David R. Henderson  

Krugman on Health Care: I Advocate Horror

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Paul Krugman writes:

the attack on Obamacare depended almost entirely on lies, and those lies are becoming unsustainable now that the law is actually working. No, there aren't any death panels; no, huge numbers of Americans aren't losing coverage or finding their health costs soaring; no, jobs aren't being killed in vast numbers. A few relatively affluent, healthy people are paying more for coverage; a few high-income taxpayers are paying more in taxes; a much larger number of Americans are getting coverage that was previously unavailable and/or unaffordable; and most people are seeing no difference at all, except that they no longer have to fear what happens if they lose their current coverage. [emphasis mine]

and:
Many of us argued all along that the right's chance to kill reform would vanish once the program was actually in place; the horror stories only worked as long as the truth wasn't visible. And that's what seems to be happening.

This is from "Beyond the Lies," August 19, 2014.

In other words, the whole idea of "death panels," panels that would say no to certain medical procedures for people on Medicare, is, according to Paul Krugman, a horror story.

By the way, this is not my view: I think it makes sense for Medicare to say no to paying for various procedures as long as the government leaves people free to spend their own money. In other words, I do advocate "death panels," properly understood. And I don't see them as horrible.

And guess who agrees with me, or at least, who agreed with me in 2013. That's right. In a speech in a Washington synagogue, Krugman advocated death panels. (See here, from about 2:04 to about 2:23.)


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COMMENTS (32 to date)
Steve Reilly writes:

The death panels were made up by Palin when she said, "And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care. Such a system is downright evil." Which is different than a system for rationing care, and, of course, a myth.

Your link to the Krugman video just goes to his op-ed, but even without seeing it I can safely assume he doesn't support the sort of panel that Palin worried about.

KLO writes:

I am not entirely sure what a death panel is, but the name implies that it is a panel whose decisions regarding medical treatment determine who receives life-saving treatment and who does not. While I suppose such a panel could be described as one that says "no to certain medical procedures for people on Medicare," the major thrust of those who used the term death panel in arguing against Democratic proposals to radically alter the health care system is lost in this rather general description. Presumably, everyone agrees that Medicare should have standards that restrict what it pays for, but these restrictions only become death panel-like when they restrict life-saving treatment.

David R. Henderson writes:

@Steve Reilly,
Thanks. The link is corrected now.

vikingvista writes:

Is there a Nobel Prize in shamelessness?

foosion writes:

One of the things I find odd about the attacks on Obamacare is the ease with which the attackers switch between two contradictory thoughts

1) Any attempt to control costs is a death panel. The Federal govt should not even study and report on treatments that are better and cheaper than others (some of the usual legal suspects are pushing litigation to this effect - see this link).

As others have noted, the panel which is to do this study has been labelled a "death panel" but it's a mistake to confuse the two thoughts.

2) Costs are out of control and we must rein them in to prevent disaster (e.g., Medicare will bankrupt the country).

vikingvista writes:

foosion,

Contradictory? So you are saying there is no way to for health care to be more affordable without the Federal government making an "attempt to control costs"?

Arthur_500 writes:

I guess if you say something long enough people think it is the truth. I recall being taught in elementary school that everyone knew, at the time of Columbus, the earth was flat and boats would fall off over the horizon. Just last year I heard an adult tell the same story. Regretfully it never was true but people still tell that story.

Indeed there are death panels in the ObamaCare law. There is a healthcare Czar who is to decide what procedures are acceptable. the law favors 20 - 50 year old individuals and weighs against the very young and the very old. In other words, the Czar will decide which people get to receive the care necessary to live.

But the fundamental question for economics is actually two questions. First is how to make healthcare work. The market does a pretty good job here when it is left to normal forces. With individuals not paying the bills the entire system is skewed by the payment systems from insurance companies and now ObamaCare.

The second question is what is the value of a life. No one wants to answer this question because it might mean a Death Panel. I can make the decision in a living will but I don't want you to make that decision for me.

However, return to the first question and we see that Death panels be they from insurance companies or ObamaCare Czars are appropriate since they are the ones paying the bill.

We don't need to control costs. We don't need Death panels. We need personal responsibility for healthcare.

Some good people will die and some useless people will live. Oh well, in Vegas some people win big and others lose big.

The elimination of ObamaCare would be a good start towards making our healthcare system more sane.

Greg G writes:

Obviously, any system of paying for healthcare will have to say no to some procedures including some that might prolong life. No system can pay for unlimited amounts of everything.

The "death panels" term had a much more specific and cynical origin. It originated as a criticism of a provision in the ACA that would have paid for physicians to advise patients about hospice care options at the end of life.

