Thursday, April 29, 2004

The Elephant in the Room 

That would go by the name of social security. Cato's Michael Tanner writes that neither candidate is approaching straight-talkin' about the most important political issue for the next 50 years:
President Bush has been willing to discuss Social Security reform, at least conceptually. He would allow younger workers to privately invest a portion of their Social Security taxes through individual accounts. But, so far he has been unwilling to put any political capital behind such proposals. And, he has been maddeningly short of details on issues such as how big private accounts should be, or how he would finance short-term cash shortfalls during the transition to individual accounts.

Bush's Democratic opponent, Sen. John Kerry, has so far defined his position primarily by what he is against. Campaigning in Florida, Kerry told a group of seniors, "I will never privatize Social Security. Never, never, never!" Kerry went on to say that he would never support any cuts in Social Security benefits either. "Not me. Not my party. Not ever." That's all very well-but then what is he for? As former President Bill Clinton pointed out, there are only three options for Social Security reform: raise taxes, cut benefits, or invest privately. Kerry seems to be taking benefit cuts and private investment off the table. Does that mean he supports tax increases? If so, he isn't saying.
Check out Cato's new book, Social Security and Its Discontents.

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Wednesday, April 28, 2004

Political Polarization 

Virginia Postrel examines the political devide between "red" and "blue:"
The danger, of course, is that people will believe the stereotypes of their political opposites, because they don't actually know anyone on the opposite side of the red-blue divide. Why do both families see their political opposites as people who complain all the time, who are (my words) essentially anti-American? They aren't thinking of neighbors or family members they disagree with. They're thinking of the voices they hear on TV and radio, where conflict and explosive, extreme statements sell.
And then there are people like me who despise the philosophies on both sides of the debate. I generally believe both the right and left share the common goal of controlling our lives and engineering society (without regard for the Constitution); they only disagree on how to properly do it. Where do I turn?

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Tuesday, April 27, 2004

A Big Fat Lie 

Via The Health Care Blog, Paul Campos has written a new book, The Obesity Myth: Why America's Obsession With Weight is Hazardous to Your Health. Read this at The Guardian. An excerpt:
The case against fat proceeds on the assumption that if a fat person becomes thin, that person will acquire the health characteristics of people who were thin in the first place. Although this assumption may seem like simple common sense, it is, like many commonsensical assumptions, quite dubious. If a person who is physiologically inclined to be fat loses weight, this does not transform that person into someone who is physiologically inclined to be thin.
There's a lot of stuff in here - not surprising considering the amount of research done on obesity. Campos' pont is that much of it bad research and the good research shows that we are just a little too preoccupied with our weigth itself. He concludes something we've always known but never seem to get through our heads - exercise is the thing.

Anyway, it's hard to come to any conclusions about his points without going back to look at the data myself, something I'm not inclined to do today. Or for the next few months for that matter.

And another thing, don't bother reading the last third of the article, where he theorizes why we have fallen for the con. Right or wrong, I don't think it really matters - I'm much more interesetd in determining if the con exists.

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Sunday, April 25, 2004

Catchin' Up 

Just came off the abominable gynecologic oncology service, spent the first of the weekend getting my catch-up sleep, now it's time for some catch-up blogging. I was disappointed that I was so busy this week considering the amount of interesting things out on my favorite sites. Here's a quick rundown:I'm back.
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Saturday, April 24, 2004

Painful Policy 

Jacob Sullum reminds us why the War on Drugs leads us down some very undesirable paths.

Many physicians complain about those patients who seek drugs in unscrupulous manners. No doubt they are out there in large numbers. But if we insist on being drug gatekeepers, than this comes with the territory.

Pain can be both undertreated and overtreated. I've heard many argue that we can't allow patients to get all the narcotics they want because some may become addicted. So we restrict access. The result is true pain sufferers subsidize those who would become addicted - not in cash but in constant pain.

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Thursday, April 15, 2004

Tort Reform 

The issue of medical liability and tort reform has been the source of much controversy throughout the United States, but especially here in Kentucky. Unlike universal health care, tort reform has actually reached the latter stages of the legislative process. Just about everyone agrees that patients suffer from lack of physician availability and that the present malpractice/tort system contributes to a decrease in availability, but there is great disagreement as to what would work to change this system in a way that improves health care and still properly allows for reclaiming damages and penalizing negligent care.

Supporters of tort reform usually advocate capping non-economic damages at some level or setting up specialized juries or tribunals to try malpractice cases. Award caps have been shown to work in decreasing malpractice insurance premiums, most famously in California, and thus do improve patient care. However, many are uncomfortable with the prospect of limiting the ability of truly injured parties to recoup proper damages. Plus, the level of capping often is set at an arbitrary level that I am not comfortable with just saying, "That's the magic number." Also, specialized tribunals, while seeming to work in Indiana, do carry with it the problem of violating the tradition of jury trials, making people uncomfortable. Finally any reforms, regardless of kind, that come from the federal levels make federalists like me unesay. I believe in tort reform, but I don't think Congress has the Constitutional power to implement such measures.

As paltry as these suggestions (usually coming from the right, the medical lobby, or from libertarians) may be, the ones from the other side (usually the left and the trial lawyer lobby) may be worse. These groups see the medical and insurance professions as the problem, and aim their reforms in that direction. The insurance companies need to be regulated more; they're jacking up premiums to make up for money lost in the stock market bubble. Forget that malpractice liability insurance is already more regulated than other insurance industries and the percent of assets in stocks is less in malpractice insurance than in the others. Doctors need to clean up their act and answer calls to reduce medical errors. Forget that the current medical environment is super-sensitive to liability and medical errors, and that the real costs of malpractice suits are not the damages themselves, but the indirect costs of defensive medicine and doctors leaving underserved areas with high insurance premiums. And Democratic candidate John Kerry has argued for forcing all doctors to share liability insurance evenly, forcing primary care physicians to cover the sky-high premiums of surgeons and OB/Gyn's. I won't even address that one.

To me, none of the arguments of either side are completely satisfactory. (To be sure, the arguments for reform are true, I'm just not comfortable with them. The arguments in opposition are factually false.) I'm compelled to look for other ways to accomplish the goals sought on both sides.

David Friedman, in his book Hidden Order, describes the economic choice between caveat emptor, buyer beware, and caveat venditor, seller beware. Liberals (often proposing to be in favor of consumer protection) usually favor the former, while conservatives and libertarians (usually espousing rhetoric of personal responsibility for choices) generally favor the latter. So it is with medical malpractice. But in picking between one extreme or the other, we are condemning all to live under the same rule, and all the benefits and consequences that flow from it. But why does it have to be one extreme or the other - couldn't we let patients decide? In his discussion of the two forms of liability, Friedman touches on this issue:
A still better solution is the combination of either caveat emptor or caveat emptor with freedom of contract. Suppose the rule is caveat emptor, and further suppose that consumers would much prefer to buy under a rule of caveat venditor, even at a price that compensated the producers for the cost of that rule. In that case, producers will find that selling their product with a guarantee (at a higher price) is more profitable than selling it without a guarantee. The producer who offers a guarantee is converting the rule for his product into caveat venditor - voluntarily making himself liable for product defects.

