Where to spend health dollars

Donald Berwick writes,

Decades of research on the true causes of ill health, a long series of pedigreed reports, and voices of public health advocacy have not changed this underinvestment in actual human well-being. Two possible sources of funds seem logically possible: either (a) raise taxes to allow governments to improve social determinants, or (b) shift some substantial fraction of health expenditures from an overbuilt, high-priced, wasteful, and frankly confiscatory system of hospitals and specialty care toward addressing social determinants instead. Either is logically possible, but neither is politically possible, at least not so far.

Pointer from Timothy Taylor.

I agree that medical procedures are less important for longevity than other factors. If we spent money effectively on other factors, then that would be more cost-effective at the margin than spending more on medical services.

But the essay overall is a brief for the Progressive agenda, which I doubt will move the longevity needle in the right direction.

32 thoughts on “Where to spend health dollars

  1. Let’s be honest. By health determinate we mean that people put bad things in their body (food, drugs, drinks), and don’t get enough exercise. With the former being the biggest driver.

    And especially, to get the poor/minorities to stop doing that stuff, but like not actually shaming or otherwise providing much stick.

    What the hell would more spending on social determinate mean? We all know. Some government worker/contractor that will occasionally meet with some lower class member and ask them to eat a vegetable, which the lower class member won’t do. Some free gym memberships nobody uses. And some celery in some kids school lunch that he trades away with another kid for some candy, slathers in salad dressing, or just throws away.

    There is no real plan to get the underclass to treat their bodies better. It will just be another social worker jobs program.

    • According to the Left, the solution to the crime problem is also another social worker jobs program. Is there nothing social workers (and their bureaucratic managers) can’t do?

    • @asdf, this is a angry, pessimistic response. I’m optimistic that the masses, including the poor, can adopt healthier lifestyles. I genuinely support that, and try to give positive encouragement to people I know, even black people, when I think that encouragement is helpful and appreciated.

      The better argument is that while it’s entirely plausible that guys like Berwick could have some positive impact, it would come at a large cost. Additionally, people similar to Berwick who feel entitled to large amounts of public money, authority, and power already have way too much public money, authority, and power.

      • This is just a softer way of saying the same thing. The cost of Berwick’s program would not be justified by the meager results it would produce.

        Beyond coercive repression of acts defined as crimes, we have no idea of how to change mass dysfunctional behavior into mass functional behavior. Why not just admit that.

      • Yesterday I took my kids to a pool, something I’ve been waiting to do for some time this summer (amongst lots of other things I’m not allowed to do anymore). When we got there several items, such as slides, were turned off. With big cones and gate guarding it so kids wouldn’t try to play. See, according to phase 3.1.4.2 of the supreme leaders (governors) re-opening plan, the pool is safe but the kiddie slides in the pool are not. Of course everyone there finds this absurd, but order are orders.

        So I have to try and explain to my toddler why we can’t use these obvious functional kiddie water slides as she tries to pull away the gates and engage in her own little protest of sorts. And I just have to basically lie about what’s going on because nobody that innocent could understand the titanic levels of bullshit that create this situation.

        And meanwhile I’m being told even the state of affairs of the pool being open might get reversed because some other states have a second wave from a bunch of young people getting the virus strangely enough a couple weeks after that had mass demonstrations right on top of each other to promote their black supremacism movement. Where apparently having giant destructive riots where you are packed on top of each other for hours isn’t a problem, but the town July 4th parade can’t go forward because its too much of a health risk!

        And I’ve got to hear on the news over and over again how RACIST it is that blacks/browns die of this thing more, and that’s my fault. As if I’m responsible for some black dude shoving another quarter pounder down his throat so that he becomes so obese Coronavirus kills him and my damn kid needs to be kept from going to the pool as punishment for that fat bastard.

        And it was great earlier the same day when I went to the playground and I saw this family where they are all wearing masks in 90+ degree weather including forcing little kids to do it even though its a suburban playground with barely anyone around and plenty of airflow and sunlight to kill the virus. And these kids are obviously really hot and uncomfortable and their overbearing progressive corona parents can’t even just let them play but have all these overbearing instructions on how to play.

