A Christian Scientist’s guide for opting out of Medicare

You will find it here (pdf), and the broader set of links is here, some of the key material starts at p.10.  There is some general background here.  You can’t get your “money back,” but you can have the payments transferred to a qualified Christian Science care facility.  In other words, Medicare will pay for prayer.  A few points:

1. It would be easy to generalize this idea, and also easy to give people — whether or not they are Christian Scientists — some of their money back in return for forgoing higher levels of care.

2. American society recognizes the right of Christian Scientists not to pursue traditional forms of Medicare.  Can not that principle be extended, and in a way which saves money?

3. There is no public outcry about the horrible life outcomes, and endings, suffered by older Christian Scientists (there is a justified outcry about foregone treatments for the children).  It is not obvious that they have worse or less dignified deaths.  Here is a JAMA paper showing higher death rates for Christian Scientists, although presumably some of that effect is due to withholding care from younger people.  There is more information on the young here.   A Washington State study, cited in the JAMA piece, suggests the overall life expectancy effect of being a Christian Scientist is negative but small.

4. In any case I see no obvious moral repugnance, or public unacceptability, to giving people more money, in return for the equivalent of Christian Scientist health outcomes at later ages.

5. That said, taking the money instead of the Medicare does not (at all) require you to consume zero subsequent health care.

6. Large numbers of American retirees in Mexico and Costa Rica receive a lot or all of their health care without Medicare intervention.  Again, this is not considered scandalous nor are these horrible lives with horrible ends.  I am simply proposing that we pay people to be willing to do this.

7. The Medicare Advisory Board will be able to find only so much “pure fat” in its spending cuts.  And fiscal considerations will require a relatively modest federal mandate, in terms of the number of conditions it covers.  One way or another, letting some people do without massively subsidized care will become a reality (in fact it already is a reality), we are simply debating its scope and the fairness and efficiency principles for its implementation.

8. In the German system, if you don’t sign up at the right time you can be left uninsured.  A German may face this issue when living in the United States, but perhaps returning to Germany, namely when to let coverage lapse.  Again, this does not make for major scandals or unacceptable outcomes.  Some Germans choose to take that chance and of course they save some on the premium, with some risk at the back end.

9. If some individuals take the cash and secede from full Medicare, that frees up medical services, and lowers prices, for others.  The net decline in medical services isn’t as large as it appears at first.

10.  In the comments I read so much about choice biases and hyperbolic discounting, but no one mentions that most people significantly overrate the effectiveness of medical care, relative to the results in the RCT and refereed literature.  The comments themselves are evidence for this proposition.

11. There is nothing sacrosanct about the current division of benefits between Social Security and Medicare.  And no matter how you chop that one up, some important marginal needs are left unsatisfied.

12. Here are comments from Ezra Klein and Kevin Drum and Karl Smith.  Here is my last post on the topic.

Comments

A major issue with your last post on the topic was what we would do with a senior citizen who needed expensive care they couldn't afford (and wanted that care). Nothing in this post addresses that issue.

2) Christian Scientists presumably would not want care when needed. That's a major difference from the general case.

Allowing people to opt out of Medicare is highly unlikely to save money. Consider adverse selection and the April CBO letter regarding Ryan's voucher plan (not exactly the same, but close enough). Also consider the current phenomenon of people avoiding regular checkups due to cost, so treatable conditions get worse, leading to more expensive treatment later, increasing overall cost.

5) The issue isn't requiring people to consume zero healthcare, it's what to do with seniors who need healthcare and can't afford it.

6) Same issue. If they're in another country, they're not asking for healthcare in America.

7) We are debating what to do with seniors who need healthcare and can't afford it.

9) Allowing opt-outs will increase costs. Whether decreased demand more than offsets this increase is not obvious, a priori, but evidence suggests otherwise (see rational in CBO letter, etc.).

10) That's a problem, but there's no evidence that individuals are better at judging the efficacy of treatment than Medicare

11) True, but not relevant to the central issue.