Suppose instead that the rule is caveat venditor. The consumer could convert it to caveat emptor by signing a waiver agreeing not to sue. One area where such waivers could make a very large difference is medical malpractice. Given the high cost of malpractice insurance, a doctor might offer a much lower price to a patient who agreed to limitations on his ability to sue.
However, under current laws, this is not possible. Any waivers are not enforceable in a court of law. But why shouldn't people have this choice? I can't think of a good reason to dismiss it out of hand. It would solve the problem of many of the tort reform proposals and would not be so fraught with increasing regulation seen in the liberal approaches. (I believe it also will contribute to solving the problem without touching the peripheral battles of Democrat vs. Republican and doctor lobby vs. trial lawyers - which is most likely why it has never been seriously discussed or considered.) Most importantly, it gives individuals the freedom to "correct the court's mistakes by contracting around them."

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You Can't Beat Fun At the Old Post Office 

While standing in line with about 20 others (probably mailing their tax forms and checks) at the post office today, the following conversation took place among everyone in the room:

"M-I is Missouri."
"No, Missouri is M-O." ("No," others exclaim)
"Maine's M-I"
"No, Maine's M-E" ("M-E," "M-N," and "M-A," echoed throughout room)
"What's M-I?"
"Michigan." "Minnesota."
"What's Mississippi"

I guess you had to have been there, but it was pretty hilarious.

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Tax Day 

Cato's Chris Edwards has a interesting list of the various and sundry ways the tax laws violate civil liberties. Tyler Cowen examines where your money is going. And Econopundit explains who pays how much.

April 15 probably has a negative connotation with most, but for me it is a day to celebrate. My father is a CPA, and every year April 15 signals the last day of a 3-and-a-half month period where he dedicates his life to his work. It is a day where he can sit back, relax, and finally enjoy some of the things he has worked so hard for. Congratulations, Dad.

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Tuesday, April 13, 2004

I'm Way Too Lazy To Address This Right Now 

Here's a question: If we implement some sort of nationalized health care policy, how do we address personal choices and still respect liberty? Would we want to start banning cigarettes, or limiting unhealthy foods? Mandating exercise? When we're all paying for one anothers health care, should we be interested in how each other uses our bodies? Discuss amongst yourselves.
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Top 5 Underrated Movies 

As a huge movie buff, here is my humble opinion of some popular (and not-so-popular) films that deserve more recognition than they get:

1. True Believer (1988). Stars James Woods and Robert Downey, Jr. An inmate serving a sentence for murder kills a skinhead in self-defense while in prison. His family approaches Woods' Edward Dodd, a former civil rights attorney currently working in defense of drug addicts and pushers, to defend him. Dodd, with the help of his new idealistic assistant, played by Downey, discovers that the prisoner may not have committed the crime that landed him in prison in the first place. But in his investigation of what appears to be an ethnic gang hit he uncovers a political scandal. In the end, Dodd finds his place in the world is redeemed just as much as his client.

It's appropriate that this most underrated film stars two of the most underrated actors of our time, Woods and Downey. Downey shined more in other movies, but Woods stole the show here. His performance is dazzling and the plot itself is interesting. It's funny - I was conscious in 1989 and don't even remember this one in the theaters. It now ranks highly on my list.

Best line: (Dodd) "Good fight? Do you think I'm going into court to make a fucking statement? Do you think Shu gives a shit if we go down, but go down nobly? This is a man looking at forty years of hard time. He coulda had a deal and been out in five, but he bet it all on me! Don't give me that liberal, yuppie bullshit about a good fight. This isn't fucking Yale. A good fight is one you win!"

2. Amadeus (1984). Starring Tom Hulce and F. Abraham Murray. Your probably wondering how a formar "Best Picture" winner (and seven other Oscars) could be underrated. It's hard to do, but this movie deserved that from the stunning music alone. Throw in the wonderfully acted, scripted, and directed story and your talking about an all-time great. This story about human greatness climaxes with the antagonist Salieri spending Mozart's last night composing music with him. Salieri gets a brief glimpse into the mind of a genius.

Best line: (Salieri) "I will speak for you, Father. I speak for all mediocrities in the world. I am their champion. I am their patron saint. Mediocraties everywhere, I absove you...all."

3. Things To Do In Denver When You're Dead (1995). Starring Andy Garcia and Christopher Walken. Garcia stars as Jimmy "the Saint," a former wise guy turned citizen who owns a compnay that records "advice" from the dying to give to their young or unborn children. When Walken's "The Man With the Plan" calls Jimmy and his misfit bunch of former criminals to do a job, Jimmy must say yes to keep his business afloat. When the action goes wrong, Walken calls in the hit on the henchmen but lets Jimmy go if he leaves Denver in 48 hours. As Jimmy tries to get his friends into hiding, he misses his deadline and the hit is called on him, too.

What appears to be a low-rent knock-off of Pulp Fiction with slick-talking, bumbling gangsters, really is a poignant story about the different ways people deal with death. As a medical student, I think this should be required viewing in school.

Best line: (One of "The Man's henchmen is talking to Jimmy after informing him his parole officer had recommended finding a hobby.) "He wants to see, ya, Jimmy." Jimmy: "Ah, come on, what for?" Gus: "He says, 'Gus, I want to see Jimmy, 'the Saint'.' I say, 'boss, Jimmy, 'the Saint' ain't mixin' it up no more.' He says, 'Gus, I want to see Jimmy, 'the Saint'.' Here we are. The point of me arguing seemed, uh, specious." Henchmen #2: "Gus is reading the dictionary." Jimmy: "When does he want to see me?" #2: "Now." Jimmy: "Now?" Gus: "Anon."

4. Glory (1989). Starring Denzel Washington, Morgan Freeman, and Matthew Broderick. Another film with Oscar nods underrated? Certainly. Denzel, the best actor of our time, in his best performance. An uplifting story. The best score I have ever heard. How it got beat (along with Field of Dreams, and Dead Poets Society) for "Best Picture" by Driving Miss Daisy is beyond comprehension.

Best Line: (Morgan Freeman as Rawlins) "And who are you? So full of hate that you have to fight everybody, because you've been whipped and chased by hounds. Well that might not be living, but it sure as hell ain't dying. And dying's been what these white boys have been doing for going on three years now, dying by the thousands, dying for you, fool. I know, 'cus I dug their graves. And all the time I'm digin' I'm askin' myself, "When, when, oh Lord, is it gonna be our time?" Well, time's comin' where we're gonna have to ante up. Ante up and kick in like men. Like men! You watch who you call a nigga. Any niggas around here it's you. Smart-mouthed, stupid-ass, swamp-runnin' nigger. if you ain't careful that's all you ever gonna be."