        Meanwhile, a group of a dozen black kids watched by a single female are all running around hooting, hollaring, climbing on and hitting each other, using the equipment in a dangerous way, and generally violating a degree of personal space that would exist even in normal times.

        No doubt those prog kids stuck in their damn masks will be blame if any of those black kids gets coronavirus. The news will say that its a matter of public health and systematic racism.

        And I look forward to the day when no matter where I send my daughters to school she’s probably going to get lessons about her white privilege shoved down her throat at some absurdly young age by people paid for by my tax dollars to let he know she god damn deserved to not be able to go to the pool!

        Yeah, I’m angry.

        Yeah, I’m pessimistic.

        If you aren’t, you are insane.

    • @asdf How did the government get people to use seat belts, and how did they get people to stop smoking? [no personal attacks–ed. ]

      • The government didn’t get the lower orders to stop smoking, only the middle class and above. Seat belts I honestly don’t know anything about.

        Public shaming has already worked in terms of getting the upper middle class to eat better and exercise.

        I sincerely doubt you could put cigarette level taxes on Big Macs and all Big Mac alternatives, though I’m not against the idea philosophically. I think its a lot harder to do practically then cigarettes, the number of potential unhealthy foods are limitless.

        • One just might assume that some folks have preferences for large amount of sugary drinks, thus choosing to drink them, and then getting fat. The rub comes when those persons want the rest of the populace to subsidize their consumption in the way of healthcare payments. Unfortunately, the government does not have the ability (within reason) to implement a tax that will stop those persons from getting fat. A Big Mac tax or soda tax won’t do it. Unless you can regulate what individuals eat and how they exercise, it will not be effective.

          Public health is the new mantra of leftists and socialists worldwide. Their philosophy is fundamentally incompatible with individual choice.

    • I think that we’re forgetting that education has been shown to provide better health outcomes. If we invest into the next generation with great education instead of writing them off as underclass burdens we might see some real change. Of course, our healthcare system isn’t the only bureaucratic mess that contributes to, and benefits from, problems with public health. We need to find the right incentive scheme and use tech to change lives.

  2. Berwick advocates the need to increase public, national “solidarity” so that “individuals in the US legitimately and properly can depend on each other”. One of Bryan Caplan’s big arguments about immigration is

    One of my arguments is that immigration increases diversity, which undermines solidarity, which mutes public support for the welfare state.

    The claim isn’t that open borders will “destroy” solidarity or the welfare state, but merely that open borders will undermine both. And while free-marketers may well agree that some degree of solidarity is good, it’s also hard for free-marketers to deny that current levels of solidarity are excessive. Solidarity stands in the way of free-market reforms in pensions, education, health care, taxation, agricultural policy, and much more.

    Caplan says large shocks of diversity and demographic change will undermine and reduce solidarity to pave the way for free market reforms in health care, which is of course, entirely the opposite of what Berwick is saying. I understand Caplan’s logic, it’s a valid argument, I hope he is right, but it’s not very convincing. One likely possibility with a large demographic change is that the existing Republican Party is annihilated and eventually the Democrats will have to split into two parties. It’s possible that the future political battle results in free market health care, but I sure would bet against that for the forseeable future.

    • Caplan is pushing over a strawman version of the argument.

      The argument about *public support* – that more immigration might undermine support for welfare programs – came from *the left* (well, the old left) because they were trying to defend those programs, understood the logic of “welfare magnetism” even as they denied it in public, and thought that the idea of lots of foreigners coming in just to get on the dole was going to make those welfare programs even more unpopular.

      The argument from *the right* (and libertarians like Milton Friedman) was about *fiscal limits*, that there was an “impossible trinity” for 1. Open Borders, 2. Generous Welfare, and 3. Government Solvency. That argument relies on welfare magnetism as an explicit assumption (sometimes called “obvious common sense”) and came from people who couldn’t care less about the prospect of there being less public support for welfare programs because they *wanted* those problem to become less popular. Solidarity had nothing to do with it.