Vouchers are not "close enough" to voluntarily opting out of Medicare and receiving cash. They are totally different.

Isn't it pretty obvious what Tyler is proposing happen to people who "need" health care and can't get it because they chose not to get it paid for by the government, do not have the money to pay for it themselves, their family cannot pay for it, and charities will not pay for it? They don't get it. Happens all the time.

Also consider the current phenomenon of people avoiding regular checkups due to cost, so treatable conditions get worse,

The evidence is heavily in favor of "regular checkups" not improving health. Cf "most people significantly overrate the effectiveness of medical care."

Tyler, you insist on analyzing and proposing some ideas without advancing a complete proposal for the provision of health care. You know that this strategy will trigger many nonsense comments but apparently you're trying to maximize the number of comments. Please change your strategy and advance a complete proposal --you may start by identifying your criteria for defining the main categories of people that may justify differential access to health care.

I don't really get it... If it's not immoral to deprive people of cancer care, then why is immoral to deprive them of emergency trauma care? If they *chose* not to get insurance, why don't we just let them bleed to death in the street?  Just saying.

Because enough people will need government assistance once they get sick and their insurance or lack of insurance doesn't cover them that they will form a voting block that demands benefits. Guilt and emotional attachment of their family, friends, and fellow citizens will produce enough bleeding hearts that when combined with the direct benefit seekers will have the political power to extract benefit payments from the political process.

Who is choosing not to help?

Why are doctors and hospitals refusing to give charity? Is it because they are mulcted by the state-imposed and ever-expanding bureaucracy?

Why can the poor souls not get 1950s-era level of care?

Where there are no vestiges of old Christian charity, even the purest courtesy is somewhat cold, hypocritical, hard.

Note trauma care has clear and large positive net benefit. Cancer is more questionable.

When someone is in a car crash and lying naked and bleeding and unconscious on the side of the road, there often isn't time to check a list to see if he's on it.

I will answer your question taking its literal meaning: people bleeding to death in the streets are a public nuisiance and perhaps a traffic hazard and obstacle. But if you move a injured person you become legally liable for his outcome, so of course we need to trust to medical professons to transport them elsewhere and then provide healthcare for them to avoid wrongful deaths lawsuits.
Additionally you have no idea what an unconscious stranger's healthcare arrangements and preferrences might be (and perhaps no way of finding out easily), and any death that resulted from dalys in treatment could also become a tort. So it is incumbent to provide all such people with trauma care (yes, even Christian Scientists) and let the acountants sort it out later at their leisure.

<3

I've long loved the idea of offshoring the elderly; it's how I want to do it when I'm too old to care anymore. To be honest, there seems to be a perfectly good opportunity for a trade agreement: Costa Rica, et al agree to streamline immigration for our retirees and we agree to let some of their young people in. For the third world, the American elderly generate badly needed consumption of goods and services without also demanding employment. For the US, the third world provides badly needed young people to work and pay for all those retirement benefits.

We need young workers, they need old spenders. I don't see why we can't trade here.

Good arguments – but I´m still feeling paternalistic.

I do like when my parents, friends and even people I don´t know get the chance to e.g. travel the world or enjoy a nice bottle of wine – but I don´t fell terrible when they don´t.
If they were denied relatively cheap healthcare –I would fell terrible – probably to the point where I would have to pay for it myself (more if it where my parents, less if it where people that I didn’t know) .

This is simply my preferences – and they aren’t likely to change substantially. When I force a insurance upon my parents, I get a insurance for myself. My utility function contain more things than those that physically affect me.

Sorry for not fulfilling my role of completely self centered consumer.

Nice post. You're even willing to pay for it yourself just on the basis of common sense and guilt avoidance, which is very admirable, and that's not even taking into account the practical economic reasons.

