I think that dental care is probably the weakest part of the British system. (Well psychiatric care for schizophrenics ain't great either, but I don't know of any country that has been willing to put a big investment into that.)
I do think that there's a cultural attitude that has nothing to do with the quality of universal healthcare. Braces have gotten more popular, and I noticed that Eton will automatically enroll its pupils in private dental insurance, but I also think that a lot of British people don't think that perfect teeth are terribly important and the mock us for our obsession with gleaming, unnaturally white teeth.
My sister spent some time at a school in the rural Southwest and her crown broke. She had to go to the dentist on the NHS to get it fixed and she asked for a cleaning too. THe hygenist asked her the last time she had had her teeth cleaned and fond it strange that my sister would want to have her teeth cleaned more than once every few years. Then, they just said, "oh. it's because she's American." I bet that any American system of universal healthcare would have a decent provision for dental care.
Oh, I'm sure there's all sorts of stuff wrong with NHS dental care; lots of which was detailed in the story. I was just griping about the implicit message that the problem was the existence of the NHS at all.
Anyone in Britain who wants to go to a dentist, and has the money to pay for it, can see a private dentist whenever they want, just like in the US. The only thing the NHS is doing is providing free dental care to those who otherwise couldn't afford it, or don't choose to pay for it. So a story about the rotten teeth suffered by the poor British who have been failed by their NHS is terribly incomplete -- they've been failed by the market provision of private dental care, and the NHS hasn't managed to fully compensate for that market failure.
You are partially right--the problems with NHS dental care in Britian do not prove that universal health insurance will not work. In particular, you are right to note that [a]nyone in Britain who wants to go to a dentist, and has the money to pay for it, can see a private dentist whenever they want, just like in the US.. However, I find it hard to imagine that anyone who read that article would have drawn the conclusion that private dental care was not available--it certainly mentioned it more than once--so you are creating a bit of a strawman if this is your objection to the article.
In your effort to defend universal health insurance, I think you are putting a spin on the facts which does not seem warranted.
There is a problem. People are paying taxes for dental care they are not receiving. I did not notice anything in the article to indicate that the rationing of what scarce NHS dental services there are is being done on any rational basis (except for emergency treatment--which for teeth, is too late). Rather, it seems to be a matter of who managed to get on the patient list for a NHS dentist and who did not--kind of like rent controlled apartments.
Further, you talk about a "market failure" in the provision of private dental services, but there is no indication of such a market failure. Indeed, that is the only market that seems to be working.
Market failure is not the right way to describe the failure of the NHS to provide services, because it is not a market, it is a government service. Like most attempts at central planning, it is not working well. Now maybe it is not working well for reasons that say nothing about the unworkability of universal health insurance (which I would actually support if it took some rational form). Indeed, it appears to simply be a case of wanting to provide a government service but not being willing to fund that service adequately. But you can't look at this article and pretend that it is about failures in the free market rather than in the administration of nationalized health care.
So, while you are absolutely right that this article is not proof that universal health insurance will not work, it seems to me that it is important reading--and a cautionary tale--for anyone who wants to try it.
Sorry, I wasn't entirely clear. I was basically agreeing with your point that Britain's less than perfect dental care was not a reason to avoid a system of universal health insurance.
The British don't get great dental care, because it's not that high of a priority for them. The final paragraph of that article says as much. I'm pretty sure that we would get pretty great dental care under a system of universal insurance.
It's also true that poor people in this country get shafted when it comes to dental care. One bright spot: In Massachusetts Health Care for All succesfully sued (or threatened to sue and thereby got a negotitated settlement) the Romney administration to restre dental benefits to MassHealth recipients.
Ideal, I think you're misreading LB on market failure. She's saying that the people with bad teeth haven't got dental care through the private market; that's the market failure. If the private market were working, then people could be getting dental care through it. Now, it may be that the private dental care market is all messed up because of the NHS's interference -- that seems not implausible -- but there's still a private market failure here, if people can't get the care they need on the private market.
bg, I'm not quite so optimistic. Poor people in America pull their own teeth too, and for the past few years I have either been not offered dental insurance or been offered such crappy dental insurance it wasn't worth taking. But maybe in a world in which we get universal health insurance it will be more like the insurance MassHealth gives its patients than what Texas gives its public employees.
Further, you talk about a "market failure" in the provision of private dental services, but there is no indication of such a market failure. Indeed, that is the only market that seems to be working.
Of course there is -- there is a demand for dental services, and the private dental care market is not filling that demand. The private dental care market is failing to satisfactorily provide dental care to people in Britain.
You're right that whatever is going on with the NHS isn't a market failure -- it seems to be a combination of underfunding and cultural problems. But the result is that it is failing to fully compensate for the failure of the private market to provide sufficent dental care -- not that it is spontaneously creating the problem.
re: 5-6
I think we disagree on what a market failure is. From the facts available, tt seems to me that the market for private dental services is working as it is supposed to--there are willing sellers of services and willing buyers of services and there is no indication that the supply does not fill the demand at a price at which the suppliers are prepared to provide services.
You seem to think it is a market failure if people cannot get the services they want, even if they do not want to pay for them. That's not a market failure, that's a market. In a market, sellers are not compelled to sell at any price.
even if they do not want to pay for them
This is why I'm not a conservative. "do not want to" s/b "cannot." If a functioning market is one in which lots of people are priced out of dental work that they need, then bring on (better, please) government intervention.
I have to admit that I think Idealist is right here. It would be one thing to say that there is a way to provide provide dental care at a cost that is both affordable and that gives the provider a healthy profit, but the Brits won't do it. It's another to say that private dental is not currently affordable for the Brits--at a minimum, I would think that you'd have to ask whether the Brits have so little DI after taxes that they can't afford non-necessaries like dental care.
But my point is, however you slice it, that Brits who can't get their teeth cared for haven't been failed by the NHS alone. They have been failed by the private market for dental care, just as many people in the US are. The NHS has then failed to care for everyone failed by the private market.