      The idea that “diversity shocks” undermine support for welfare does not even make sense in theory, but in practice the data we have make the notion completely ridiculous. Look at the most ethnically diverse cities and states in the country with the highest proportions of foreign-born residents. Are these places notable for their stingy approaches to benefits, like a bunch of miserly scrooges? Or for their vigorous embrace of libertarian ideology and free market alternatives to government-run programs? Are their local politics dominated by candidates trying to signal they will cut welfare programs more than the other guy, to thunderous applause? “The only problem we have with welfare, is welfare itself!”

      Yeah, no. Quite the contrary. That’s why 1. “Libertarianism as a surviving ideological tradition of any political relevance whatsoever” is also in an impossibility trinity with 2. Open Borders and 3. Democracy.

      Caplan doesn’t have any answer to this because there is no answer to this. It’s just how things are. There is no answer to things falling down because gravity is how the universe works. But he keeps pretending and insisting that the non-answer things he says are those answers.

      I like Caplan a lot, and on pretty much any other subject he is at the top of his game, a world-class public intellectual, and a valuable voice for heterodox truths when the mainstream view is completely nuts. But when it comes to the topic of immigration he is simply unreliable and his standard of rigor drops a few standard deviations.

      • No. Caplan, generally doesn’t make strawman arguments. That’s not his style. Caplan is known for the ideological turing test to avoid strawman arguments. This isn’t something that Caplan has backed away from or downplayed over time. Caplan has clearly stated this argument repeatedly, consistently, with full sincerity. This is a core pillar of Caplan’s argument on immigration. If Caplan has ever been sincere about anything, this is it. Did you read his graphic novel?

        The idea that “diversity shocks” undermine support for welfare does not even make sense in theory…

        I disagree completely. It makes perfect sense in theory. Large diversity shocks absolutely will undermine support for the welfare state.

        … but in practice the data we have make the notion completely ridiculous. Look at the most ethnically diverse cities and states in the country with the highest proportions of foreign-born residents.

        If you look at the the present left-wing political coalition, you’re right. The present left-wing political coalition absolutely flies in the face of Caplan’s theory. But that political coalition won’t last. The present Democrat party is unified in opposing markets and supporting radically larger government and welfare states. But a lot of that is just to reflexively oppose the current political right. That current political right is facing imminent annihilation.

        Tyler Cowen recently wrote about progressive favorite Elizabeth Warren, “she has the worst economic and political policies of any candidate in my adult lifetime.” At the moment, progressives are enraged and eager to rage vote for the most destructive policies as long as it hurts the current political right. Eventually, some of those ideas will really hurt their day to day lives and their appetite for rage voting against the old political right will quickly and completely vanish and be replaced by basic self-interest.

        • Progressive cities are already unlivable with huge problems in their day to day lives for everyone outside a tiny elite. Does anyone think the quality of live in progressive cities is good?

          Well, if you were that dumb I hope a last few months of coronavirus, martial law, mass riots, murder sprees, and all around anarcho-tyranny to a level that is downright comic at this point has enlightened things at least a little.

          It hasn’t change the electoral politics one iota. If anything, it’s gotten more insane.

          Can you point to a single existing country that Caplan would say is his end goal? Because the only countries without welfare states are third world hellholes that can’t afford one.

          The closest thing to a “free market healthcare system” in the first world is the one set up by eugenicist and Chinese Supremecist LKY who laughed out loud on Charlie Rose about the idea letting “fruit pickers” become citizens when asked about immigration.

          • Sweden’s support for it’s universal welfare dropped quite a bit as immigration began to increase dramatically. There has been a steady shift towards means tested programs to try and stem the cost to the government.
            On the other hand, I think Caplan might be wrong in this case. He seems to be assuming that people vote for their own selfish interests as opposed to sociotropic, or for what they think is the best for others. The latter seems to be much closer to the truth overall, and so we might not see any change in attitudes towards welfare.