Hospice care ought to be the easiest part of the healthcare debate to agree on. Hospice care reduces costs because hospice patients consistently choose fewer extreme treatments when fully informed of their options. Hospice increases patient options and improves quality life. It also often slightly increases the life span of terminal patients because patients often die from aggressive methods of treatment and they have a stronger will to live when pain is properly treated.

vikingvista writes:

"restrictions only become death panel-like when they restrict life-saving treatment."

Yes, but you have to also keep in mind that procedures that are not directly life saving, like hip replacements for osteoarthritis, can be life saving, as immobility from severe refractory hip pain can lead to someone's premature death. Delays and denials in non-emergent care are not infrequently deadly.

Additionally, it matters whether or not an entity, like the Federal government, forces someone into a program. The Federal government has not only forcibly monopolized health insurance for those 65+ years, it forces everyone to deplete income on the program, which only further reduces options. This in addition to the many other ways that same entity uses force to increase the cost of health care and health insurance, while simultaneously decreasing people's ability to pay for them.

Declining to sell someone a service in a competitive market is entirely different from forcibly monopolizing a market and *then* declining to offer services. The latter places considerably more culpability for the subsequent adverse patient outcomes.

RPLong writes:

The problem with death panels is that they make it more difficult for willing payers to obtain the medicine they want. This happens because the government is a large enough consumer of health care that its decisions sway the market. There's nothing wrong with controlling costs, but restricting the access of willing payers access to medicine they need is morally reprehensible. It's similar to fundamentalist parents who refuse to give their children vaccines or life saving blood transfusions, only in the case of death panels, it's conducted institutionally on a national scale. It's terrible. People like Krugman can only advocate for them because they have never been on the receiving end of their wrath. I wouldn't wish that feeling of helplessness on my worst enemy.

Charlie writes:

It's funny how much DH cares about words sometimes--how dare you say "we" when you mean the government. How dare you say conservative when you mean libertarian! But he's totally cool with cost-effectiveness = death panel. Why not be consistent?

David R. Henderson writes:

@Charlie,
It's funny how much DH cares about words sometimes--how dare you say "we" when you mean the government. How dare you say conservative when you mean libertarian! But he's totally cool with cost-effectiveness = death panel. Why not be consistent?
Your beef is with Krugman, not me. He’s the one who used the term "death panels."

Daublin writes:

KLO, Greg, how else would you explain the concept to the general public?

In the general public, there seems to be a feeling that socialized care means that any patient can get any treatment that a doctor thinks is worthwhile. EconLog readers know this is obviously not true, but I assure you, it's a popular idea.

Fundamentally, any third-party system is going to involve a bureacratic agency that, among other things, will sometimes rule that a treatable patient should be left to die anyway. As an example of this, babies in the UK do not get treatment by the NHS if they are born before 22 weeks, despite a ~10% chance of survival if treated. How is that not a death panel?

mucgoo writes:

@Daublin
It is a "death panel" although known in the UK as NICE

The UK also achieves comparable healthcare outcomes (better on a life expectancy basis by 2.5 years) at 40% of the cost.

Granite26 writes:

I'm pro death panels.

I think the best argument against Obamacare is that Americans are so bad at them...

It's always possible to achieve excellent outcomes when an organization is rating itself.

Charlie writes:

David,

Why do you keep putting quotes around death panels? Isn't because you know that a "death panel" isn't a death panel?

Were you not aware that to the right death panel means something entirely different? They actually mean death panel. A Palin said, "The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,'"

Can you really not tell that Krugman was being snarky in his speech and delivering a laugh line? He was talking about "death panels", when in this article he was clearly talking about death panels.

Notice that like you, he uses scare quotes when he talks about "death panels," rather than death panels.

"I said something deliberately provocative on This Week, so I think I’d better clarify what I meant...

So, what I said is that the eventual resolution of the deficit problem both will and should rely on “death panels and sales taxes”. What I meant is that...health care costs will have to be controlled"

http://krugman.blogs.nytimes.com/2010/11/14/death-panels-and-sales-taxes/?gwh=B3CCFAD0293DB7951FF7D876BFDA3B22&gwt=pay&assetType=opinion

These posts where you pretend to be obtuse are the worst part of this blog.

RPLong writes:

Charlie, wasn't Prof. Henderson quoting Paul Krugman in his last comment, when he mentioned the panels? Isn't the problem that Prof. Henderson said "death panels" instead of the more appropriate "'death panels'"? *

* Note: I am not quite sure where to place the question mark in that last sentence, so I moved it outside of all the quotation marks to reduce ambiguity.