5. Shawshank Redemption (1994) Starring Tim Robbins and Morgan Freemen. Morgan Freeman makes three of my all-time top ten, with this, Glory, and Seven. Now I know people will wonder how a movie with several Oscar nominations, #2 all-time at IMDB, and more showings on TNT than any movie ever can be underrated. Hell, the average US citizen has probably seen this movie 6.3 times. But I just can't say enough about it. It may not me the best movie of all time, but it is without a doubt the best all-around movie of all time. The acting and directing are outstanding, the story is riveting, the script is loaded with great lines, the score is wonderful, and the narration of Stephen King's beautiful words is the best movie narration of all time. I can't think of a single element of film that is not done extremely well..

Best line: (Freeman as Red) "Get busy living, or get busy dying. That's goddamn right."
Bonus Best line: (red) "I have to remind myself that some birds aren't meant to be caged. Their feathers are just too bright. And when they fly away, the part of you that knows it was a sin to lock them up DOES rejoice. Still, the place you live in is that much more drab and empty that they're gone. I guess I just miss my friend."

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Government Regulation, the Unseen, and Type of Error 

The Marginal Revolution and The Binary Circumstance have commented on this from the NY Times about the Department of Agriculture refusing to allow a Kansas beef producer from testing his beef for mad cow disease:
The Department of Agriculture refused yesterday to allow a Kansas beef producer to test all of its cattle for mad cow disease, saying such sweeping tests were not scientifically warranted.

The producer, Creekstone Farms Premium Beef, wanted to use recently approved rapid tests so it could resume selling its fat-marbled black Angus beef to Japan, which banned American beef after a cow slaughtered in Washington State last December tested positive for mad cow. The company has complained that the ban is costing it $40,000 a day and forced it to lay off 50 employees.

The department's under secretary for marketing and regulation, Bill Hawks, said in a statement yesterday that the rapid tests, which are used in Japan and Europe, were licensed for surveillance of animal health, while Creekstone's use would have "implied a consumer safety aspect that is not scientifically warranted."

Lobbying groups for cattle ranchers and slaughterhouses applauded the decision, but consumer advocates denounced it, saying the department was preventing Creekstone from taking extra steps to prove its product was safe.
I have caught some heat in this space in the past for my denouncement of most government regulation. But I'd like to see anyone try to defend this one as in the public interest.

And since we're on the subject, I'll take this opportunity to explain in detail why most regulation for "public protection" is undesirable. This ground has been well-covered before by those who share my opinion, but I am addressing this toward those who support all the regs. When I mention the costs of FDA regulation, some reply that these laws are needed to protect consumers from dangerous drugs. When I denounce other health care regulation, people love to point out that they extend health care to people who can't afford it.

But is all this true? It seems that supporters are missing a main point about cost-benefit analysis. It's easy to see the benefits from such regulations, and it's easy to see the problems when arguing for a regulation to be passed. But you have to look much harder to see the costs that are incurred. These are what Milton Friedman referred to as "the unseen." It's was easy to see people who died from unsafe medicines, but it's much harder to see people who died because safe medications were wallowing in FDA-mandated clinical trials. One has to look at these costs and balance them against the benefit of waiting. Many economists have found that the costs outweigh the benefits, but that is not even the issue here. The issue is that it seems that most people who argue for the regulations totally ignore these costs.

What we have here is a trade-off of the two types of error. In science, when testing a hypothesis, there are two possible outcomes, accept or reject, and thus there are two types of error - falsely accepting (type I error) or falsely rejecting (type II error). (Note: to be precise, type I error is actually falsely rejecting your null hypothesis, which the opposite of the true hypothesis. Type II error is falsely accepting the null hypothesis.) When testing the hypothesis that a regulation is necessary, these are the possible outcomes:

Regulation beneficialRegulation not beneficial
Regulation presentno problemType I error (harm is unseen)
No regulationType II error (harm is seen)no problem

Now seeing this, it is obvious that when looked at this way, the bias will always be toward applying unnecessary regulations (because their costs are unseen) rather than throwing them out (because their costs are seen). The simple fact of the matter is that when honestly studied in this manner, most regulations are unnecessary and costly.

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The Economy of Compassion 

Read this wonderful article about DDT and malaria.

With the growing price tag of the war in Iraq, it would be helpful to think what that money could buy in public health infrastructure throughout the third world. If we are going to invest in other countries, this should be numbers one, two, and three on the list. I want the Iraqi people to be free, but at some point you have to look at cold numbers and decide how to stretch your dollar the farthest and help the most people.

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Monday, April 12, 2004

2 For 1's Are a Civil Right 

The local government of Madison, Wisconsin, the University of Wisconsin, and local bars all agreed to limit the bars' drink specials in an effort to reduce college-age drinking. So what happened? The students sued the bars for price fixing. (link via Newmark's Door)

Those guys are my new heroes.

When some companies allegedly fixes prices, it's worthy of an anti-trust suit. When the government and business conspire to fix prices, it's should be subject to the same consraints, right?

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Saturday, April 10, 2004

More From the War On Porn 

Eugene Volokh follows up on his earlier comments here, here, and here.

And Deinonychus antirrhopus has this to say:
Eugene Volokh looks at Ashcroft's War on Porn (because terrorists aren't really a threat after all), and here are his three likely scenarios:
The crackdown on porn is doomed to be utterly ineffective in its stated goals of preventing the supposedly harmful effects of porn on its viewers, and on the viewers' neighbors.

The crackdown on porn will be made effective -- by implementing a comprehensive government-mandated filtering system run by some administrative agency that constantly monitors the Net and requires private service providers to block any sites that the agency says are obscene.

The War on Smut will be made effective by prosecuting, imprisoning, and seizing the assets of porn buyers.
So...which one do you like? Personally I think Ashcroft wants number 3. After all, with this jackass it isn't just that the porn is out there, but that people are looking at it and liking it. In any event the bottom line is still the same: resources that could be used to reduce the threat of domestic terrorist attacks will be spent fighting....porn.

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Friday, April 09, 2004

To India With Love 

Jessica leaves tomorrow for India for three weeks. She asks what I want her to bring back for me. I reply a Gandhi bobblehead doll and some outsourced jobs.

Have a safe trip, Jessica.

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Via Reason, here's an interesting portrait of John Ashcroft, the new porn czar.
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But I Play One On TV 

Imagine my surprise this morning when I saw the Marginal Revolution describe my blog as an econ blog. I'm flattered, but with my medical education and two semesters of economics in college, I hardly qualify. However, I am interested in economics and how it applies to health care. If any economists specializing in health care are out there blogging, please stop by from time to time to keep me honest.
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Thursday, April 08, 2004

The Choi Watch 

A lot of ink has been spilled about the Cubs' offseason moves and theit in-season chances. People praised the acquisition of Derek Lee and Greg Maddux. But I would have chosen to keep Hee Seop Choi and Juan Cruz and the $15-20 million the Cubs could have used to lure Ivan Rodriguez. So this season I'm keeping what I will call the "Choi Watch." Who will have more Win Shares at the end of the season: Maddux, Lee, and Michael Barrett? Or Choi, Cruz, and Rodriguez? Forget that my moves would still have more money left over. I'm pretty confident that the young risky guys would have turned out to be worth the risk.