            On the other hand, some cultures are very work centered, or at least negative towards non-contributors, and those immigrants would likely be anti welfare programs. (I am thinking specifically of Hong Kong here, but I suspect Singapore and similar places probably share a lot of the same tendencies.)

    • Caplan has professed his admiration for Singapore repeatedly. Singapore runs on a tight guest worker program in which workers are brought in when necessary and housed in dormitories where their day to day activities are controlled. Illegals in Singapore face mandatory jail time as well as three strokes minimum caning. One might think that this suggests some inconsistency in his thinking. Not really though. When you take into account his advocacy of governance by a genetically superior class of elites, his opposition to single family housing, and the libertarian doctrine of free trade that posits any compensation received by USA workers in excess of that received by their Chinese counterparts is a moral outrage that can only be explained by protectionism and must immediately be dealt with by further advantaging Chinese producers and deeper submission to China’s global industrial policy, it all becomes clear. The libertarian utopia is pretty much the same as their Stalinist allies on the left: working class Americans living in dormitories in perfect energy efficient equality in their own country much as guest workers live in Singapore.

      • Guest workers also can’t intermarry without the lords permission or get pregnant, and are subject to regular pregnancy screenings whose failure results in immediate deportation. It’s an awful lot like conditions in the antebellum south but with modern technology, which if course Caplan considered the worse thing in the world and wants to remind everyone how he would NEVER act like Thomas Jefferson who really has no excuses.

        And of course there’s the fact that even the world’s best government can’t make their cattle cars Corona proof.

        https://www.nytimes.com/interactive/2020/04/28/world/asia/coronavirus-singapore-migrants.html

      • There is much to admire about Singapore, though one can criticize their model too, which seems to depend for sustainability on being able to constantly import more high-wealth or high-human-capital people like Facebook co-founder Eduardo Saverin or Jim Rogers.

        But what exactly is the realistic path to American-Singapore?

        Sequencing matters. Let’s say you want to do a river restoration and dam removal. There’s a big difference between draining the reservoir, then removing the dam, vs just demolishing the dam before draining it, and the consequences of the devastating flood is not your problem.

        I may even agree with you that the river should be restored, but if you start advocating for “Demolish this dam!” without adding “But only *after* we drain the reservoir and make it safe to do so”, then I am going to have a hard time taking your advocacy seriously.

      • Caplan has professed his admiration for Singapore repeatedly.

        Yes. Praising Singapore’s health care system is entirely reasonable for a free market type to do. I believe Caplan is being intellectually dishonest in praising Singapore along immigration and identity lines. They are ultra-nationalist, strengthening their preferred ethnic, racial, linguistic identity with the power of the state. It’s not white identity, but it’s that same mindset.

  3. According to the Left, the solution to the crime problem is also another social worker jobs program. Is there nothing social workers (and their bureaucratic managers) can’t do?

  4. A vast amount of waste in the USA healthcare spending is simply the multiplicity of federal programs creating administrative complexity and burdens. One example: the US Office of Personnel Management has an Office of the Inspector General that spends about $130 million a year auditing federal employee health claims to identify those that should have been paid by Medicare. Multiply that by about 50 to get an idea of how much money is wasted because of the federal health farrago.

    The Brazilian model is wholly superior. Just set the percentage of federal receipts that you want to go to health care spending, say 12 percent, and then block grant those receipts to the states to deliver health care services or provide insurance, whichever the prefer. States can determine whether or not to supplement.

    The best thing about Medicare for All was that it would have axed most but not all of the superfluous federal health programs. Biden, of course, is opposed to such reforms because they would reduce opportunity for the campaign donation shakedowns that were the hallmark of Obamacare. The Republicans have no excuse for not putting forth a federal health program consolidation and reform package.