It makes no sense to write the article from a perspective of 'what's wrong with the NHS vs. market,' as both have failed the people described.
Okay, let's talk about France or Germany instead.
In France, you pick out a dentist, often based on recommendations from friends or family, get an appointment, and you and the dentist together fill out the national health insurance paperwork.
Same deal in Germany.
French and German people tend to have rather healthy teeth.
(Btw, the stereotype about British teeth dates back several centuries, and I have read that it derives from their comparative wealth; as the imperial center, they could afford to consume more sugar than was good for them.)
I don't think anybody is proposing a UK-type system for the US. The NHS is a truly unfortunate strawman for anti-universal healthcare advocates to bat at.
Mmm. I think you're right that it's wrong to write "what's wrong with the NHS vs. the market," but I think it's wrong because you can't easily disentagle the NHS from the market in the UK. Rather, the comparison is or should be the UK vs. the US in the dental field.
Part of this is confusion on my part about what is meant by "market failure" here. It might be that consumers are not picking services that they should, or it might be that providers are not providing economically viable services that they should. I'm sure there are other kinds of failure that I don't know about, but from where I sit, it looks like (per BG) the market is working and perhaps the Brits don't care that much about dental care.
The article seemed to alternate between taking potshots at the British for not valuing ceramic smiles, and pointing to problems with the NHS.
And the article failed to note that if you don't have dental coverage in the U.S., you're in a remarkably similar boat as the British person. My dad's had some bad luck with his teeth, and it's cost around $22,000 to repair. (They'll pay it off when they're 87, we think.) This was comparable the prices in the article.
My parents don't have dental. Reading the article would give one the impression that a person in similar financial circumstances in the U.S. would have gleaming white teeth. Perhaps this is a problem with any system where some people are insured and some aren't, since it does drive up prices. But I don't think it's a problem peculiar to Britain's NHS, and it seems remiss to treat it that way.
The NHS has then failed to care for everyone failed by the private market.
Maybe we are just quibbling over wording, but I think you are wrong in a very important respect here. The private market does not fail people who cannot buy services at the market clearing price, it just means that they cannot get what they want on the market. For example, you would not say that the market for mansions in the Hamptons has failed because I do not have one (assuming I wanted one). The market has worked, I just cannot afford what I want.
The market for private dental services seems to be working in the UK. Now, does this mean that there is no need, as a matter of social policy, to address the fact that some people may be priced out of the market? Of course not (or at least, I think of course not--others may reasonably disagree). But this is not a market failure problem. It is a problem of people not being able to afford a service which we might think, as a matter of policy, is essential and which should be provided to them regardless of their ability to participare in the market.
Dental care under the NHS used to be quite good. However, it was pretty much intentionally BROKEN by the last Conservative government.
Now it is extremely difficult to get NHS dental care in many areas and appointments can involve quite long waits. I have an NHS dentist -- I believe I am signed up with the only NHS dental practice remaining anywhere in Oxfordshire -- but when I want an appointment it's a fairly long wait. A couple of weeks, minimum.
It's also worth noting that dental care, like eye glasses and optician's appointments in general, is generally not free at the point of delivery, even for those who see an NHS dentist. In this respect the dental service is unlike the rest of the NHS.
So, there's a lot wrong with NHS dental provision. None of things are to do with the nature of universal health care but rather to do with specific policy decisions made with respect to dentistry. You can't draw any general conclusions vis a vis the NHS as a whole when looking at dentistry.
when I want an appointment it's a fairly long wait. A couple of weeks, minimum.
Is that not normal? With my craptacular grad student dental insurance, I'd be lucky to get an appointment at the dental school this month.
And again, it's worth pointing out that it's not just a British NHS problem. I tried to get a dental appointment for the end of this month six weeks ago. Not having any luck, since the appointments generally book a year in advance. I don't have a dental plan to blame this on.
Idealist, you seem to be clinging unnecessarily tightly to an economics textbook. You're quite correct that it's not a market failure if guns cost two butter and I only have one butter. On the other hand, it still seems to be a problem if guns cost two butter and a substantial group of people can only pay one butter, and they really, really need that gun.
Maybe not for the mansion in the Hamptons, but surely it's not unreasonable to think that when going to the dentist regularly costs a month's mortgage or rent, that something's gone wrong. Which is all I think LB and Weiner meant by market failure.
Maybe in NYT reporter land, dental coverage is great and you can get an appointment the next day.
Idealist, you seem to be clinging unnecessarily tightly to an economics textbook.
Maybe. It seems to me that accuracy in defining a problem is awfully important in understanding and fixing it.
Gee whiz! Me too. Which is why I think it's inaccurate to describe not being able to afford thousands for dental care as not wanting to pay for it.
I could edit the post to say 'failure of the market,' rather than 'market failure,' to avoid the defined term?
Which is why I think it's inaccurate to describe not being able to afford thousands for dental care as not wanting to pay for it.
Again, this seems like a question of how much disposable income the Brits have, where it is going, and to what extent potential disposable income is decreased by the UK's specific system of welfare programs.
There is something specifically broken with NHS dentistry that is not broken with the rest of the system. I don't know why. But when we moved here, ten years ago, there were four NHS practices. One after another, they all went private. Then a new one opened, and, after signing up everyone who needed it, suddenly announced that it, too, was going private. Essentially, they do it because they can, and because the patients have no choice. The quality of care has not changed at all. I'm still being seen by the same people for the same sort of treatment. I just have to pay twice as much for it. This does not lead me to believe that private provision is better, philosophically or practically.
My guess is that the rules have been rigged in some way that makes it hugely advantageous for dentists to go private. That's not market failure. It's a political failure. But the effect is just as bad.
Sure, I'd be wiling to bet that paying for regular dental checkups is a lower priority for British people than for Americans.