Performances from opening series':
  • Maddux: 6 IP, 4 H, 3 R, 2 BB, 3 K, 4.50 ERA
  • Lee: 10 AB, 2 H, 2 R, 1 2B, 1 HR, 1 RBI, 1 BB
  • Barrett: 8 AB, 3 H, 1 R, 1 2B, 1 3B, 1 RBI
  • Cruz: 2.2 IP, 2 H, 1 R, 2 BB, 1 K
  • Choi: 11 AB, 2 H, 1 R, 1 HR, 4 RBI, 1 BB
  • Rodriguez: 18 AB, 2 R, 7 H, 2 2B, 1 HR, 3 RBI, 1 BB
I know some might object to this, saying that since Dusty wasn't going to play these guys anyway, we might as well have traded them. But if this comparison yield a negative win share balance, and Dusty was the main reason these moves were made, isn't he responsible for loss of wins?

My challenge to Jim Hendry: $10 per win share to the charity of the others choice.

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Decisions, Decisions... 

Catchin' a little bit of heat this week. 2md takes me to task (to be precise, "nuts" is the word he used) for my posts about socialized health care. Myria recreated the debate we had in the "comments" section of my recent post on the merits of "health insurance" as we like to finance it today. The first one was expected - the second not so much. But I am moved to respond to both. My dilemma: it's 9:40, I'm tired, which one do I do first.

I went with 2md because, well, it's shorter and much easier.
I think he's nuts for lumping all these inefficiencies and piecemeal regulations together (many of which, like the 1996 Kennedy-Kassebaum bill, had to be created as a result of the best that free market health care has ever achieved---managed care) and equating it with nationalized health care. Anyone who has studied the single-payer model probably stopped reading halfway through because it was such an insult to the term "national health care."
First of all, let's get one thing straight. I couldn't really care less what you call it. I use "socialized," people have a problem. I use "nationalized," no good either. You know what I'm arguing about: free-market health care vs. "NOT" free-market health care. Call it whatever you want, just know that I'm saying it's not free market [from here on out referred to as (NFMHC)].

Now that that is straightened out, he seems to have a little problem (so much of a problem as to question my mental health) with my characterization of supposedly "private" money paid to cover regulatory costs (and not just the "inefficiency" costs - the whole costs) as contributory to NFMHC. The whole point was to illustrate that when government mandates the payments through implicit taxes, this is anything but free-market (to paraphrase a fellow blogger, calling it so is a bastardization of the phrase), and is better characterized as NFMHC. A bunch of excessively brilliant people (like Nobel prize winners and famed academics) agree with this assessment. Now that doesn't mean its right. It just means that merely smart people have to agree or provide another explanation. What would anyone else call the dollars spent to cover these mandated costs? Since he failed to address this or pose an alternative accounting, I have to assume he has none.

And if one chooses to read my follow up to the original post, one would see that I did admit that a truly "nationalized" system would be more efficient than the "piecemeal" NFMHC we have today.
In 1962 the Canadian province of Saskatchewan instituted national health care. There were lots of folks like Trent out there suggesting that it would die an early death. Five years later, when the other provinces saw how Saskatchewan was doing, they were all going to institute their own health plans. The result was the comprehensive national program that still enjoys broad nationwide support today.

So I'll gladly scoop up that gauntlet: Let's try out a single-payer system in one U.S. state. Give it a fair shot, and see what happens. I bet you'd see other states follow.
I'll get to this in a minute, but in no way did I say anything like nationalized health care would die an early death. To the contrary, I proposed that we currently have a vastly NFMHC system, and it's still living. Actually, most anti-NFMHC's understand that these systems will die a long, slow death. They realize that the benefits of such a system lie in the near term and the costs, while much larger, lie in the long term.

I suppose you bring up the almighty Canada to imply that it is a health panacea. This is laughable. But I'd take the Pepsi challenge if I could - bring it to Kentucky. So many people are on Medicaid, Medicare, and SSI that your system really wouldn't be much different. Just make sure you carry your study out long enough to catch all the costs. We should do it for Connecticut, too. Richer population I would guess. We'd have a lot of good information. And a lot of bad medicine.
I wish I had more time to write, but instead I'll just devote a paragraph to stamping myself an incorrigible liberal. I was sad to see that nowhere in Trent's discussion was the fact that under a true national health care plan, all citizens of this country would have access to basic primary healthcare. 18,000 people die every year because they don't have health insurance (that's from a report by the Institute of Medicine). It may not factor into the dollars and cents, but it matters.
This one makes me think he didn't even bother to read the damn thing. There's a reason I didn't discuss the merits of a nationalized health care plan. Because that is not the point I was addressing. Does this guy have a pathological aversion to understanding the thesis. I was in no way even letting the merits of NFMHC into the debate. I was simply stating, directed toward those who object to our free-market health care system, that no sane and fair assessment could characterize our system as free-market. And to those who favor NFMHC, our system is camouflaged to hide its NFMHC status. The question remains, when we do get it, and nothing changes, what then?

To those whose eyes aren't now bleeding, here are some of the comments around the blogosphere about the original post.Thanks for all the press, guys. I'll have to get to Myria tomorrow. Stay tuned...

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The War On Porn 

We're being overrun by porn - and the Department of Justice is not going to take it anymore. Read Reason's G. Beato report on this matter. And here's Eugene Volokh's analysis of the possible outcomes of the DoJ's efforts. I guess since the War on Drugs has been such a huge success, it follows that the War on Porn will be a cakewalk.
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Wednesday, April 07, 2004

Nationalized Health Care Recap And Redux 

This is in light of a few objections to yesterday's post regarding the implicit nationalized health care that I contend currently exists in this country. First, let me restate the argument: The federal government currently pays nearly half of the country's health care spending from its own coffers. However, this statistic severely understates "public' spending because it count costs that are paid from private consumers' pockets to fund publicly mandated regulations as "private." If these costs were counted as they truly exist, implicit taxes on all health care consumers, the "social" percentage paid would be much higher than 50%, and thus would represent a health care system that is more nationalized (or socialized if you will) than free-market. In addition, with future costs that have been more or less committed, this figure will only increase.

First, to clarify, I was not stating my personal unscientific estimate as 65-70% as I appeared to do in the original post. My conservative guess is more like 60-65%. But with the future commitments (Medicare drug benefit, etc.) this figure will soon grow to the 65-70% I cited. I realize it may be a little weak to rest on what essentially are guesses, but they are educated guesses and I did not have the resources handy to make better estimates before I had to hit the sack. Anybody who would like to give some of these costs a more academic approach, I would love to collaborate.