Charlie writes:

RPLong,

DH thinks a fair reading of Krugman's sentence is, "There are no cost-effectiveness panels." He thinks (or at least is pretending to think) when Krugman called death panels horrific, he was calling "death panels" horrific. That is a panel of bureaucrats denying to reimburse care that was deemed to do little to no good at a high cost.

Obviously, a fair reading is that PK actually meant death panels, the horror story that republicans were telling, and not "death panels" the snarky reality. It's also obvious that when PK calls cost-effective measures "death panels" he's making fun of Republicans as in the speech.

I think DH is being deliberately obtuse, but it is possible he's being unintentionally obtuse. Which is the more generous conclusion?

Moebius Street writes:

@Charlie - you're drawing a distinction between "'death panels'" and "death panels", and rather than explaining the distinction you see, you're simply asserting that our honorable blogger is dissembling.

Aside from being presumptuous, this is a very poor way to make your point. In fact, I'm not seeing the distinction you're making.

What I recall is that, during the ObamaCare debates (such as they were), there were hyperbolic comments being made about provisions for death panels (I'm not sure whether to include quotes here or not, as I don't follow where you believe they're to be used). To anyone paying attention at the time, the hyperbole was obvious, but so was the underlying truth that there must be some decision made about what treatments will be covered, and for whom.

And today, that underlying truth is becoming increasingly clear on the surface.

So to anyone who has been paying attention to the issues, I don't see that there's any distinction to be made.

But perhaps you're trying to stand up for those who were taken in by the false rhetoric? Maybe you're trying to say that to someone who was unable to filter the political pretenses from the clear facts, these might somehow be considered different things, and in deference to those who misunderstood before, we should pretend that in the initial debates, the hyperbole had no underlying truth, and that somehow the need for bureaucratic controls has been an unforeseeable complication?

Greg G writes:

Daublin

>----"Greg, how else would you explain the concept to the general public?"

I would explain it by pointing out that "Death Panels" had its origin as a deliberately inflammatory and misleading term. I would point out that if the denial of some forms of life prolonging care means death panels exist then every insurance company and every socialist system uses death panels.

The public is not nearly as dumb as you think they are. There is nothing in the above paragraph that is hard for anyone to understand.

Tom West writes:

I use the term death panel because I dislike hiding the idea that in *every* single case, someone is making a decision on whether to spend money vs. letting someone go without treatment.

This will be the government, or the insurer, or the grieving parent that decides *not* to mortgage her other children's future. But in the end, whoever is paying is going to have to make a decision.

However, I also have contempt for those who pretend that it's only a death panel if it's the government deciding.

I'm a big supporter of single-payer health-care. But those who think you can get roughly equivalent outcomes for half the price *without* death panels, wait lists, fewer tests, and less convenience are dreaming in technicolor. There is no free lunch.

Charlie writes:

Moebius,

I will slow it down for you.

"Death panel" = cost-effectiveness review of medical procedures, so that a high cost isn't being spent on care that does very little good.

Death panel = what Republicans actually meant taking them at face value: "And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society"

Dave Henderson wants you to believe that cost-effectiveness measures are a horror story to Paul Krugman. "Death panels" are a horror story.

But obviously, it's the actual horror story about death panels that Krugman thinks is a horror story. It's taking Republicans at face value and actually believing what they said was true that is a horror story. That is why the whole idea of calling cost-effectiveness measures "death panels" caught on with those of us in the know. It's a snarky way of making fun of Republicans.

I guess I can understand your position. As someone with some knowledge of reality, it seems almost impossible for you to imagine that anyone would actually believe that Republicans meant what they said. You can't even fathom the possibility that Republicans actually meant what they were saying--death panels.

You even referred to it as hyperbole--the fish I caught was THIS big. But saying the government would deny someone care, because they were mentally handicapped and didn't have enough "productivity to society" is not hyperbole. It's a vicious and ridiculous lie.

Maybe it's so vicious and ridiculous you think no one should take it seriously, but obviously that's not the reality of the country we live in, nor the environment PK is writing in.

Greg G writes:

Charlie has it exactly right. Advising more people of their OPTIONS for hospice care lowers costs, improves health outcomes AND increases choice.

Characterizing THAT as an attempt by Obama to get rid of unproductive people through death panels was some kind of world record for hypocritical cynicism.

The customary criticism made of Democrats is that they want to spend too much on unproductive people. But that got stood on its head the moment there was a chance to appeal to people's paranoia and ignorance for political gain.