But that's not the point of saying 'not wanting to pay for it', is it? When used rhetorically, it's meant to make it sound like the choices were between buying a luxury car or paying for a root canal, and stupid consumer just valued the luxury car more. Then everyone can nod and point out that it was a free choice, and therefore not one worthy of concern. You just need to get your priorities in order.
Now, maybe that's true for a $100 cleaning, but I'm not sure thousand-dollar surgery is something that everyone can afford, but just choose not to.
not wanting to pay for it.
Fair enough. How about not wanting (or in some case, being able) to pay the market prices for those services.
I could edit the post to say 'failure of the market,' rather than 'market failure,' to avoid the defined term?
This makes sense if what you mean is the failure of the market to make dental services as available as we, as a matter of policy, would like. Sure. I think that is what is happening in the UK (and here are well). I think this is important about this is that we should find solutions that recognize, and build upon, the fact that there is a functioning market for these services.
I think this is important about this is that we should find solutions that recognize, and build upon, the fact that there is a functioning market for these services.
And I think that it is important to make clear in any such discussion that part of the meaning of 'functioning market' is 'market functioning such that significant numbers of people are pulling their own rotten teeth out with pliers at home.'
I'm of two minds re. a national single-payer system. Obviously it's a lot better for those who don't have health insurance at all, and I think it would be much better in terms of employment, too, given that health insurance is a major expense for employers. OTOH, my experience of single-payer systems is that there can indeed be a genuine problem for non-emergency care. When I sprained my ankle in Britain I was thrilled to be able to get taken care of immediately, and free. OTOH, my dental appointments need to be made at least *six months* in advance; my waiting period for mental health care was likewise six months (which is unacceptable if you're severely depressed but *not quite* suicidal enough to be hospitalized); people often have to live with chronic pain or suboptimal care for fairly common problems like asthma for quite some time while the system grinds through its waiting list; the shortage of providers means that even if you are willing/able to pay out-of-pocket you still have to wait; and because national health covers basics, most private insurance (ime) is "supplementary," which means it won't cover things that are covered by the government.
Obviously, part of the problem is the "that's because you're an American" thing: it's true that for middle-class Americans with decent health insurance, things like waiting six months to see a dentist or a shrink *are* unacceptable. I don't actually think that's bad. It does mean, though, that we need not only a single-payer government-funded system, we need one that works for the kinds of expectations we have (and of course, we'll need to adjust our expectations according to what's possible). One of the things we'll need to take into account while developing it is going to be the profit problem: doctors *can* make quite good money in an unregulated market, because people will pay a lot if they really need something, so a regulated market or a single-payer system needs to offer them *enough* money to keep them from simply taking their services elsewhere.
Part of what's going on there, as far as I can tell, is that the NHS is a strong candidate for the worst system of universal health coverage in the world. If you look at essentially any other country with universal health coverage, they're going to have shorter waits, higher quality.... if an American system of universal health coverage could be devised that would produce even average results, by international standards, we'd be much better off than the NHS, and probably as well or better off than the portion of the population that now has top-of-the-line private insurance.
I think we disagree on what a market failure is. From the facts available, tt seems to me that the market for private dental services is working as it is supposed to--there are willing sellers of services and willing buyers of services and there is no indication that the supply does not fill the demand at a price at which the suppliers are prepared to provide services.
My memory of economics is rusty, but what I do remember about the concept of market failure accords with LB's usage. Not a definitive source, but this wikipedia article includes among examples of market failures "situations where market forces do not serve the perceived public interest", i.e. the price of dental care in an unregulated market will exclude more people from non-plyers-at-home dental care than a particular society finds acceptable.
But just out of curiousity, Idealist, could you give an example of what you would consider a market failure? Is it only when there are willing buyers with enough money (i.e. effective demand) but for some reason there's inadequate supply?
27: I suspect one's intuitive responses to the NHS sorts of scenarios depend very much on one's current ability to get medicine and health care. I'm insured now, and it takes about six months to get a dental appointment (dental is not covered.) It takes me about a week to get a clinician appointment; any referral is two-three months.
But growing up, my familiy had minimal health insurance (read: $10K per person deductible.) When I was eleven and fell roller-skating, and we decided that I needed an x-ray, it cost $400 (this was 1992). When my sister two years ago had an intestinal problem, it was $4000 for one night in the hospital. And frankly, any system that would have *not* had my sister crying that she was sorry she went to the doctor and cost mom money would be a plus. I would be totally okay with a six-month wait for a yearly checkup if the alternative is no checkup at all. Uninsured medical care is expensive, even if you leave out serious diseases, and I think a lot of the discussion in general seems not to recognize that. Have kids? Hope none of them ever breaks a bone, because it costs more than a $10 copay. Hope they don't get strep throat either. $100, before you get medicine.
That said, LB's right. Britain's NHS is a lot worse than, say, Canada's in terms of delays and shortages.
I agree with Idealist that a marker failure is something more specific than unfulfilled demand, or even unfulfilled demand for an essential. One usual (but I don't think essential, I'm also having trouble explaining what I take the term to mean) characteristic is a positive or negative externality associated with the good or service such that it's under- or over-supplied.
With the exception of the sprained ankle, my description in 27 was of Canada's health care. It's nice to have, but my private health insurance in the States was way, way better. (Except for the military's HMO program, which didn't have huge delays in getting service, but which liked to play the game of "yes we'll pay for that, oh no we don't and who said that we did?" until you got frustrated with the endless phone calls and just ended up paying the bill your own damn self.
32: That's interesting. According to this page, Canada's health coverage generally doesn't include dental.
Where in Canada are you from?
32: It may depend on your health care here and where you were in Canada. My boyfriend's from Alberta, and has never had a problem seeing a doctor, nor his aunt being treated for diabetes and cancer. His coverage is better than mine. And what's really nice is if you leave your job, you still have coverage. You're billed for it just like you would if you were working, and eventually, they'll hunt you down and make you pay for it, but in the meantime, you can still see the doctor.