However, the technical difference between my present and future estimations and estimate and fact are rather insignificant because I ironically disregarded one HUGE regulation. Earlier in the week I debated that government laws and tax breaks give our employers the incentive to offer us health insurance rather than wages for our work, and that this imposes huge costs to consumers because health insurance for routine health care is a poor financing system. That the government imposes this system upon us and causes skyrocketing premiums needs to be counted as a public expenditure. These regulations/tax breaks essentially act as payroll taxes that go toward the employees socialized health care costs (since that is what insurance is. Readers may object to this, but the reason it counts as "public" and not "private" is because it is essentially mandated). I would argue that this practice takes away a big chunk of the remaining 30-40% of health care which is privately funded in the true sense of free-market care.

Some objected to my inclusion of mandatory licensure laws and a few other regulations, stating "what would your free-market health care look like?" The implication is that free-market care would have no such "safety" measures. This is nonsense. The purely free-market system would have exactly the amount of regulation and "safety" measures the customer demanded. This could include certifying agencies, independent drug researchers, etc. Whatever your imagination allows. What would necessarily exist would be the amount of this voluntary regulation that would satisfy consumers. It would not be legally mandated regulation that, again, acts as a tax added to the price of the goods. Would you have me count some of Medicare as private because seniors would still buy health care without it?

One reader objected to my accounting for the VA and military benefits as "public" since he freely chose to stay in the military specifically for the benefits. Would you count Medicare as "private" because the seniors opted not to forego it in lieu of private insurance? It is "public" because our tax dollars pay for the expenditures.

Finally, I suppose most would object to my characterization that we currently have a nationalized system with regard to funding that is so fragmented as to be more inefficient and unfair than a truly nationalized system. 100% socialized funding the way I have described it would be much worse than a true "national medical card." I couldn't argue with this. This is part of the reason why I would argue that truly nationalizing health care would not make a significant difference because the cost of completely knocking off the last 15-20% might be balanced by efficiency gains from merging it all into one system. Of course, to restate the main point, it won't help much, either.

Which now brings us to the main objection from Sasha Volokh of the Volokh Conspiracy. He contend that my original assumption, that free-market vs. nationalized health care could be measured on a one dimensional scale from zero to 100% of total expenditures, is not really as fair as I assumed:
I'm not sure "we," the hypothetical Trentian readers ("Yes, Socrates"), should be so quick to agree there. When I think nationalization, I think not only of who pays but also of who controls. For instance, suppose the government stopped providing public schooling (where it controls the curriculum) but paid for all private schooling through generous vouchers (where the private providers would control the curriculum). By Trent's definition, that's still a perfectly nationalized system, but voucher advocates would characterize that as a free-market alternative, since government curriculum would have dropped from 100% to 0%.

...in this new two-dimensional model (with control on one axis and funding on the other) you can't characterize it as Trent did, a la "How can you ask for more 'nationalization' when we're already so 'nationalized,' so presumptively 'nationalization' is the source of our problems?" -- a question that seems to rely on a loose understanding of "nationalization."
His idea, that my one-dimensional assessment of health care funding is incomplete and should be assessed on a two-dimensional scale to measure true nationalization (or socialization if you prefer that word - most liberal friends object to it so I stopped using it just so they'd listen to me), is interesting.

My first thought was "damn, how could I make the mistake of thinking in one dimension when I always criticize those who don't think in two or more?" My second thought was, "Is that right?" My answer is "yes" and "no."

Yes, a 100% socially funded health are system that involves total consumer control is drastically different from one with total central control, and it's not fair to really think of them the same. Those two questions most likely are the most important when defining the current system and you have to address both for your assessment to be meaningful.

But here's why "no." If you were to graph these two variables on a 2-D coordinate system, like I believe Sasha is asking me to do, you have to first make the assumption that "who pays" and "who controls" are independent variables. They are not, at least not in any empirically true way. (To be more precise, there are many points on this 2-D graph where (x,y) is undefined - so much so that large areas of the graph do not exist.) To pay for is to control to a large extent, if not completely. I can't think of a single example of the government or society funding something that they didn't control.

I contend, and now revise my argument, that these variables of funding and control exist in some sort of fractal dimension between 1-D and 2-D. This may be getting out of my comfort zone a little, but for simplicity sake we could agree that the assessment of the current health care system should be measured on a 1.5-dimensional scale and should answer both questions honestly. Now the question becomes: how do we measure "who controls?' It certainly isn't at either extreme; maybe somewhere in the middle. I bet you're a little tired of reading and I know I'm a little tired of writing, so I'll leave that one up for everyone (and hopefully Sasha) to chime in.

Regardless of this redux, I still stand by my original argument. To call our present system "free-market" is a crime against the English language. Judged on who pays, we most definitely have a socialized system. Judged by who controls, it is open to debate. But while the extreme of publicly funded and publicly controlled could exist, the opposite of publicly funded and privately controlled could not. And only the hard-core left-wingers would want totally government-controlled health care. On balance, our health care system today and in the near future is much more socialized than not, and the question remains: we don't have much farther to go - what happens when we get there and nothing improves?

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Tuesday, April 06, 2004

So When Are We Going To Get That Free-Market Health Care Everyone's Complaining About?  

Ask many people how to fix the mess that is our health care system, and they'll have a surprisingly easy answer - institute a nationalized health care system. Ask them if a free-market system of health care delivery would not be better, and you'll generally hear two things: 1) the market for health care is fundamentally different than any other market, and 2) look what our free-market health care system has gotten us into. I don't want to address #1 today, but I would like to focus on #2. The first question we need to answer is "How do we define and measure the types of health care systems?" The second is "What type of system do we really have at the present time?"

How do we define and measure the types of health care systems?
I think this is the easy question to answer in a way that all in the debate can agree. I would define it such that a perfectly nationalized health care system would be one in which the government (at any level) paid for 100% of total health care expenditures. Anything above 50% is marginally nationalized. Conversely a perfectly free-market system would be one in which this figure was 0%. Anything below 50% is marginally free-market. Anyone have a problem so far? Good, I didn't think so.

What type of system do we really have at the present time?
This is where it might get a little bit hairy. According to the OECD, in 2001 total US health care expenditure equaled $1.4 trillion. 44.4% of these expenditures were paid by public systems such as Medicare, Medicaid, the VA and other military care, public heath clinics, and various other programs. So it seems an open and shut case that we currently have a marginally free-market health care system.

But not so fast.