    As for as “science” spending, such federal spending can be eliminated as well, or similarly block granted to the states to use to subsidize their medical education programs. Back a few decades when I was in academia, the research assistants for the tenured professors were lined up 10 deep with boxes of cards waiting to run cross tabs on race and every variable for which near-plausible data could be ginned up. Every disparity was turned into a paper and the same tiresome culprits Berwick regurgitates blamed. If anything the problem is orders of magnitude worse today. Such “science” has improved human well-being not an iota. At the state level perhaps such research funding might be put to practical ends.

    But of course the political reality is that such reform would be difficult to achieve. Brazilians, after all, have pride, live in a free country with an authentically representative democracy, don’t suffer fools, and are thus much different than many of the elites in the USA. As the events of this summer instruct us, the only way to effect change in the USA will be for people to riot and burn down stuff . Only then will elites pay lip service to serving the people and advancing reform.

  5. As my fellow commenters have noted, the progressive propaganda in Berwick’s statement is pretty shabby by now.

    But I would question his core assumption that we are not investing in “human well-being.”

    I do not have all my statistics handy, but my reading suggests that Americans live longer and more pain-free that at any time in our history. Anecdotally, I have perhaps 30 relatives over age 65 who are in every single case living more healthfully than their parents (many of whom were dead before age 65.)

    Even among the poor, who Berwick aims to help the most, millions of citizens survive chronic illnesses and cancers that were universally fatal before about 1970.

    It is true that if you look at group family and old workplace photographs, the average American was skinnier back then. I suppose this is a health problem, but it does not keep me up at night. If Americans need to improve their diet, they can do it without massive public spending. Banning the most toxic sugary products would help.

    • Lockdown is saving a considerable number of young lives not because of corona but because of stopping a lot of risky behaviors. The government could improve longevity and health by banning all sorts of fun stuff, even make money by taxing calories and alcohol to the sky.

      You see the problem? Who trades off public health engineering with choice and pleasure? How do they do that? Why not more or less?
      The only way to come to non-arbitrary answers is to assume we are all livestock.

  6. The first thing a proper benevolent dictator would do would be to institute a waist tax. Every inch over 38 costs you a thousand dollars. I bet this tax would dramatically reduce obesity in the United States, and health outcomes would rapidly converge to those of Western Europe. Ultimately the tax burden would be low because for most people it will be worth their while to lose the weight and save the money. (Alternatively it would be a great Pigovian tax, but very regressive.)

    • Japan already moved in this direction 12 years ago. The national limit for average male waistlines is 33.5 inches, and one’s local government or company do the measuring as part of one’s mandatory annual checkup. They started using the euphemism “metabo” instead of “fat” or “overweight” because Orwell.

      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.

      There were critics

      “I don’t think the campaign will have any positive effect. Now if you did this in the United States, there would be benefits, since there are many Americans who weigh more than 100 kilograms,” or about 220 pounds, Mr. Ogushi said. “But the Japanese are so slender that they can’t afford to lose weight.”

      • Wow… 33.5 would be really rough here. I am not that huge, but hell, my pelvis is nearly 32 inches around. If I were retaining some water I might fall afoul there.
        I wonder how many NBA players have waists bigger than 38″, or professional athletes in general. I suspect any number would end up making about as much sense as using BMI.

        • Wow that’s awesome! Didn’t know this approach has already been adopted. Eric, it appears they are shooting for an average so someone like you with a large pelvis would be compensated by some scrawny fellow. And you would be safe from my tax up to 38″.
          I’m pretty sure that in general taller and stronger men don’t have much bigger waists. When Schwarzenegger was a body-builder he was very tall and very strong and heavy, but his waist was reported as 30 inches.

  7. Is there really a “mandatory annual checkup” in Japan, or is this last post a little bit tongue-in-cheek?

  8. Our food is calorie dense and sparse in nutrients and in Europe and Asia it is the other way around. That is why we are fat and have inflammation related diseases which drives a lot of our health care spending. Have an egg, chicken, strawberry or whatever in Europe and compare it to the taste here. Our food is garbage and is making us sick.

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