But it doesn't include dental or vision. Neither does mine, so that's a wash. He'd have a delay getting an artificial knee, but my clinic would probably try to treat it with crackers and apple juice first. (Ah, universities.) As I understand it, Canada's system isn't nationally organized, just nationally mandated and provincially organized, and I'm only familiar with Alberta and Ontario.
Part of what's going on there, as far as I can tell, is that the NHS is a strong candidate for the worst system of universal health coverage in the world
Almost certainly true, because it was one of the first outside the USSR - therefore experimental, and all subsequent attempts to reform it have been piecemeal rather than strategic. Nevertheless, in most branches of medicine waiting lists are acceptable for essential treatment.
Dentistry was an exception from 1945, because the dentists' lobby almost refused to buy into the NHS and therefore had to be heavily bribed with privileges. If I have a heart attack, I can be reasonably sure of some sort of hospital accomodation pretty damn quick and treatment by a competant specialist. If I have an abcess, I can wait a week or go private.
Also, NHS dentistry isn't free unless you are a pensioner, a child or in receipt of state benefit. It's heavily subsidised - the other day I was charged about $60 for two fillings, but even these kind of charges hurt for people who are only just making ends meet anyway. Root canal work can cost hundreds.
Recent bureaucratic changes have caused most dentists to say they won't accept any more NHS patients (they're allowed to do that). While I was waiting for my fillings, a colleague came in with his 10 year old son, who had a toothache. They were trailing round every dentist in the neighbourhood, trying to get somebody to treat the kid on the NHS, and failing. I doubt if the guy makes much more that $17-18K, so it would be no joke if he had to buy treatment at full price.
I'm not "from" Canada, but I live in Ontario. And I think you're right that I don't have dental under OHIP; that's covered by the private insurance my employer provides. It sucks anyway, though: the standard of care is a cleaning once a year and a lot of services that were covered by my U.S. private health insurance aren't now. I don't know if that's typical, but it seems to me of a piece with dealing with OHIP.
You're right, Cala, about things like diabetes and cancer. I have a colleague (also an American) who has some kind of serious autoimmune thing and he's way happy with OHIP. OTOH, I have depression and had to wait all winter to see a specialist (while my g.p. dicked around with meds, inadequately) and even now talk therapy just isn't covered--or rather, as my meds doc explains to me, it *is* covered, but there just aren't enough shrinks to provide it b/c they have people who need meds beating down their doors. I can't get a light box, which my shrink recommends, because *that's* not covered either (although my university will provide them to students--but not faculty). My husband has low-level chronic things that *might* be symptoms of some kind of autoimmune whatever, but because they're all low-level, no one wants to do any testing (if they became acute, like my colleague's sudden platelet loss and hemmorhaging, that would be different).
I've found it really frustrating. And although I've long been in favor of some kind of single-payer program in the U.S., and when I moved to Canada was initially thrilled (as most good American liberals would be), it's been reallly eye-opening in terms of thinking about how important it is to do these things *right*. I'm sure it can be done, and my sense is that part of Canada's problem is the fact that physicians (and patients with money) can just up and take their business a couple of hundred miles south, but I have to admit that if/when the question of a single-payer system comes up, I really hope the U.S. ends up with a better system than the one I've experienced here.
And I think you're right that I don't have dental under OHIP; that's covered by the private insurance my employer provides. It sucks anyway, though: the standard of care is a cleaning once a year and a lot of services that were covered by my U.S. private health insurance aren't now. I don't know if that's typical, but it seems to me of a piece with dealing with OHIP.
Well, no. Not remotely. If you're talking about problems with universal health care, complaining that your private dental insurance sucks and lumping that in with Canada's Medicare system makes no sense at all.
All that said, it is better and more fair on average than the U.S. system because yes, everyone is covered (though I was told there was a 5-year waiting list for a g.p when I arrived--I managed to jump the queue because the university pulls strings for new faculty). But it isn't what I'd call a "good" system.
Crap. LB or someone, can you change the attribution of 38 to reflect my slightly-more-anonymous pseud?
Re. 37: I think it makes sense in terms of what's considered an acceptable standard of care, is what I meant.
Idealist, could you give an example of what you would consider a market failure?
I think I generally agree with the neo-classical view of the matter described in the article to which you linked. My objection to what the linked article describes as the liberal and marxist definitions of market failure is not just that I think those approaches to market intervention are terribly misguided (although I do) it's that if market failure means nothing more than that the outcome of the unregulated market is something other than your preferred policy choice, then the phrase market failure is meaningless as a way to talk about what is going on in the market, that is, the interactions between buyers and sellers. It makes market failure synonymous with "bad", and thus not very illuminating or helpful.
23 and 35 raise a question I would like anyone with knowledge of how things work in the UK to answer: It looks like what happens is that a dentist can establish a practice as an NHS dentist and then go private, taking some part of his/her established patient base along--not all of them, but enough to make going into private practice worthwhile. So, the state is in effect funding the start-up of private dental practices. Is this right?
And that will be a lesson to me on being more charitable to people I don't know. I was getting all bristly with the first comment mentioning England, and then you weren't talking about England but Canada, and then you were blaming Canadian Medicare for the failures of private dental insurance... I had you pegged for a troll, making stuff up to make universal coverage look bad.
Now I feel like an uncharitable idiot. Which is good for me. Motivates self-improvement.
I agree with idealist about the terminology. I would rather call the private dentistry situation a "market inadequacy".
It seems to me that the issue with dental care in Lubbock is pretty similar to the one described in Britain and maybe Canada. There's a relatively cheap DMO (dental maintenance organization), but basically no one in town takes it and those who do don't stay on it. Then there's a much more expensive dental plan which, when it kicks in in full in the third year, has benefits capped at $1250/year (handy for those $22,000 bills Cala's dad has!) and for the first year has benefits capped at $500/year with 30%-100% copay. Not till the third year is cleaning/oral exam fully covered. My colleagues largely don't bother with dental insurance.