The WHO defines total health expenditures as public expenditures plus private expenditures, where private expenditures are out-of-pocket costs plus insurance premiums. That is the definition I used to calculate the figures above. But there is a fundamental problem with this definition. Some private expenditure can be counted, in my estimation, as public expenditures. Think of it this way - if the government, through the FDA, imposes a regulation on a drug, the drug company includes the cost of the regulation in its price, and I pay the price out of my own pocket, this is equivalent to me paying a tax to the government and the government subsidizing the drug purchase. It only cuts out the middle man. So while a majority of the price of the drug is a private expenditure, the part that goes to paying for the regulatory cost is most definitely a public expenditure. If the regulation did not exist, 100% of the drug could be characterized as privately-purchased, but the expenditure would be much lower, the total expenditure for health care would be lower, and thus, the percentage of public expenditure would be increased.

To restate this another way, the equivalent regulation could be paid for through increasing taxes and fully funding the regulatory compliance If it was done in this way, we would have to count it as public expenditure. That it is done in a way so our beloved members of Congress can hide tax impositions doesn't get the public side off the hook. What I have done is valid because the regulatory taxes have the force of law, the consumer has no choice, and it is antithetical to the free market. That is why we should not count it in the "free-market" column.

Note that this has nothing to do with a judgment on the regulation itself. I am only stating that the cost of regulation that the consumer pays from private funds are miscounted as such. They should be accounted for as public expenditures and change the balance of the above equation.

Unfortunately, the government has a lot of regulations that impose private expenditures that should be counted on the public side:
  • The various FDA regulations mentioned previously. US citizens spend 12.4% of their health care dollar on pharmaceuticals, and 88% of that is funded privately, yielding ~11% from private expenditures. I could not find data estimating what percent of this went to cover regulatory compliance, but I can safely estimate it's enough to say that a few percent of total health care expenditures can be transferred from the private side to the public side.
  • The relatively new HIPAA regulations. These have enforced new privacy laws that have placed a cost burden on health care. Hiring compliance personnel, changing infrastructure, etc. - these have all increased the prices we pay from our "private" stocks. It is difficult for me to estimate what these costs are due to the paucity of data from these relatively new laws. It is safe to assume they are not insignificant.
  • CLIA. These regulations affect all lab tests performed by or for a physician. Laboratories rival pharmaceutical as the most heavily regulated sector of health care. Lab tests make up a significant portion of health care expenditures. Again, the burden is not insignificant.
  • Private health insurance regulations. Private insurance premiums make up a large portion of total private expenditures, but they are not all "private." There are numerous regulations and laws that dictate certain things that private insurers have to cover that they may not otherwise. These increase premiums. But you have to count them as public expenditures for the same reasons as above, and I would guess (though am not sure) that these represent the largest number on this list.
  • Physician licensure requirements. Med students, residents, and physicians have to undergo rigorous and expensive testing and review for licensure. These costs are passed along to consumers in fees and are not insignificant.
  • Finally, all similar state regulations that work above and beyond federal regulations. This number may be insignificant.
  • Oh yeah, I almost forgot, compulsory prescription requirements. This number may be small, but I have to bring it up, well, just because.
Again, I want to make it clear. These have nothing to do with the merits of the regulations themselves. Certainly they have some, or even a lot of, benefit. It's just that these costs, imposed by the rule of law, have to counted as "public" even though they come from "private" pockets.

So where am I going with this? That's a lot of regulations, or to rephrase, a lot of indirect taxes paying for public expenditures. A few percent here and a few there, and we are talking about public expenditures that fly past 50% and lookin' for more. So now we have in my estimation a marginally nationalized health care system. Looking toward the future, we have a $50 billion/year (and quite possibly much more) Medicare drug entitlement that will add a few more percentage points to the "public" ledger. Increased spending on public health to battle obesity and smoking will no doubt be "public" expenditures that could be shrouded in a "private" cloak. There's no doubt which direction we're headed.

If I had to make a wild guess, our health care system will be paid for by explicit or implicit public funds at a rate of 65-70%. My question is this: if we have a nationalized health care system now, and that system is by your estimation broken, is more nationalization the way to go? Especially when every other sector or industry in this country is privately funded and avoids this problem. Except, that is, for education and the military. Oh, yeah, they're publically funded, too. (The problem of getting health care to the poor is independent of this - there is a big difference between publically funding for those who can't pay for themselves and publically funding those that can.)

I, if you didn't figure it out, think a totally free-market health care system is the way to solve our health care problems. But many may be surprised to learn that I almost think we should nationalize it. Why? Because, as I have shown above, it wouldn't be that much different than what we have now. It can't hurt much (but it certainly won't help). But at least we would have gained the knowledge once and for all that nationalized health care does not work and is a bad idea.

Now, is the market for health care fundamentally different than other markets? We'll leave that one for later.

Update: Tyler Cowen takes up the case over at The Volokh Conspircy.

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Monday, April 05, 2004

Top 5 Favorite UK Games 

As I watch the end of the first half of a boring NCAA Championship Game I have no rooting interest in, I will take this opportunity to reminisce about my favorite UK games.

5. The 1995 SEC Championship game vs. Arkansas. Down 9 with 90 seconds to play in OT. Rod Rhodes misses two free throws to clinch it in regulation only to have unheralded and solid (and one of my all-time favorite players) Anthony Epps hit his to win the game. Comebacks will be a key element to most on this list.

4. The NCAA Championship Game in 1998 vs. Utah. I had seen UK win it all just two years earlier, but that year they were so loaded it wasn't much fun. You expected them to blow out every opponent. There was no real joy, only potential disappointment. In '98, after Pitino left, and more importantly, Delk, Walker, McCarty, Mercer, Anderson, and Pope, just about anything was going to be special. During the game, the Cats came back from a 10-point halftime deficit to take control in the second half. Party ensues on Woodland and Euclid!

3. "The comeback" in 1994 at LSU. Down 31 with fifteen minutes left, the game was over. Then Chris Harrison actually hit some three and you knew something special could happen. Seriously, I felt compelled to keep watching; it seemed like I knew they would make game of it. To this day I am proud I stuck with it and watched the greatest comeback in college basketball history.

2. The regional final in 1998 vs. Duke. This was the chance to get revenge for "The Shot," but down 17 with nine to go, it didn't look good. But thank God for Wojo. His slow white ass couldn't keep up with Wayne Turner time after time down the court. I think I had a paper due the next day - I'm sure it was probably the worst one I have ever written.

1. "The Shot." Most UK fans probably would be surprised that I look back fondly in this game. And sure, I didn't speak a word for a good fourteen hours. But I knew it was truly a special sports moment that I was fortunate to be a part of. The ultimate overmatched underdog taking down a dominant team for 44 minutes and 58 seconds. The rest, I don't remember. What happened?

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It's So Easy 

I finally now have two functioning syndication links - one for RSS and the other for Atom. I kept reading how freakin' easy it was, but for some reason mine would never work right. My feedster account would act up, my links were dead, you name it. Thanks to those of you who humored me through this. Now, everbody please syndicate my site - if not for your sake, do it for mine!

Update: Or maybe not. When I test it in my reader, the most recent post is from, like March 22. Can somebody, for the love of God, please tell me how to correct this. This is one of the problems I keep having, and I don't know how to fix it.