Example: If the US had no Medicare, Medicaid and Social Security of any kind, and all the revenues generated to pay for them stayed in the pockets of the population; even assuming the wealth distribution was equal, which seems unlikely, would the economic health of the country improve? If so, by how much and for how long? If not, ditto? If the answer is "not", would that not mean there is a measurable, real, baseline value to providing these services as they are today; and furthermore, by investing more in them, would the ROI be worth it?

Then why should anyone be allowed to travel the world or enjoy a nice bottle of wine? Are they stealing from our health care?

Is it because it is better to live a happy life of your own choosing, rather than to raise a stranger from death to short-lived life?

"It would be easy to generalize this idea, and also easy to give people ..... some of their money back in return for forgoing higher levels of care."

This is only an effective means of controlling health care costs if our society and government are both fully prepared to follow through on that latter part of the agreement. That is to say, we would all need to be willing to deny life saving and/or life extending care to people who at some earlier time decided that their money was more important to them than their health. Without this willingness to effectively 'pull the plug' on another living human, the net result will be that people will still receive the life saving or life extending care when it is ultimately needed - and the resulting costs will be absorbed into - or maybe more correctly transferred back into - the overall cost of delivering healthcare.

I see no real increase here in the efficiency of healthcare delivery - unless we are willing to put a price tag on human life and to let people die (or some would say 'to kill people') when it would cost to much to save them. From a simple statistical and logical modelling perspective the approach to controlling costs by allowing people to opt out makes sense. However, once you introduce the human element the situation becomes less clear - Ask yourself if you are willing to die today or if you are willing to watch a loved one or relative die today simply because someone decided it would cost too much to save your/your loved one's life?

"I see no real increase here in the efficiency of healthcare delivery – unless we are willing to put a price tag on human life and to let people die (or some would say ‘to kill people’) when it would cost to much to save them."

We ARE willing to do this. We do it all the time. We let people die who's lives could be extended by an organ transplant because organs are scarce (costly) and so they go to people who have a longer expected lifespan after transplant. People in general don't seem so outraged about that, though I'm sure there are some plenty of cases where people would like an organ but can't get one and are pissed. So what is the big difference between telling an 80 yr old "you can't have a heart transplant because you are too old" and telling them "you can't have avastin for your terminal cancer because you opted not to pay for it"?

I guess the difference is just that the supply of hearts is more intuitively scarce than the supply of avastin, but hopefully people can understand that resources other than organs can be scarce and cost vs. benefit calculations need to be made even if they involve someone not having every minute of life that medical technology would allow.

My religion forbids Medicare, and substitutes houses, cars, vacations, and fine restaurants. How do I get my money tranferred?

"Higher death rates for Christian Scientists"? Higher than the 100% human average?

Medicare doesn't take in enough money via premiums and co-pays to cover its costs, since medical care for the elderly is so expensive. But even if folks opt-out of medicare they'll still urgent medical care. If they can't pay for it society pays for it somehow, just not through the mechanism of medicare. Any medicare change that pays seniors in cash instead of medical care is really giving them a choice. They can stay in medicare now, essentially buying more future cash in the event that they have large end-of-life medical bills. Or they can opt-out and take cash, getting a more enjoyable life now in exchange for a worse life if they have large future medical bills, since they'll still get covered but medicaid will take all their money, including the SS payments. (I'm assuing that regular medical care for healthy seniors either has a negligible cost or can be forgone with little penalty in health. A mix of those two possibilities is probably mostly true.)

If the high costs of medicare come from regular ongoing costs then an opt-out scheme would definitely appear to save medicare money, though if it does then medicare should also be able to control costs better. OTOH if the high costs of medicare come from end-of-life care I doubt being able to opt-out will actually save the government much money.

Anyone know where we can find the full text of the original studies?

I'm interested in the magnitudes of the differences between faith healing and modern medicine, because it gives some insight into how valuable modern medicine actually is.

The full text of the Jama article was right next to the abstract, unfortunately it's pretty old (it dates back to when US health care spending was just beginning to really took off), but it'd be interesting to see if there's been divergence now that we're spending 1/5th of our economy on health care.