My objection to what the linked article describes as the liberal and marxist definitions of market failure is not just that I think those approaches to market intervention are terribly misguided (although I do) it's that if market failure means nothing more than that the outcome of the unregulated market is something other than your preferred policy choice, then the phrase market failure is meaningless as a way to talk about what is going on in the market, that is, the interactions between buyers and sellers. It makes market failure synonymous with "bad", and thus not very illuminating or helpful.
This is interesting, and is something that's been bothering me since law school about economics based policy arguments. There are a lot of terms used in an economics context that sound, in a lay context, as if they are making larger claims than they are. Economic 'efficiency', for example -- a result is efficient if there is no way to change it without injuring any person. So a state of affairs in which Bill Gates has all the money and everyone else starves is efficient -- redistributing the money he has to any degree would injure him, regardless of how many other people it would help. When you actually look at the definition, it becomes clear that 'economic efficiency' is not a useful or interesting concept from a policy point of view. But it sounds as if it should be.
Likewise with 'market failure' -- it sounds in a lay context as if a market operating without failure should produce desirable results. But of course that isn't true, it can produce results in which people pull their own teeth at home.
This doesn't make economics a bad thing -- it just means that I have to remember to be very wary about economic vocabulary in a policy context.
(And b? 43 was intended as an apology. Sorry for thinking ill of you without justification.)
I seem to recall an explanation coming from one of the financial bloggers, perhaps the fat Welshman, to the effect that dental insurance was better understood not as insurance but as a little extra income. His point was that dental insurance (I know this to be true of private plans in the US) does not much cover expensive emergency care, the kind of thing you would expect insurance to pay for, but does cover inexpensive preventative cleanings, the kind of thing you would expect to pay for in an insurance plan's deductible. I don't know how this relates to national dental insurance though.
45: Maybe the moral of the story is that dental insurance sucks. Most plans I've seen cap treatment at about $1500 a year. Better than nothing, but it's really kind of 'Which teeth get the root canal this year?' if you have a serious problem, and if you don't, just needing an average cleaning/occasional filling, it's not worth the premiums. My 'dental insurance' is 'here is a list of relatively low-cost dentists.'
I don't know if this is right, but I get the sense that dental care is a lower priority than, say, regular checkups, until something goes wrong and you get an abscess, which means it's a bad candidate for most models of insurance coverage.
A-men to 46. Often it seems as though economists are not as scrupulous as they might be about observing these distinctions when making public policy arguments.
Doesn't that actually make it ideal for universal coverage, if anyone would set it up? Preventive care (regular cleanings, filling of small cavities, early on) seems as though it should be comparatively cheap, compared to the treatment of major dental problems, which are largely avoidable. A system that encouraged everyone in for frequent free cleanings and checkups would, I would think, result in better dental health for less money than a market system.
This doesn't make economics a bad thing -- it just means that I have to remember to be very wary about economic vocabulary in a policy context.
Yes. Now that does not mean that economics does not have a lot to tell us about means, because it is about understanding what is happening, and knowing where you are is the first step to figuring out how to get from where you are to where you want to go (a policy choice). Thus, my belief in the importance of individual liberty, including economic liberty, does not stem from economics, although economics might help answer questions about how people exercise that liberty.
So has comity been restored?
my belief in the importance of individual liberty, including economic liberty, does not stem from economics
Those may not be the best examples, as your beliefs are wrong. Comity dethroned!
I don't think so, LB. Lemme try to explain why.
The basic of the most basic basic strawmen health plans goes like this: we all put money in the kitty for regular care, even though it would be cheaper from my perspective to just pay for my one doctor's visit per year, because if I need lots of care I can't afford, the money will come out of the kitty.
With dental care, I think people feel a) it's a lower priority than other medical care and b) that it's a lot more predictable. I would probably purchase health insurance if I didn't have it, but I don't have dental, and I don't care, because I've had no cavities so far with minimal dental coverage (biyearly cleanings) as a kid. So there's no strong desire for me to put money into the kitty, because I figure emergencies are covered by my other insurance, and things short of emergencies, like decay, I can predict pretty comfortably that I won't be needing.
It's not the same with medical care. I'd pay $1500 a year for health coverage, knowing that it's unlikely I'm going to use it, because if I do need it, it will be very costly and probably a surprise, like a car crash or a broken bone. Not sure I'm willing to throw $300 a year away on dental insurance. Most I'm going to need, knowing my dental history, is about $55 a year for a cleaning. Not much of an incentive, and even less of one given that the best of plans will cap me at $1250-$1500.
It's sort of like the problem in general with funding health insurance. Young people who are strapped for cash figure they'll take their chances, if they're healthy. (This is why we don't just let people buy Medicare. The only people who would buy it are those who are sick.) It's just that with dental insurance, I suspect the numbers of people willing to just take their chances are a lot higher.
I think you're absolutely right about the incentives to buy dental insurance. What I was getting at is, if we assume that all the regular preventive care is effective in preventing major problems, that a universal system that made preventive care free and convenient would be likely to reduce the total sums spent on dental care (and the total pain and suffering from bad teeth as a bonus!). It seems reasonable to me that people systematically under-purchase dental care and end up spending more down the road, and that a universal system might fix that.
54 -- but then somewhere, someone would surely be paying taxes for dental care that s/he was not using, which would be inefficient.
Yes, I agree with that, LB. I was mostly referring to why the caps on current programs are so ridiculous as to make dental coverage largely a joke (and a bad candidate for a rational purchase now). I mean, really. $1250 in coverage, and no orthodontia covered? I'll take my chances. It wasn't even worth it for my dad and his messed-up mouth.
I'm not sure there's the same groundswell of support for dental services, though, due to the incentives. I'm talking mostly ex recto, but I think I could live with a system that took care of basic health care and then left dental and vision up to me and my budget.
I'm not sure there's the same groundswell of support for dental services, though, due to the incentives.
You're probably right. I'm in favor of universal dental coverage, because it strikes me as a big social justice issue. Visibly bad teeth are one of the things that make someone look ineradicably poor, and they can cause a lot of suffering. But it's not my highest priority, and it probably isn't as popular as universal medical coverage.
