Remarks by Mrs. Laura Bush U.N. Commission on the Status of Women
March 8, 2002
"Human dignity, private property, free speech, equal justice, education, and health care - these rights must be guaranteed throughout the world."
<http://www.whitehouse.gov/firstlady/news-speeches/speeches/fl20020308.html>http://www.whitehouse.gov/firstlady/news-speeches/speeches/fl20020308.html
Yesterday, Dr. Reinhardt commented on the projections of health care expenditures made by the Office of the Actuary at the Centers for Medicare and Medicaid Services. That report is now available online at:
<http://www.hcfa.gov/stats/nhe-proj/proj2001/Proj2001.pdf>http://www.hcfa.gov/stats/nhe-proj/proj2001/Proj2001.pdf
The abstract of the Health Affairs article is also now available (the full article is available only to subscribers or by purchase):
<http://130.94.25.113/1130_abstract_c.php?ID=http://130.94.25.113/Library/v21n2/s25.pdf>http://130.94.25.113/1130_abstract_c.php?ID=http://130.94.25.113/Library/v21n2/s25.pdf
One quote from the Health Affairs article is noteworthy:
"After 2002, growth is projected to gradually slow to 5.9 percent by 2011. This deceleration can be primarily attributed to slower projected per capita real income growth, a move toward more restrictive forms of managed care, a rise in the uninsured population, and an increase in the use of consumer cost sharing."
Comment: We don't have much control over per capita income growth, but the other three factors are cruel and inhumane mechanisms of slowing the growth of health care costs. Instead of continuing to erect more financial barriers to care, we could replace those mechanisms with a globally-budgeted, publicly administered program of universal health insurance. Excess growth would be constrained, but in an equitable and humane manner.
Theodore Marmor responds to Uwe Reinhardt:
Uwe--your arithmetic was helpful to see what is at work with projections of future national income and what one scenario forecasts for health expenditures as a proportion of that national income. But arithmetic neither produces plausible predictions (as against conditional forecasts) and, more important, does not provide the grounds for analysis of that future. (Were CBO forecasts in 1993 l8% of GNP for health by 2000? That was their forecast!)
I particularly want to contest your claim (repeated often by you) that "Americans have signaled that they don't want any cost control at all...." Kip challenges your claims about the effects of what is called managed care. I want to challenge your interpretation of the connection between mass American wants and both public and private policy. It is decades too late to continue to repeat the fallacy of revealed preference in politics. It does not follow that because outcome A takes place, the citizens of that jurisdiction 'wanted' A. It might be, but the use of the effect to specify the cause is a logical fallacy. Until and unless you can find reason to believe mass opinion shaped events decisively, stop blaming the victim. I don't for a moment believe the American mass public has any clear idea about the extent to which cost control arguments are true, false, or misleading. Our political system is far too structured against mass majority rule to explain health policy outcomes as the result of their 'wishes.' Sure, a different distribution of wants and attitudes might make some policies more likely, but the locomotive conception you use is genuinely misleading and unsupported, as I have mentioned before, by the public opinion literature.
Ted Marmor
Theodore R. Marmor Professor of Public Policy & Management Professor of Political Science Yale University School of Management
Beth Capell, Ph.D., responds to the Reinhardt and Sullivan comments:
As one of the prime architects of the California HMO Patient Bill of Rights (with much guidance from our CaPA leaders), one key observation:
The HMOs had promised to deliver all medically necessary and appropriate care--and were required by California law to do so. Every dime of cost they attributed to the Patient Bill of Rights was proof that they were denying necessary and appropriate care.
Time and again in the negotiations over the Patient Bill of Rights the HMOs were caught in this trap: if HMOs were giving people the care they needed, what was the problem with requiring them to do so? Contraceptives, diabetes management, independent medical review, second opinion, you name it: if consumers were getting the care they should, the reform cost nothing. If the reform cost money, it demonstrated a denial of care. An analysis by a Senate Insurance Committee skeptical about so-called mandates found little if any cost associated with most of them.
The one exception to this case was mental health parity where plainly consumers were not getting care they should have. This provision unquestionably cost purchasers money---because by failing to provide decent mental health coverage, the purchasers and the HMOs had shifted costs to the public sector and simply failed to provide needed care.
And costs in California were rising well before HMO reform was fully enacted in late 1999.
Beth Capell, on behalf of the California Physicians Alliance.
Theodore Marmor on the predictions of the Office of the Actuary:
Watch out for the idea that projections are anything but forecasts whose validity is utterly dependent on the accuracy of the premises. They can be useful for sensitivity analysis. But anyone who thinks you can predict economic and medical life 10 years hence needs medical care.
Theodore R. Marmor Professor of Public Policy & Management Professor of Political Science Yale University School of Management