Christian Scientists are politically marginal. I think Tyler is correct in all points except what happens when a mainstream AARP type runs out of money in public view.

My thoughts exactly. Christian Scientists are passionate about their beliefs to the point of withholding medical treatments from their loved ones. I know I don't have that kind of commitment to my principles, and I doubt even most fringe lefties and righties do either.

Wow. The Ezra Klein referrals are really tedious.

Amen, brother!

This post again skirts the issue. There is no outcry about Christian Scientists refusing medical care or Jehovah's Witnesses refusing blood transfusions because they refuse it. The issue is what happens when an American chooses cash over Medicare, gets deathly ill, and shows up at the emergency room, desiring treatment. You are arguing that we should refuse them care - which is morally repugnant - and that our failure to have the political will to do so is a rational, technocratic failure. If you are not arguing that we should refuse them care then you are arguing for free riders and a more expensive medical system (treating acute symptoms is much more expensive than treating the underlying condition) which is stupid policy.

Your proposed solution to America's fiscal problem - to give people cash to move to third world countries that guarantee decent medical care - is pathetic. If Mexico, whose GDP is a tiny fraction of America's and is fighting an out and out war for its very survival, can guarantee its citizens decent medical care then why shouldn't America, the richest country in the history of civilization? So right wing ideologues like you aren't subjected to government "theft"?

These posts display a basic lack of understanding of basic aspects of the American health care system (e.g. cost shifting) and a serious lack of decency. Why should America offshore it's medical costs when every other rich, Western nation has made a credible commitment to low cost, universal healthcare? Why should we think up these retarded schemes rather than emulate a system that is decent to its citizens and works?

"Why should America offshore it’s medical costs when every other rich, Western nation has made a credible commitment to low cost, universal healthcare? Why should we think up these retarded schemes rather than emulate a system that is decent to its citizens and works?"

This is just a stab in the dark, but would "greed" have anything to do with it?

It seems unlikely, as Americans aren't particularly greedy, as the world goes. Indeed, my experience of Americans, as a non-American myself, is that they're amazingly generous on an individual basis.

Actually, your comment skirts the issue. The issue is, we cannot pay for all the medical care people want. Should we determine by government fiat what and who gets denied, or should we allow people some choice in the matter.

Agree. The dynamic in these threads is much worse that the usual high quality comments this site elicits. It is not sufficient simply to disagree with a cost reduction proposal without either justifying the status quo of cost escalation or advancing an alternative. A choice of some kind has to be made. Noting a flaw in one idea and being otherwise silent is a vote for the status quo.

Some commenters are also vague as to whether their criticism is simply descriptive (it won't work) or prescriptive (It should not be implemented even if it would work).

"It is not sufficient simply to disagree with a cost reduction proposal without either justifying the status quo of cost escalation or advancing an alternative."

How is it cost reduction when you don't even know how much Tyler is proposing to pay out in cash? If he is proposing roughly how much Medicare costs per capita, I think it will end up costing more, because of adverse selection and free rider problems.

I am generally skeptical about end of life care (i.e. hero medicine that keeps people hemodynamically stable indefinitely with no hope of recovery) in the United States and think we spend way too much on drugs and devices of no proven efficacy. So my solution is: the NIH.

"Why should we think up these retarded schemes rather than emulate a system that is decent to its citizens and works?"

Because people in America trust their government less for a variety of reasons, one of them being that it flat out tends not to do a good job at most things.

Healthcare reform was 60/40 positive in support at the beginning of the process. The last time I looked it was 40/60 against. Who changed their minds? Most of the people in my office are centrist that supported health care reform but where disgusted by the actual bill and process to the point of being against it. The backroom deals, the sleazy special interest exemptions, the obvious frauds. Add in the fact that the government bailed out Wall Street and sent nobody to jail, led us into a war under false pretenses that we are still fighting despite a change in party, and the corruption seems equally present in both political parties. People don't trust the government because they don't trust the people running it.