I wonder if basic dental screening couldn't be done in the schools. We discovered that I needed glasses and didn't have scoliosis or poor hearing through a quick test at school. Maybe the same could be done for dental problems. You'd still need to go to a dentist to fix the problem, but I had to go to an eye doctor, too, and it might help catch problems early on.
43: No apology needed! Whatever you may have thought, you didn't *sound* like you were thinking ill. Everything you were saying was totally reasonable. I'm glad you thought I was someone else, though--reassuring re. the statement about where I live. Funny thing is I figured it would be obvious to the regulars whose comments those were, in part b/c many (but not all) regulars "know" me. (Which is why I didn't differentiate between England and Canada in the first post.)
Anyway, the point of it all is that I haven't by any stretch of the imagination done a comparative study, and so I'm quite tentative about drawing any real conclusions from my experience. Which is purely anecdotal and of course I'm comparing one kind of single-payer system to my former good private insurance (including my grad student insurance, which was pretty good, I must admit). But as I was saying, the experience has made me a lot more aware of what Americans with decent health coverage worry about when we start talking single-payer, and the importance of expectations: while obviously getting depression meds prescribed by a g.p. and waiting six months to see a specialist is a lot better than no coverage at all (so that if that's your basis for comparison, the Ontario system, at least, is going to look quite good), it's really shitty if you're used to having insurance that covers mental health. Of course, it's also acknowledged that mental health coverage under OHIP (and, I believe, in the UK) is pretty crappy and needs improving. But it is true that in a single-payer system, if something needs improving you're pretty much stuck until the improvement happens; you can't just find a new provider.
Another interesting thing I've also learned is that the primary role of Planned Parenthood in Ontario seems to be education *and* providing abortions (which are covered by OHIP) to young women who don't want to disclose a pregnancy to the family provider who also sees their mom and dad and has known them since they were a baby--not because they don't trust confidentiality, but just because it's awkward and difficult. I certainly know that asking for STD testing from the same doc who sees my kid and husband was a bit awkward....
That last is a very good point under any system; My wife, daughter and I have different primary care physicians, and I think that what might otherwise be awkwardness, not that I've until now thought about it that way, is bound to be avoided by such an arrangement. The "family doctor" of yore may be obsolete for essentially social and privacy reasons.
54: Isn't this in fact the primary logic behind single-payer proposals (and HMOs)? I think it's true that, averaged across populations, relatively inexpensive preventative care is a lot cheaper than not having preventative care and thereby ramping up serious problems. OTOH, the problem with HMOs/single payer systems is that if you *do* have a serious problem, especially one that isn't paid for by the system (root canals, you get into an accident and break your teeth, mental illness, whatever), you're fucked in a way that you aren't if you have good private insurance.
It's something I've started thinking about as I've gotten older. It seems to me that everyone I know takes meds or sees a doc fairly regularly for *something*--after all, if you think about it for a minute, a state of perfect health with an occasional cold is not really the natural state of affairs. Most people by their late 30s, I'd imagine, have had *some* kind of low-level longish term medical problem: shin splints, depressive episodes, carpal tunnel, asthma, high cholesterol. I think the idea that health problems are preventable with basic care is really a pipe dream, one that's a reflection of a really high standard of living where we've learned to expect good health as a default state of being.
So yeah, in their 20s most people without kids can afford not to have insurance (although ime a lot of young women use Planned Parenthood to access basic health care--I know my sister-in-law used them to get prescriptions for pneumonia and to have regular checkups, not just for gynecological care). But I'm really wary about the idea that medical insurance, including dental and vision stuff, should privilege preventative care *over* major problems. It seems to me that sooner or later most of us are going to have some kind of "major" or chronic condition that preventative care alone won't cover.
I think what I'm in favor of, personally, is a single-payer system that's supplemented by private insurance (as an employment benefit) and non-profit or legislative support (e.g., hospitals have to take care of you if you come in bleeding, insurance or no) for those who can't get private insurance. I don't know what to do about the high cost of testing for rare but dangerous conditions with symptoms that are the same as the symptoms of regular low-level shit, but that's another thing that worries me about single-payer plans.
I remember reading a statistic (that, of course, I can't find) that losing one visible tooth reduced future earnings by something like 20% and even more for additional teeth. (Since there is the stereotype of people with missing teeth being less educated and because employers don't want to hire people with missing teeth for customer-facing service jobs, be that a waitress, secretary, store clerk, etc.) Bad dental care is a contributor to cyclical poverty - poor families can't afford dental care for their kids, so their kids lose teeth, which limits their future job prospects. So, not only would you be preventing future, more costly dental work, subsidizing preventative care would help ensure people's future employability and keep them off welfare. (At least I think so - this could be a total overreach.)
Re. liberty: I recently read an interesting article, don't remember where, about a study that someone had done about what people meant by that word. The results were that for those who are relatively privileged (like most of us, I imagine), it means "freedom to"--that is, the ability to choose. Whereas for the poor and the working class, people who don't *have* as many choices in daily life, it means "freedom from"--the ability not to worry, not to *have* to choose between unacceptable options (root canal or food for the kids?).
It definitely made me think about the ways this distinction might be used politically. It seems to me that conservatives get away with some of their policies, which really screw over a lot of their core voters, by using the word in the first way and having it understood in the second, and that this distinction might be one that liberals could benefit from paying more attention to.
Is this a correlation or a causation? I have read that statistic, and part of me, having worked in image-conscious consulting, believes it.
On the other hand, it strikes me as a cart-before-horse sort of problem. Is it because of bad teeth that people end up in low income jobs, or are people in low income jobs more likely to have bad teeth plus more likely to live in a bad school district, being unable to afford college, etc. If it's the latter, then just fixing the teeth, while a fine thing to do, won't help with the underlying problem. (Fine, now you have fixed teeth, but your school district still sucks.)
