forced on them = undermining is….wow…ballsy.
Bill: "We die sooner."
Yes, but that's not a reflection of the quality of the health care system. Americans die sooner because of:
1. genetics (persons of African descent account for most of the differences between European and American life expectancies);
2. homicides;
3. lifestyle choices;
4. different definitions of infant mortality.
In the U.S., we spend most health care funds to treat illness and injury, to reduce suffering and wait times, and to marginally extend the lives of those who will soon die. Adopting a single payer system is not likely to change those priorities and is not likely to change the three causes for our slightly lower life expectancy.
gnat: "I understand that if you take the HSA account you cannot take other health insurance and that IRS enforces the rule."
(Note, I corrected the original HRA to HSA per gnat's correction).
Actually, the IRS requires that you have other health insurance in order to use an HSA. It requires that you have a high-deductible plan and the contribution limits are related to the deductible (I believe that the contribution limit equals the deductible, but I'm not sure that's 100% accurate). So you have insurance that is actual honest to goodness insurance for things that happen that you couldn't afford to pay for out of pocket (hit by a car, cancer, etc.) and then you pay cash (pre-tax) for manageable expenses like flu shots and physicals.
If we're discussing rational ways to pay for health care, HSA's and high deductible plans ought to be front and center. Just like it doesn't make sense for car insurance to pay for your oil changes, it doesn't make sense for health insurance to cover a routine visit to the doctor. You want car insurance to pay when you're in an accident that totals the car just like you want health insurance to cover your cancer treatments. Rates for high-deductible plans are vastly lower than rates for first-dollar coverage since insurance companies know they won't have to pay a dime for most covered people in most years and the savings in many cases can cover a pretty hefty fraction of the deductible/ HSA contribution.
If you want to pay much more for below average outcomes, be my guest.
Here, by the way, is a study which adjusts for homicide and acident differences and life expectancy. We spend twice as much and have worse outcomes.
The report is from AEI: http://www.aei.org/docLib/20061017_OhsfeldtSchnei…
Andrew, What is your factual support for the claim that we over pay for end of life? If we overpay for everything, including non-Medicare, it must also be true we overpay for end of life. I am about as sick of nonfactual assertions as I am about people throwing around claims of socialized medicine even for countries like Switzerland or France which use publicly supported private insurance models.
I am unclear about the facts for end-of-life care, and it looks like the facts are muddled to the point that it would be a significant effort to wade in and try to sort them out. I don't want to do that now, and also I'm not sure who to trust to do it for me — it's the sort of thing where subtle interpretations can make all the difference and it's easy to misinterpret stuff.
But I want to point out that this is an ideal minefield. On the one hand we have old people who hate the idea of spending their last months of life being tortured by people who think that every day they survive to be tortured more is a victory. On the other hand, we can probably dig up some cases of people who had expensive treatment at age 70 who then had 20 years of active happy life before dying at age 90. Deny them treatment so they die at age 70? Because *you* think they're at end-of-life? From various angles it turns into issues of competing rights and competing morality, and once we get sucked into that swamp we'll never contribute anything toward affordable healthcare until we get out again.
So if you don't want anything to change, talking about end-of-life issues is a good strategy.
Hardly anybody understands the details of health care expense. Everybody has an opinion about the morality of end-of-life care.
Why not go on the moral offensive?
"You oppose Obamacare?"
"No." End.
"Yes."
"Do you have health insurance?"
"No." "The old system didn't help you at all, why not try out a change?" End.
"Yes."
"And you're afraid that government officials would limit the healthcare you could get?"
"Yes, they'd have to cut costs."
"How does your current insurance plan decide which medicines and which medical procedures to disallow?"
"I don't know."
"Did you know they have a girl — a high school graduate — in a windowless building in Chicago, and when your doctor prescribes something, she checks a computer program which gives her advice and then she decides? She has a quota, she's supposed to disallow at least a certain minimum number a week."
"How do you know that?"