What countries are these that have made this credible commitment to low cost healthcare? The US has higher levels of spending on health than anywhere else, but everywhere is facing growing cost pressures. Doesn't sound that credible to me.

http://www.businessweek.com/the_thread/economicsunbound/archives/2009/09/where_are_healt.html

I like to think about the issue as if before you were born you were given the choice as to whether you wanted to live an extra year say from 76->77 or have an extra $100,000 to spend during your life. I think a lot of people would think there lives would be better if they could take the cash and spend it on more holidays or stuff they really enjoy. In a way the government already makes this decision. Maybe the cost for 78-79 is $200,000 and at the moment the government is not willing to pay for that. The fact that people aren't able to make these decisions that are welfare improving is evidence of government/market failure.

I can just hear Deirdre McCloskey reminding us (and the author of the cited paper) of the difference between "statistical significance" and "importance" To my eyes the differences between the death rates, by sex, are surprisingly small. (They are statistically significant with p=.04 and p=.003, male and female, respectively.) Thus the paper would seem to show that the net benefit of medical care (over prayer) must be close to zero!

Tyler, very clever pointing to Christian Scientists, but I think the commenters are spot-on in that the Christian Scientists are a) a small and not very visible group and b) dedicated to taking no healthcare from a moral standpoint. I suppose the moral standpoint part may apply to elder Libertarians, as Libertarians tend to see finance and morals on equal ground, but I am even doubtful about them: even Ayn Rand made some intellectual leaps to justify taking Medicare payments for her devastating lung cancer treatments. She was correct that she had been forced to pay into Medicare, so she might as well draw from the system, but she was Ayn Rand for goodness' sake!

It seems more likely that even the fiercer advocates of privatization who might take money at 60 will be complaining and tugging on heartstrings publicly if they're suddenly in need of an expensive bypass surgery at 75. And as for American society's general view on medical care, I will point again to the EMLATA, signed 25 years ago this month by Ronald Reagan, demanding that any hospital that takes Medicare treat anybody who shows up in their emergency room. Americans simply don't like denying care that will save lives, and while there are costs to society for this (and to Libertarian economists who can't stand people that don't act like perfect individual consumers), I for one celebrate the fact that I live in a society with at least that level of compassion.

You might be able to save some cash in a privatized system by denying cancer treatments to those who opted out, but heart bypasses and other expensive treatments that do save lives of the elderly immediately will still need to be provided unless you can convince Americans that we should let that fellow just keep having heart attacks until he's dead (maybe reinstitute sanitariums?). All of this, incidentally, points to the need to have some type of "death panel" to decide which treatments are covered, whether those death panels be Blue Cross Blue Shields' or Medicare's.

Can't blame anyone for taking back from the illogical amalgamation of injustice that overtakes the state.

"I for one celebrate the fact that I live in a society with at least that level of compassion."

I don't, its weak and unsustainable. But it is the reality of the situation and you don't fight reality, you get on with dealing with it.

Heart bypass surgery show very little benefit over cheaper less invasive treatments. Dr Nortin Hadler claims (in his book "The Last Well Person") that Heart bypass surgery is only better if it is the upper left ventricle.

Mr. Cowen, this comparison with Christian Scientist is greatly dishonest. First, It is very true that forgoing medical treatment is their own chodice, but I believe that if somebody has a sudden change of mind he still has a choice to use standard health care. So strictly speaking their freedom of choice - to live or just to let die according to their beliefs is available to their very last breath. This is not so in your idea of cash in advance payment,

Second, the fact that there is "no public outcry" if you do not count that "[Mainstream medical groups] also point out that church facilities are exempt from many of the government regulations that apply to hospitals and nursing homes" may be due to the following:

1. In one of the links, it is clearly stated that "Last year alone, Medicare spent $8 million for services for 851 patients at 22 Christian Science facilities nationwide". 851 patients, that can hardly be something in the center of the healthcare public discussion.