62: I remember a NYT article that seemed to make the case that that isn't an overreach at all--one of the people profiled was an older woman who specifically couldn't get a Wal-Mart job (and was therefore on welfare, which had gotten cut off) because of her awful teeth. It was very sad.
FDR's "Four Freedoms" part of his emerging late social vision that Cass Sunstein has been trying to draw attention to and re-invigorate, were specifically addressed to "Freedom From" issues.
There's a story in this Sunday's Times about a woman who couldn't get a checkout job after losing all her teeth. I debated adding it to the post, and then forgot.
But I'm really wary about the idea that medical insurance, including dental and vision stuff, should privilege preventative care *over* major problems.
This shouldn't be necessary. If preventative care is effective at all (that is, if it's really preventative, rather than ineffective money-wasting) it should reduce (not eliminate, but reduce) the amount of major problems. A system that pushes preventative care where it's effective and covers major problems as well should come out cheaper than one that just covers the major problems.
(All uses of 'should' in this comment should be understood to read 'I think this is how it comes out, but I haven't done the math.')
Agreed, and I think the math does support it, at least based on what I've read. And I don't think the U.S. would embrace a system that didn't allow private coverage *at all*, which would be the model I'd really worry about.
if something needs improving you're pretty much stuck until the improvement happens; you can't just find a new provider
I'm curious as to whether this differs at all from the average U.S. insuree. I'm healthy (kina hara) and haven't worked at the same job for more than a year since grad school, so I don't know much about the details of my health plans. But I've always been under the impression that I had two or maybe three plans to choose from, and that if one of them needed improving I was going to be pretty much stuck until the improvement happens.
IOW, the private market for health insurance in the US doesn't actually yield much consumer choice because your insurance is tied to your job, and the people who pick the insurance for your job do not act as you might if you were fully informed and getting insurance for yourself. Which, AFAICT, is a market failure in the purest neoclassical sense.
But do other people have experience of more choice in the US system?
the people who pick the insurance for your job do not act as you might if you were fully informed and getting insurance for yourself. Which, AFAICT, is a market failure in the purest neoclassical sense.
Well, I do not know if it is a market failure so much as an indication that it is employers, rather than the beneficiaries of health coverage, which are the active participants in the market. While your employer has your interests at heart in the sense that the quality of the health plan they offer is part of the compensation they have to offer to induce you to work for them, basically, they are acting in their interest rather than yours. That is, to me, one of the arguments for letting people participate directly in the market for health insurance by having the government pay for some level of coverage (which individuals, employers, etc. can supplement).
But if you have choices, can't you choose at the end of the fiscal year?
Maybe my sense that one can change has to do with the fact that between Mr. B. and I, we've had different jobs/insurance providers pretty much annually... :P
71: But the problem with direct individual participation is that the only way to make premiums affordable is to average out the risk on the insurer's behalf over large groups.
But the problem with direct individual participation is that the only way to make premiums affordable is to average out the risk on the insurer's behalf over large groups.
You are, of course, absolutely right (although this is a fixable problem). That's why this is so hard to do. Many people agree on the problem and agree on the goal, but getting there is darn complicated.
Sorry, that last one was me.
Back to "liberty." Isn't there a problem with privileging an idea (liberty) over a practical material reality (something like half of America lacks health insurance)? I mean, the theory's great, but don't you at some point have to realize that if the theory doesn't actually work, it needs revision?
The problem with preventive care in a non-single-payer environment is that it doesn't pay for itself for the providers would would pay for it for any individual at the time it would do any good. Because of job mobility (or lack of job security), the average American switches healthcare provider every few years (I forget the exact number, I want to say somewhere between 3 and 7). The insurance companies know this, and therefore know that any long-term preventive care they pay for will not save them any money, only the competitors to whom the insured have switched. One of the many reasons I want single-payer ASAP.
Isn't there a problem with privileging an idea (liberty) over a practical material reality . . . if the theory doesn't actually work, it needs revision
So far, liberty has a pretty good track record. It's doing better than many of the modern alternatives.
More to the point, I do not see the strong contradiction between liberty and health insurance that you see. Sure, if liberty means extreme libertarianism of the sort which disavows all public services, OK, but that is like my saying that all governmental programs must fail because the Soviet Union failed. In making government programs, it is indeed instructive to consider the utter failure of central planning, but that does not mean that there is no need for a government and any of the services a goivernment can provide.
On the other hand, if you value liberty as I conceive it, you place great weight on the right of the individual to make her own choices (you ought to support that, B.PhD), as long as those choices do not unreasonably interfere with the interests of others.
Well, the problem with "liberty has a pretty good track record" is that "liberty" means (as you're pointing out) a lot of things. It has a great track record in a lot of areas, and a shitty one in others.
There's a distinction, surely, between people's "right to make their own choices" in areas where the options are more or less actually within their control, and people's "right to make their own choices" in areas where the options really aren't. The former is a genuine choice; the latter uses "choice" as a screen for abandoning the idea of social responsibility.
But if you have choices, can't you choose at the end of the fiscal year?
Sure, but the choices seem to me to be extremely limited. As I said, I haven't ever looked into it in great detail.
Ideal, as I understand this is an agency problem, in that the employer is acting as the employee's agent in the insurance market but has very limited incentives to act in the employee's interests. (The recruiting effect seems very limited to me -- I've had pretty much no choice in this way, and did I mention that my employer wouldn't even insure me for the first three months? but if I want to work in my field I had to take this job.) So market forces aren't going to allocate services efficiently; even if a worker would be willing to give up something for better insurance, that's not going to be on offer.
And as to people's right to make their own choices, I already think I don't have that in the health care market. My employer sticks me with an HMO, and the HMO will stick me with a specialist if it ever comes to that. (Did I tell you about the time I sprained my thumb, and the HMO referred me to a specialist who was on vacation for three weeks -- to get my fucking splint put on? When I was in a temporary splint that I'd been instructed to get replaced in 3-5 days?) If I have two insurance choices, and the only way to get a different choice is to get a new job, then I don't have much liberty.