RPLong writes:

Charlie - I think you're assuming too much. I don't think Paul Krugman, or anyone else in the known universe, is a fan of cost-effectiveness panels, other than the bureaucrats who run them. Everyone else sees them as a horror story. The difference between Krugman and Henderson in this case is that Krugman sees them as the least evil, while Henderson sees them as a lesser evil. The difference between Krugman and RPLong is that I simply see them as unequivocally evil and destructive.

Another key difference is that I speak from experience.

Greg G - What you described is not what most people consider "death panels." The "death panels" are the ones that conclude that only certain therapies will be funded because the others offer too few QALYs for too much money. When those decisions result in a reduction of market supply (as they do in Canada, for example, and as they surely will in the USA) the net effect is a reduction of the number of available treatment types on the market.

You might say, "Hey, no big deal; we're only losing the inefficient therapies!" But the key insight is that we're losing the therapies that are only on-average inefficient. For an individual patient, they may be highly significant.

In short, "death panels" turn individual health care decisions into a matter of bureaucratic bean-counting. Who wins in that scenario? Certainly not patients.

Monte writes:

@Charlie,

President Obama's characterization of the Republican's 2012 campaign budget at the American Society of News Editors (ASNE) convention:

"Two million mothers and young children would be cut from a program that gives them access to healthy food. There would be 4,500 fewer federal grants at the Department of Justice and the FBI to combat violent crime, financial crime, and help secure our borders. Hundreds of National Parks would be forced to close for part or all of the year. We wouldn't have the capacity to enforce the laws that protect the air we breathe, the water we drink or the food that we eat. Our weather forecasts would become less accurate because we wouldn't be able to afford to launch new satellites."

I think we can safely assume that you are equally offended by this type of fear-mongering and demagoguery as you are the republican's use of the term "death panel", can't we?

Monte

Charlie writes:

[Comment removed for rudeness. Email the webmaster@econlib.org to request restoring your comment privileges. A valid email address is required to post comments on EconLog and EconTalk.--Econlib Ed.]

Charlie writes:

RPLong,

Krugman is in favor of cost-effectiveness reviews and has been saying so since at least the 1990s in his book "The Age of Diminished Expectations"

If you follow the link I gave, he said this recently:

"(a) health care costs will have to be controlled, which will surely require having Medicare and Medicaid decide what they’re willing to pay for — not really death panels, of course, but consideration of medical effectiveness and, at some point, how much we’re willing to spend for extreme care" http://krugman.blogs.nytimes.com/?s=death+panels

Every insurance company has to make decisions about what care should be covered. Nothing stops people from buying additional insurance coverage or paying out of pocket for additional care that isn't covered. But in general paying lots of money for care that doesn't work is a bad idea. The care may help one person, but it does nothing or even hurts others. That's why on average it performs very poorly.

You may want to buy a lottery ticket, because it's possibly you'll win, but on average you won't. It's a bad investment. Calling that reasoning evil is pretty silly IMO.

Monte writes:

Well, Charlie, maybe it's just me, but I see a rather strong equivalency in the rhetoric used by both Obama and Palin in trying to be provocative . I didn't miss the point, I just wanted to get an idea of your objectivity here. The all-inclusive last sentence in your comment addresses that.

Regards,

Monte

Charlie writes:

I don't know what you think in Obama's quote is equivalent (or even similar in kind) to Palin's quote, but it doesn't matter because you are completely missing the point.

I'm not saying Republicans and Democrats should be better. I'm asking David Henderson to be better. He completely misread what Krugman was saying, and he shouldn't whether it was deliberate or not. He should correct the post. The lies Republicans and Democrats tell should have no bearing on what we expect from DH.

RPLong writes:

Charlie, I think you may have misread my last comment. I never once claimed that Krugman was not in favor of cost-effectiveness panels. My suggestion was that he realizes that they are a bad option, even though he feels they are the best available option. See the difference?

Regarding your comment about whether my view is "silly," I think you might have missed my point. As I stated above, I'm in favor of controlling costs. What I oppose is a bureaucratic panel that reduces the total number of available therapies on the market. This is what I consider evil. Average cost-savings should not trump therapy availability for willing payers. If we disagree on that point, then that is really too bad.

However, access to medicine is a significant enough social issue in other countries that I trust you will eventually come around to my position, even if you can't imagine it from your current vantage point.

Flocccina writes:
By the way, this is not my view: I think it makes sense for Medicare to say no to paying for various procedures as long as the government leaves people free to spend their own money. In other words, I do advocate "death panels," properly understood. And I don't see them as horrible.

Me too. It would be better if they went purely evidence based and paid for nothing that does not have significant evidence of significant benefit above cost.

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