2. The Christian Scientist Healthcatre centers specificaly claim, that "Medicare only covers necessary nursing services (excluding religious-based nursing services such as reading to patients and metaphysical support), a room and meals and most nursing supplies". So no tax money for a prayer as the name of your article suggests. If these rules could be enforced I personally have no objections to existence of such centers. If somebody rejects medication and just wants to live the winter of his life in a religious comunity which provides him with all

Tyler's medicare solution is to have everyone convert to becoming a Christian Scientist.

Next problem is social security.

Tyler has some tapes from a guy named Jim Jones who offers a free one way trip to Guiana as a way to solve social security.

Don't drink the kool aid.

Don't forget that he also refers to how things work in Germany (don't they have socialized medicine there?).

Recently, I find Tyler at the limits of credibility, the classical case of someone clutching at straws as he sinks in his own ideology.

No they don't have socialized medicine over there. There is a public insurance program and a smaller but still significant private insurance program. But the doctors are not state employees.

True, they do have private insurance in Germany. But, once you select private insurance, you can never go back into the public insurance.

And for your objection 10) that cognitive biases also cause that "hat most people significantly overrate the effectiveness of medical care,". If this is so, then there is even more space for government regulation. If it is true, that there are voodoo health procedures which bring no bang for big buck, how is it possible that such dubious procedures are even approved and allowed? And this is valid even if healthcare is 100% private.

Robin would tell you that all that useless health care happens because people want to signal that they care.

Health care decisions are not made rationally, either at the private or public level.

Exactly. The myth that the government is composed of some alien beings not drawn from the population will persist to the end of time in some heads.

That is a false dichotomy. Politicians are drawn from the population, but as their career draws longer, they become more and more isolated from their constituents. After 20 years in Congress, they may feel more comfortable among their political peers than in their home state, among voters. Term limits would certainly help mitigate this.

That is good. I hope that you have the same respect for government representatives who make regulations regarding such stupid things as industrial safety measures, electric appliance norms, food and water quality norms and multitude of other. But maybe it is you who is that super alien who is capable of superhuman decision making ranging from buyng a tooth paste with most efficient ingredients to estimating risk-reward analysis for brain surgery.

How about if we give new recruits into the armed forces the same option? They can take their chances and choose a cash settlement upfront, or opt for the VA care they may need later.

I want to know how the keep people in a nursing home for $9400 / year.

Under treatment kills but over treatment kills and its costly too.

You should leave Germany out of your argument:

If you are receiving social security without being insured you still get the same services as if you were insured. (It's just social security paying and not the insurance company)
And since 1 January 2009 you are not allowed to be uninsured even if your wage is high or even if you are self-employed.

For details see:
http://de.wikipedia.org/wiki/Krankenversicherung_in_Deutschland
(You speak German, right?)

Look for following sentences:
Seit 2005 besteht die Möglichkeit, dass Asylbewerber und Sozialhilfeempfänger Versicherungskarten zu Abrechnungszwecken von einer gewählten Krankenkasse erhalten. Die Leistungen werden aus Steuer- und nicht aus Versicherungsmitteln bezahlt.

And:
Alle übrigen Personen müssen sich seit dem 1. Januar 2009 bei einer privaten Krankenversicherung versichern. Für die privaten Versicherungsunternehmen besteht insoweit ein Kontrahierungszwang zu einem so genannten Basistarif, sie dürfen den Vertragsschluss also nicht etwa wegen gesundheitlicher Risiken ablehnen.

"give people some of their money back in return for forgoing higher levels of care."

RIght. Give people -- primarily poor people -- some cash, with the idea that fifty years later you'll tell them that they can't have medication to prolong their lives.

I can't imagine any problem with that whatsoever.

The only problem is people who believe some unknown stranger has an obligation to pay thousands of dollars to extend the sunset of their lives with the latest novel inventions.

How about the state takes all our money and decide its use for our best happiness?

Can I blame the state for allowing me to keep any money, because they have allowed some unhappiness to befall me?