"I talked to a guy who managed a roomful of those girls. So does your insurance program have a list of specialists, and when your primary care physician refers you, he's supposed to refer you to somebody on that list?"
"I don't know."
"Shouldn't you find out? Because if you have a serious problem — say you get cancer — and you go to an oncologist your insurance company chose, maybe he'll know not to do anything your insurance won't allow. 'I'm sorry, your cancer is inoperable, I will start you on chemotherapy.' You are being denied various expensive treatments, and you don't even know about it."
"I'd find out and sue."
"Do you think you could win a court case before the cancer kills you?"
"Anyway, if the government did it I wouldn't get any choice. I'd have to settle for what they gave me. The way it is now, I get to choose my insurance policy."
"How did you choose it? Did you check what sorts of things they might disallow? Did you check what fraction of claims they disallow? Did you check average life expectancy for people on your plan versus other plans? Was any of this information available to you so you could make an informed choice?"
"Uh. I got the job, and they had three choices. Joe told me which one he was on and he said it worked OK."
This script is no good because if you make somebody feel stupid they won't change their mind, they'll only get mad at you. There has to be a way to get people to see truth without insulting them.
Bill,
You claim to want facts about the quality of health care systems. Here's a couple from professors at my alma mater, the University of Pennsylvania:
The effectiveness in treating cancer in the U.S. is unsurpassed by European nations:
"researchers from the Eurocare Working Group compare 5-year
survival rates for cancers … The aggregate of 41 European registries, which were drawn from 17 countries, had lower survival rates than the US from all cancer sites except the stomach, where differences were small and attributed to differences between the distributions of sites within the stomach."
A recent analysis of hypertension treatment effectiveness in the U.S., Canada, and five European nations was cited:
"Among those with hypertension, 65.5% were being successfully treated in the US (i.e.,
their levels were reduced below the hypertension-defining threshold), compared to 24.8% to
49.1% in the other countries."
The authors provide much more evidence that the U.S. healthcare system is more effective than the European systems at doing what it is designed to do: detect and treat illness and treat injury. The U.S. healthcare system should not be measured by life expectancy, which is determined by genetics and lifestyle choices.
"What is your factual support for the claim that we over pay for end of life?"
Because that's what medicare pays for. I could provide more, but that's the real answer.
But here's this anyway. http://www.ahrq.gov/research/ria19/expendria.htm
Bill, I think you are succumbing to what Krugman might call the fallacy of composition. I'd be interested to find out if other countries let the health outliers die. I'd also like to know how many of our people have have these most expensive health problems that soak up most of the spending. If you aren't saying that our system mis-directs resources, even if you conclude that expanding Medicare is the answer, then I don't understand what you are saying. If you move to outcome-based-reimbursement how do you make sure that what you are really doing won't be making doctors triage out those with poor prognoses?
Bill,
I don't think you have provided any data to show that health care is twice as expensive in the U.S. as elsewhere. I think all we know is that the U.S. spends almost twice as much as many European nations. I think a lot of what is happening in the United States is that we simply consume more health care services. That shouldn't be surprising. U.S. per capita GDP is much higher than that for the large European nations. On a per capita basis, we have more disposable income. That we spend a lot of that disposable income on health care is not surprising or bothersome to me. Does it bother you?
@John Dewey
"The authors provide much more evidence that the U.S. healthcare system is more effective than the European systems at doing what it is designed to do: detect and treat illness and treat injury. The U.S. healthcare system should not be measured by life expectancy, which is determined by genetics and lifestyle choices."
OK, try a hypothetical situation. Imagine that the USA diagnoses a whole lot of early cancers, and provides expensive treatment for them. As a result, US statistics for successful cancer treatment wind up far higher than european statistics. But US life expectancy is not affected at all.
In that hypothetical case, wouldn't we want to ask an obvious question? "What's it all about, Alfie?"
I want health care that will extend my life. I want to be healthier for longer. I do not want to be poked by machines with flashing lights that look all scientific and medical, and be impressed by how much expensive care I'm getting, and get chemotherapy etc that will not improve my life. I guess I'd pay something for that show, but not a whole lot.