63 is interesting to me, because our system of political liberty in the US has always defined freedome in "from" terms, i.e., freedom from government intrusion and interference. The right to be free from warrantless searches, etc. We have no freedome to do anything, only the freedom to be left alone. This is great for rich people. A freedome from regime provides them with the freedom to do whatever they want.
Poor people can't be free from worry unless they are given certain benefits. I'd call that a freedom to policy.
Dental Insurance. I was looking at a large company's self-insured health plan recently. It's a high-ish deductible plan, although they'll put some money in an account so that after a couple of years, you shouldn't need to pay out of pocket for the deductible.
The dental plans were completely different. The company didn't subsidize the coverage at all. The benefit was that you were getting some insurance benefit and the premiums were pre-tax, but since you could set up a flexible spending account, the pre-tax thing wasn't such a big deal.
There were three dental plans administered by Cigna. One was an HMO with great coverage, but the dentists were prone to leaving it mid-year. The second, middle-tier option was not a great deal, sicne the benefits topped out at $750. It wasn't that expensive though. The thirs one was more expensive and had much better benefits and a greater choice of dentists. The HR person specifically said that she recommended against teh second option and said that you might as well pay for teh cleanings yourself for all the value you got out of option 2.
Even some very good companies only offer one health insurance option.
mrh--True enough, and this company only offered one health insurance option, although there were three dental plans.
I didn't like the health insurance plan, since it was self-insured, and self-insured plans suck.
If you've ever spent any amount of time with a child who has a toothache, and, more to the point, ever tried to teach something requiring even a little concentration to a child suffering from a toothache, it's easy to see how, apart from the "looks poor" effect of visible missing teeth, a lack of adequate dental care in childhood can have a major effect on education, and consequently employment, outcomes.
I don't think dental care is as optional or luxurious as some in this thread have made it out to be, particularly for kids, who don't get to choose whether or not they get it.
LizardBreath, Brad DeLong picked up this post. I'm not impressed by his lead-in, which imparts a much more partisan framework to your post than is warranted.
What happened to the trackback function, anyway? Was it a victim of the server move?
The salient point that the NYT missed -- probably because its London bureau people don't get out of town much -- is that the issue of access is highly localised. For most of the country outside the capital and SE, it's not an issue; and in those areas, many employers provide supplemental dental insurance, freeing up access for NHS patients. It's a long way from ideal, and it doesn't help that dentists have, in some places, behaved like pigs in shit with regard to private practice.
Anyway, the anecdote: I had a dental checkup while back in the UK for a couple of months. Lovely dentist, no problem getting an appointment, all done under the NHS.
(Addendum: my health insurance in the US doesn't cover dental work. Or opticians' visits. Or pretty much anything, judging from the amount I have to fork out.)
re: 27
B, are you SURE it took 6 months to get a dental appointment in the UK? That doesn't sound remotely believable to me.
My dental care now is not great -- I've had easier and quicker access to dental care in every other place in the UK where I've lived -- but even with one NHS dental practice covering a city of 100,000+ people I'm still able to get an appointment within 2 or 3 weeks.
Also, there are lot of comments blithely stating that the NHS is 'the worst' etc -- on what grounds are these claims being made? Life expectancy? Prognoses for serious illnesses? What? 'Cos they sound like bullshit to me.
Matt, I suspect B was making an appointment for a routine check up, rather than emergency treatment. Many practices default these to 6 months and if you don't know the system you might well wonder.
As to the NHS being the worst single payer system around, obviously it isn't. But it is decidedly clunky. Expectations tend to be based on experience. You and I value the NHS for its solidity and the bottom line quality of care. If I was used to a culture of "customer care" and privacy, I would find NHS hospitals bleak and open wards objectionable and perhaps not notice the good bits.
The six month wait for a dental appointment was in Canada, not the UK, and was for a private dentist. Who knew?
The 'worst' comment I threw out without looking anything up; I've seen it as a commonplace of discussions of universal health care, but couldn't tell you the metric -- I'll see if I can find some backup. 'Worst' as measured against other, better funded systems of universal coverage, like France and Germany; on outcomes the UK certainly outperforms the US non-system.
Ah, OK. That makes sense. I don't really go for check-ups -- I just go whenever I think something might need done. Perhaps that explains the relatively short waiting times.
"If I was used to a culture of "customer care" and privacy, I would find NHS hospitals bleak and open wards objectionable and perhaps not notice the good bits."
I'm inclined to not give a shit if that's people's complaint, tbh.
That's not to say there aren't big problems with the NHS, of course. It's just that a lot of those problems seem to stem from attempts to make the NHS more like private healthcare rather than less.
I'm inclined to not give a shit if that's people's complaint, tbh.
Me neither, but that's exactly my point. If the NHS started using scarce resources to cosmeticise its services, I'd be the first to scream "spend the money on more scanners/lower prescription charges/better pay for nurses." But I can understand that other people with different health care backgrounds might think differently, and deprecate the NHS as a result.
What happened to the trackback function, anyway? Was it a victim of the server move?
Yeah, for a while we were suspecting that some of the server problems were due to trackbacks so I turned them off. We discussed turning them back on but we rarely get legitimate trackbacks anyway so the signal/noise ratio with trackback spam really isn't worth dealing with. The eventual goal is to add a Technorati link, when I get around to it.
re: 94
Yeah, fair point. In that case, I'm inclined to understand that they think differently and then completely ignore their opinion.
"If I was used to a culture of "customer care" and privacy, I would find NHS hospitals bleak and open wards objectionable and perhaps not notice the good bits."
Contrariwise, I notice all the leather chairs and flowers in the reception of private hospitals in the US, and think that's a complete fucking waste of money: cosmetic dentistry on an institutional scale, if you like. Of course, if you're paying through the behind to get healthcare, you do want a nice little mint on the plate when the bill comes. Each to his own.