I think we over-use life expectancy statistics in our evaluation of health care. This is probably because life expectancy is relatively easy to measure and compare, so it gets used as the primary metric for comparing the efficacy of health care programs across countries.

However, this leaves out an important (and expensive) aspect of public health care: quality of life management. For the elderly, this is a large component of health care costs, and it's the one that socialized systems tend to be worse at providing. By focusing on life expectancy, we miss this large aspect of health care.

In the case of Christian scientists, do they forego this type of care as well? Do they refuse medical devices like knee splints or arthroscopic surgery if they blow out a knee? Christian Scientists are allowed to go to doctors to have broken bones set or to repair large cuts and such, so it's not like they refuse all health care treatments. They may not allow heart surgery or cancer treatments, but how big a fraction of senior's health care does that constitute, as compared to dental work, eyeglasses, splints and canes and walkers and all the rest?

For non-Christian scientists, quality of life care can include cataract surgery, joint reconstruction, management of various hormones through drug therapy, arthritis treatments, etc. My grandmother took a large number of pills every day for the last twenty years of her life. She had knee reconstruction surgery. My mother has had multiple surgeries to correct macular degeneration.

None of this effort would show up in life expectancy statistics, but it's exactly the kind of treatment that might work with Tyler's opt-out payment model. I don't think it's feasible to allow seniors to opt out of cancer or heart disease treatment, because I fear that even if they did no one would turn them away for treatment, making them free riders. But knee reconstruction? Arthritis treatment? That might work. I could see a system that has two tiers - One for comprehensive coverage, and one that specifically deletes certain quality of life treatments.

QALY and DALY (quality-adjusted or disability-adjusted life years) is the common metric used in the literature.

To may commenters, people can still get care though they may need to go overseas like to Apollo healthcare in India or to Costa Rica or Mexico as Tyler implied. It may drain their assets and those of their children but most people can raise some money.

On pure fat, few would assume much health care has no benefit but that the problem is the benefit is less than the cost. The problem with health care is we pay by cost, not by benefit. If we did pay by benefit there would be no health care cost crisis. Any individual may value health care more and pay more, but if we valued health care by social value we would pay for much less and provide much less.

230 comments over two posts, and not one critic has really dealt with this:

10. In the comments I read so much about choice biases and hyperbolic discounting, but no one mentions that most people significantly overrate the effectiveness of medical care, relative to the results in the RCT and refereed literature. The comments themselves are evidence for this proposition.

You might try being a guinea pig and doing without healthcare if those are your true beliefs.

Are Tyler's words really that hard to read?

It's not "medical care is useless," it's "much medical care is overrated."

Which half?

You can't even read the simplest things, can you?

You mean the words you were quoting: " but no one mentions that most people significantly overrate the effectiveness of medical care, relative to the results in the RCT and refereed literature." I can read and understand that. Did you?

If 1000 people in a room were given a $1000 tax gift each, and say 20% were savvy enough to invest it all wisely and the other 80% to some lesser extent, would I want to be in that room? You can bet your invitation to the royal wedding I would. There's $800K up for grabs and most if not all of it is going to end up with the 20%.

So would this be classified as a "redistribution" of wealth? In other words, would the legislation that encouraged/mandated the tax funds to be distributed qualify as a "redistribution" policy?

I think your wrong about #9, it depends on who leaves to determine the cost impact on others. If a healthy person leaves, it will actually make costs larger for everyone left.

To what extent do you think non universal health care can account for the difference in redistribution policies between the US and Europe?

I.e. in the US, a debate about redistribution would likely include e.g. medicade , while the same kind of debate in Europe probably wouldn’t include health care (which is a given)– in effect causing the reference point/level of “zero redistribution” to differ.

To me, all the arguments made for letting people cash out of Medicare are the same as my arguments for individuals to opt out of defense.

Instead of my contributing money to national defense because I don't believe in it just like many object to national health care, why can't government give me a cash payment so I can buy guns and land mines and RPGs to defend my family,property, and neighborhood?

Or spend it on other things that matter more to me, like health care for those who can't access it.