…life expectancy, which is determined by genetics and lifestyle choices."
Ah. Like, being black in America means you have genetics that keep you from living as long? And maybe your lifestyle choices, like living as a poor person? On average….
So maybe we could encourage poor people to maintain a healthier (more expensive) lifestyle, and that would do more good on average than giving them healthcare? No, we couldn't do that. We can say everybody has a right to healthcare, but we couldn't possibly say everybody has a right to eat vegetables or take vitamins or breathe clean air etc.
J Thomas and Dan Weber,
A few comments:
1. So what if life expectancy in the U.S. is not as high as that of Europe. That does not prove that the extra money being spent on health care is not increasing life expectancy in the U.S. The lifestyle choices of Americans are certainly reducing overall life expectancy. We know that the U.S. has significantly higher obesity rates than do almost all European and Asian nations.
2. Much of the health care expenditure in the U.S. is for improving quality of life, not for extending life. Chemotherapy is only one of thousands of costly treatments the medical profession uses, and most of those other treatments do improve quality of life. Here's a few examples: in vitro fertilization; lasik eye surgery; hip replacements; gastric banding; cochlear implants; bone-anchored leg prostheses; EEG electrode implantation for controlling epileptic seizures. I don't know whether the U.S. spends more per capita for quality of life medical treatments. But I do know we spend billions on treatments that are neither life-extending nor, as you refer to it, "demonstrations of health care".
3. Yes, being of African descent in America – and being of African descent anywhere on the earth – appears to mean you have genetics that keep you from living as long.
4. The U.S. spends much more per capita on medical research than do many of those nations with higher life expectancies, though all nations on earth benefit from that medical research. IMO, that medical research is not "demonstrations of health care".
5. Defensive medicine is a costly factor driven by our unique "American rule" tort system. Every other developed nation follows the "English rule", where the loser in a lawsuit pays everyone's legal fees. There is no disincentive in the U.S. for patients who wish to gamble with malpractice suits. As a result, U.S. health care providers and insurers prescribe and require far more medical tests than are required.
J. Thomas,
Thanks for the response.
I agree the U.S. population needs to eat healthier and exercise more. To me, that is a personal choice matter and not something the government at any level should get involved in. Unfortunately, socialized medicine (Medicaid and Medicare) makes it the taxpayers problem. As long as we continue with socialized medicine, I suppose we must either pay the price of lifestyle choices or accept a government nanny state. Glad I won't be around 50 more years to see how this plays out.
I've seen research showing that in controlled studies, where factors such as income and education are held constant, persons of African descent still have higher instances of hypertension.
I think we do fund as much medical research as we can afford. We're the richest nation on earth by a long shot.
Your idea about having patients sign away their right to sue is interesting. Do you think it will hold up in court? The real and simplest solution to "American rule", of course, is to change it to "loser pays", the system used everywhere else on the planet.
Incidentally, malpractice insurance costs are part of the reason for defensive medicine. But medical practitioners I know tell me they would order more tests even if someone else picked up the malpractice premiums. Malpractice suits damage reputations and divert physicians from their real, revenue-producing work of treating patients.
John Dewey,
Thank you for the rational response! That's refreshing.
I agree the U.S. population needs to eat healthier and exercise more. To me, that is a personal choice matter and not something the government at any level should get involved in.
Local government gets involved in automobile safety, when that perhaps should also be a personal choice matter. I hate that the intervention started with the purpose of increasing safety and turned into a method to generate revenue.
Government gets involved in drug abuse. They fund treatment centers etc. You could argue that the government exists only to serve us, and if a private citizen wants to go to hell his own way the government should just stay out of it. But the government and its supporters don't think that way. They want to have a strong economy which can support a strong military. They do not want it to be a nation of drug abusers and alcoholics.
If you want to argue in favor of weakness, that the US government should do as little as possible to strengthen the nation, you could campaign for the Tea Party. Campaign against public health, for tobacco and alcohol and heroin, against public roads and public schools and for prostitution and private charity and private ferries instead of bridges etc.