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Sunday, April 04, 2004

Can Lighting A Match Help Save Rome? 

Over at 2md, Cameron has some interesting things to say, inspired by this article, about chucking the health insurance system:
Always a profession of concrete thinkers, doctors have begun to realize that the term "fee-for-service" can be taken literally. A growing number have stopped working with insurance companies and started accepting cash payments only. An AP article on this phenomenon put the smiley shiney face of it up front:

Before, [the doctor] charged $79 for an office visit and got $43 from an insurance company months later, minus the $20 in staff time it took to collect the payment. Now he charges $50 - and he never worries about collection costs, because patients pay in full after every visit.

Later in the article, it seems to occur to the reporter that "a $50 charge can be powerful incentive to delay seeing a doctor until you're in pain - which can lead to more expensive health problems later."
Of course, this wouldn't even be a debate if their wasn't insurance for catastrophic health outcomes:
Still, the proponents of cash-only medicine have finally hit on a powerful analogy to build support for their vision:

Cash crusaders acknowledge the need for some type of insurance. Without it, expensive surgery or hospitalization would force most people into bankruptcy. But they think health insurance should work more like car insurance: you pay for the routine maintenance and little dings yourself, and insurance pays for more expensive repairs.

It sounds nice. Unfortunately, this system is inherently regressive. A $50 visit is a much greater burden to someone making $19,000 a year than to someone making $250,000. If the entire country shifted to this model it would be like increasing taxes on the poor and decreasing them for the rich. And no presidential administration would ever tolerate that, especially while the country is in a recession.

...Everyone agrees that this is no solution to our healthcare crisis. But hey, if Rome is already burning, why not light a match?
Presented in this way, Cameron is absolutely correct that such a system is undesirable. For it to work, the benefits have to be greater than the increase in out-of-pocket expenses, and it most probably is not.

But...and this is an especially large but...

Cameron is missing one thing that swings it back the other way. Employers are forced, by government regulation and incentives, to offer some of their wages as health insurance. If they did not do this, employers would have to just give them their wages in cash. Employees would be much better off getting their wages in cash and buying their own health care (out-of-pocket for routine care and catastrophic insurance for the rest) than the curent system of insurance for everything. The cliched example is that you wouldn't buy auto insurance that paid for routine car maintenance, because then everyone would have an incentive to buy too much routine maintenance. In the end, premiums would skyrocket to cover this cost, and people would stop buying car insurance that covered routine maintenance. It is cliched because it is true.

Well, health insurance works the same way, only most consumers of health insurance don't have the option to stop. If they opt out, they lose coverage and their wages going toward health insurance just go right down the drain. There is no incentive.

Last year I made $20,000 in wages plus $3,000 in health insurance (only about $300 of which I paid myself). I used exactly $0 for health care (being 25, I didn't really need it). I would have been much better off getting that $3,000 in cash, buying catastrophic insurance for a much lower premium, and betting on the very strong odds that I was going to have less than $3000 (minus the catastrophic premiums) in basic health care needs. I, and a lot of other people, would have come out way ahead. But I couldn't do that. All my suiting employers were willing to pay me $20,000 in cash and $3,000 in worthless health care, but not the $23,000 I was worth to them - because it would have reduced their profit. I was made poorer than I should have been - and the government gave my employer an incentive to make me poorer! Thanks a lot.

There is another reason why this would be a good idea - it gives people an incentive to live healthier lives. If I have insurance that covers health maintenance - and I don't exercise, don't eat right, and do other unhealthy things because I enjoy them more than healthy activities - other people cover my costs. This forces health insurance premiums up. But if I pay health maintenance costs out-of-pocket, I'm the only one to pay for my poor health habits. Is it any wonder that exploding premium rates have been concurrent with the explosion of obesity rates. Don't be so quick to say it's a coincidence.

Even if some proponents of nationalized health care agreed that this would have been an improvement on our health care financing system, they will still complain that it doesn't do much for those people who have neither health insurance nor government aid. Well, first of all, those people would be hardly worse off than they are now. No better, granted, but no worse. But a vast majority of the 80% of people who do currently have health insurance (yes, some of who make $3 million per year, but most of which who make $40 and $50 thousand a year) would gain. Secondly, we would be richer so we could extend government programs to these people who can't obtain it if we so desired. Either way, we're better off.

Many people righteously call for nationalized health care because the system is not working. One day soon (after I am done with the rotation from hell - OB/Gyn) I will explain why we have nationalized health care and that is precisely why the system is not working.

Update: DB's Medrants discusses this as well.

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Saturday, April 03, 2004

RSS Maybe? Finally 

I think I have an RSS feed, but I'm not sure. I tried to test it, but couldn't tell if it worked or not, and frankly I got frustrated. Would anyone out there with an aggregator give it a shot? The URL is:


The first person to be successful wins a free "Proximal Tubule" t-shirt as soon as they are available. :)

Update: I now have both RSS and Atom feeds. Syndicate this site via the links on the right of the page. Thanks.

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Thursday, April 01, 2004

Think Happy Thoughts, Think Happy Thoughts... 

I was in clinic today when my attending and the patient joined each other in bashing NAFTA, trade to China, etc., each agreeing that in some time we would all be unemployed and destitute. Those who know me well know that my medical career almost ended today before it began.

In light of our recent conversation about prescription drugs, it struck me that while doctor's don't want people playing armchair physician, so much so they make it illegal, they have no problem playing armchair economist. Anyway...

Rep. Barney Frank (D-MA) was giving a speech today that stopped my channel surfing. They were debating extending unemployment benefits, and we was obviously in favor. He made a curious point. He was saying how he believed free trade brought gains to the US. He just thought we should not pursue extending free trade unless we redistribute the gains or retrain the unemployed, implying he would not be in favor of one without the other. I will work with his assumptions that both these policies are good things. There are two possible ways to vote for free trade (yes and no) and two possible ways to vote for redistribution (yes and no). Each policy gets a point for "yes." Also, let's play along with his assumption that free trade increases the disparity (which I certainly disagree with) and that gains without redistribution subtracts half. So here are the possible outcomes:

redistribute yesredistribute no
free trade yes20.5
free trade no10

Now, based on his assumption, you would vote for unrestricted free trade no matter what. If you hold the redistribution variable constant, regardless of whether it is yes or no, you would vote for free trade. So why does he want to link the two together. You should vote for free trade regardless of how you vote for redistribution/retraining.

Upset: Jacob Sullum's recent article makes the claim that there is no inherent difference between outsourcing and obsolecence. Nobody in their right mind would complain that 50% of the US population isn't farming anymore, and nobody should be upset that we employ Indians and Chinese.