And just like others say they don't want to run up large end of life costs, I don't want to run up big end of life defense costs. If the UK finally retaliates, say for Reagan's invasion of a member of the British Commonwealth, and nukes me, I don't want the end of life of millions or billions of people in a MAD response. Give me the cash for my defense and I'll spend it more wisely than government.

I'm with mark on the quality of the comments compared to what usually goes on here, and that just demonstrates how messed up our views on this topic are.
This is so polarized to the point of not being that useful. Why aren't more people (mulp excluded) complaining about the high-end of life costs we see now? Furthermore, if all of you do indeed feel so awful about the people who are going to die because they made bad decisions earlier, why don't you start a charity and evaluate their cases and give them the money to continue end of life care? Nobody is stopping you. In a system like the one being proposed (or something similar) there is an enormous potential for charity that nobody is discussing. The opportunity for people to set up philanthropic organizations to pay for people's care when they themselves chose not to save for it seems like it would work very well if our society cares about other people dying as much as everyone seems to think. If not, well then the arguments don't really hold a lot of water, do they?
I'd also like to mention that a lot of the complaints people have about Tyler's proposition could be mitigated by the creation of mandatory HSAs. Then what is everyone's problem with the system? That people chose to get the wrong medical care? That doesn't seem like nearly as strong of an argument as "they chose a sports car now instead of heart transplants down the road."

I think some of the comments already hit this nail on the head. 'Covering' someone costs nothing. What costs is paying for their treatment. Take a 66 yr old who is healthy and offer him to forgo Medicare for a year in exchange for a $500 cash rebate. Well all you just accomplished is increasing Medicare's cost by $500. Why? Because he is healthy so his marginal cost to Medicare would have been $0. When the 66 yr old turns 67 he starts noticing things are going down hill and declines to take the $500 and suddenly starts showing up at the hospital for various treatments. Nothing has really been saved.

Money is only saved if you make it 'bite'. If you get the guy who would have cost you $5000 in chemo treatments to forgoe care and then make it stick by saying no!. How do you do that? Well you could be really nasty and structure the 'rebate offer' to appeal to the very people who should NOT take it. The people who think they are healthy but aren't or won't be for much longer. But politically will we have the will to really enforce savings through trickerly? I doubt it.

Now maybe you could structure deals with countries like Costa Rica to have health care professionals there qualified as Medicare providers. Retirement to an emerging market with lower costs of living and lower costs of health care could be combined with 'rebates' so the American retiring in low cost Costa Rica would enjoy a $250 month Medicare rebate and get lower cost care there while at the same time saving Medicare money.

Who are we trying to kid here? It's an entertaining academic discussion point, but despite all the comments, who but a very few would truly believe a system like this one would function as intended in the real world?

What the vouchers' true value would be, is as a prepayment for guilt elimination down the road. Instead of just telling the elderly they aren't going to get medical care because we don't want to pay for it, we'll be able to tell them that we did pay for it and now it's their own fault they don't have medical care. I'm sure we'll all sleep a lot better in the comfort that we're in no way to blame.

I agree. Look right now Medicare does not cover dental. A senior knows why they don't have dental, because Medicare doesn't pay for it. They can opt to buy their own dental if they want, they can lobby for adding dental coverage, or they can opt to go without.

In voucherland, though, the senior doesn't know why dental isn't covered. Maybe the voucher is too low (that's what the insurance company will tell her). Maybe she picked the wrong insurance company (that's what salesmen from other companies will tell her). Maybe the insurance companies are too greedy and need to be more tightly regulated (what the politician running for office will tell her). The truth isn't black and white but elusive and obscured and one gets the sense the designers like it that way.

At least with the MAB if cuts start getting very deep, seniors can start increasing the amount of gap insurance they opt to buy or they society can choose to take the tax increases or other spending cuts needed to maintain service levels. We don't get the world where senior A doesn't get chemotherapy covered while his neighbor is enjoying having his teeth done at Medicare's expense.

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