But if we want to reduce healthcare costs, the big thing is to get people to be healthier. And traditionally what's done that was private wealth and public health. People are healthier when they can eat a variety of foods and not mostly the cheapest starches. People are healthier when they get clean water and clean air. Etc.
I've seen research showing that in controlled studies, where factors such as income and education are held constant, persons of African descent still have higher instances of hypertension.
Yes. But you want to argue that the difference is genetic. Traditionally the firmest evidence for genetic causes has been identical twins separated at birth, and I don't think that has been done for this. Ideally we would start with identical twins separated at birth, where one of them is white and the other is black. ( ;> joke )
I think we do fund as much medical research as we can afford. We're the richest nation on earth by a long shot.
I say we fund more medical research than we can afford. We fund extremely-expensive projects that are not cost-effective even when we find they improve survival a little bit. My evidence is that healthcare costs keep rising, to more than we can afford. Does that happen because healthcare professionals simply charge more for doing the same things? Is it just increasing profits? No, the claim is that medical science has advanced and we do new things, better things, that incidentally happen to cost more.
So we could reduce costs by reducing the rate that we switch to newer more expensive methods. We may be the richest nation on earth, but our wealth is hemorrhaging and just now we can't afford what we spend on healthcare plus what we spend on the military, both together.
Your idea about having patients sign away their right to sue is interesting. Do you think it will hold up in court? The real and simplest solution to "American rule", of course, is to change it to "loser pays", the system used everywhere else on the planet.
I like the idea of people having choices. I don't know what the legal system would actually do — it looks like pretty much a toss-up for most things. If you could get three different prices — one for no-lawsuit, a second for loser-pays, and a third for deluxe lawsuits, I'm curious what the relative prices would be. If the deluxe version is so expensive that nobody would pay it unless they plan lawsuits from the beginning, that would go a long way toward removing it. If there isn't much price difference between no-lawsuit and loser-pays, people might usually go the way you think they ought to.
And if government-funded healthcare was always no-lawsuit then the government could save some money, and private health insurance would get that extra cachet. We could study the difference between treatments to get a sense how much of our medical costs are actually due o fear of malpractice lawsuits — although there would be various confounding variables to consider.
Malpractice suits damage reputations and divert physicians from their real, revenue-producing work of treating patients.
Anything that patients find out about is likely to damage reputations. I once thought it would be good for patients to get data about surgeons that included outcomes of their previous surgeries. People would naturally prefer the surgeon who had done the best work in the past. But to some extent surgeons get to choose their patients, and the ones who refused to accept cases who were likely to die, would get the best reputations. The patient with the very best chance of a good outcome from surgery is the one who is in perfect health and has nothing wrong with him, but was misdiagnosed….
Furthermore, I'm pretty sure the effect of African-Americans on U.S. life expectancy is more than 0.5 years.
When I first heard about those statistics, they were being used to argue that we were discriminating against blacks. Blacks got inferior healthcare (true) and also had worse survival (true). It was the most natural thing in the world to believe that the reduced healthcare resulted in reduced survival. But it was likely not true. Other factors are more important, particularly wealth (blacks were poorer) and public health (blacks had less access to public goods). Now you want to say that the genetic contribution is the biggest part. If you had presented this claim 35 years ago people would have unjustly called you a racist.
The pendulorm has turned and instead of deciding on inadequate evidence that racism causes the survival difference we have people who decide on inadequate evidence that genetics does it. I would be more interested in other statistics. What's the survival difference between rich and poor? Is it mostly reduced survival of the relatively poor that makes the difference? What lifestyle differences do US poor people have compared to european poor people? Maybe some interesting hypotheses might come of that, which would justify prospective studies.
Assuming it's genetic does not lead anywhere interesting. It only gives us pathetic excuses. Of course someday the evidence might arise that proves it's true, independent of our motives to believe it without evidence.
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