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My First Fisk 

Since 2md had the most reasonable critique of my gatekeeper piece yet, I thought I'd give Cameron the honor of being my first formal fisk. The issue in question is this:
Trent puts the burden of proof on those who support prescription protections. He insists they prove that these burdensome, restricting regulations save the lives of enough people to make them worthwhile. Well, there may not yet be a study out there to prove it, but that doesn't mean lives haven't been saved by prescriptions. To Trent, that's not enough. If there isn't proof that a regulation works, we need to get rid of it.

After hammering the prescription process for having no proveable benefit---in other words, there are no randomized controlled double-blind trials to indicate their effectiveness---he writes that there is only "intuitive evidence" that having prescriptions is harmful. The real harm, Trent says, is that they restrict our liberty.
That's not exactly a perfect characterization of what I said (but better than most). I didn't just say that there is no evidence that they are beneficial and only intuitive evidence they are harmful. I said that the limited work that has been done in the field shows that there is actual evidence that they may be harmful. In addition I presented economic evidence that they are definitely harmful - it increases the cost of obtaining needed drugs. This is simply a cash transfer from patients to doctors and I consider that harmful.

And I presented situations that intuitively could cause harm. For instance, yesterday I saw a woman on Medicaid in clinic who was 8 months pregnant. She had been on birth control, but her prescription ran out. She called the doctor but he had quit taking Medicaid patients. She had to find another doctor, who claimed she needed to come in and have a pelvic/Pap before he would write her prescription. In the interim she got pregnant. Now getting pregnant is certainly a health risk. And becoming poorer (by having another child for a patient who can't afford it) is a health risk. People who disagree with me have to answer for this girl. You can say Medicaid, national health care, etc., but the simple fact of the matter is if birth control was OTC this might not have happened. I hate answering a criticism with an anecdote, the worst form of evidence, but I am sure this is not the only person who has been hurt by this regulation. Indeed, I contend that the large number that are far outweigh the people who would take PRN coumadin (which would be maddeningly few).
You can't buy Coumadin without a prescription. You also can't buy thalidomide. Or plutonium. You can't buy meat filled with prions that will give you Crutzfeld-Jacob disease. Why? Because that intrusive, burdensome government has regulations; because that awful FDA won't allow vendors to sell meat that doesn't match certain standards. That's an infringement on our liberty too.

Our freedom is restricted in lots of ways: the freedom to buy infected foods, defective auto parts, malfunctioning chain saws. Our freedom to fly across the country inexpensively is restricted: if there weren't safety standards for airlines, you can bet there would be a bargain basement version of EasyJet offering super-cheap tickets (and a 1 in 20 chance of crashing).
You couldn't resist muddying the waters, could you? This is beside the point, but I think those regulations are worth reviewing, also (and I'll get to the FDA all in good time). But you can't offer up a list a regulations and pretend that they have any weight in justifying the one we're debating. You have to debate each and every one on its own merits. And I claim that this one on its own has no merit. I concede that you may not agree with this conclusion based on the evidence I present, but you have to present evidence to support your disagreement.

I believe that even if this regulation, on net, saved lives, it is still worth scrapping because it strips liberty. However, you do not have to account for liberty when you look at this debate. If I were able to show that it restricted liberty and produced net harmful effects, you would have to concede it is a pretty bad regulation. That is exactly what I was trying to do.

And, just for your information, thalidomide is now approved by the FDA.
All of that said, Trent makes a lot of good points and I kind of agree with him. A lot of medications that are currently prescription could be made over-the-counter. Trent makes an odd logical leap here, though. He says that because we have to divide drugs into two groups (prescription and OTC), the entire concept of prescriptions is invalid. Yes, we have to draw a line somewhere between Tylenol and Digoxin. Yes, it may be difficult to decide which drugs are prescription and which are OTC. Does that mean we shouldn't be willing to make the tough decisions? Life is filled with gray areas and tough calls. This is one of them.
I don't consider that a logical leap at all. If a governmental bureaucracy draws that line at any place other than the exact point it truly exists, they are causing harm. And the odds of that line being drawn perfectly are infinitely long. So I say, while they can make recommendations all they want, let people have the freedom to make those decisions for themselves, as they bear the cost of them. Even if they are wrong, which they may be wrong on average more than the government, they should be free to see the costs and the benefits of their own decisions. To say we have to make decisions for people who are too dumb to make the correct ones is paternalistic. That is the whole point of the libertarian philosophy. You may not agree with that, but it is insultingly far from illogical.
Finally: As a big supporter of single-payer universal healthcare, my thoughts are constantly drawn back to questions of access. I might be able to agree with Trent about eliminating prescription protections, but only if I thought that every citizen with the desire to visit a doctor were able to. That's obviously not the case in America today. If all drugs were OTC, you'd see a lot of people wanting to visit a doctor for advice, but deciding against it for financial reasons. Glorfindel mentions the "short-term consequences" of getting rid of the prescription process. Without universal healthcare, those would become long-term structural consequences (not simple transaction costs, as Trent calls them), and those would be devastating.
Speaking of logical leaps, the assertion that decreasing the cost of obtaining drugs would decrease access makes no sense. Instead of obtaining drugs but not seeing the doctor, what you have now is not obtaining the drugs in the first place. This regulation increases the cost of health care by increasing the cost of drugs through increasing the price of a doctor's visit. How reversing this is a bad thing I have no idea.

Some would point to the fact that drugs switching to OTC actually are harmful because insurers no longer would cover them. This is wrong on two accounts: first, some OTC drugs prescribed by a doctor are currently covered by insurance. Second, if all drugs became OTC, insurers would still cover most or even all of them. Think of it this way. If all insurers no longer had to pay the cost of drugs, but still charged the same premiums, profits through the whole industry would skyrocket. Competition would force insurers to offer coverage for OTC drugs until those new profits had evaporated.

Educated Guesswork has an interesting proposal to test this policy:
What we need is a controlled trial. Let's take a reasonable-sized population (thousands, probably) and offer half of them unrestricted personal-use access to previously prescription drugs (excepting scheduled drugs, antibiotics, and antivirals). We monitor them for a year or two and measure morbidity and mortality.

If such a trial were conducted and it showed no significant difference would the people who are currently opposed to removing the prescription requirement now favor it? If not, why not?

Now, I don't expect that this experiment will actually be conducted--though I think it would be a good one--but that doesn't mean that we can't try to answer this question without it. Are there natural constituencies who have easier access to prescription drugs? Maybe people who live close to Mexico and can drive over the border? Has the existence of Internet pharmacies changed the situation at all? Obviously, an epidemiological study of this kind would be less convincing than a controlled trial, but it would be a good start.
And finally I'd like to leave this discussion behind (maybe) by quoting RGL over at the medrants discussion board:
What these radicals are doing is to create a straw man, under the guise of liberty, and then make these reckless statements and attack physicians' motives to serve their own narrow and selfish interests.
Virginia Postrel recently commented that she felt as if she had finally arrived when she saw her work on an on-line term paper service. Similarly, I feel like I have accomplished something to have such invectives thrown at me. It has all been worth it.

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