Sunday, November 04, 2007

One person to watch the bill

Harvard economics professor Greg Mankiw doing some interpretation in the New York Times of various accepted talking points about the American healthcare system:

STATEMENT 1 The United States has lower life expectancy and higher infant mortality than Canada, which has national health insurance.

So he sets out to show that it doesn't mean what it appears to mean. Part of the explanation is higher murder and accident rates in the US. But then --

Americans are also more likely to be obese, leading to heart disease and other medical problems ... The causes of American obesity are not fully understood, but they involve lifestyle choices we make every day, as well as our system of food delivery ... Infant mortality rates also reflect broader social trends, including the prevalence of infants with low birth weight ... The rate of teenage motherhood, according to the [Baruch college economists] study ($), is almost three times higher in the United States than it is in Canada ... The bottom line is that many statistics on health outcomes say little about our system of health care.

So note the trickery. In assessing the contribution of the different healthcare systems to overall health, he's excluding the contribution of the public health system to the different outcomes.

Americans have worse health because some are fatter and some are born with low weight at birth. Why might that be? How about poorer maternal health, more pregnant women with bad health insurance coverage, and -- together with the issue of obesity -- worse diets for parents and children. And that gets into the even bigger problem. Private incentives leading to bad public outcomes. Surely Mankiw knows what that is.

Who's telling Americans to eat healthier diets? A marginalised Surgeon-General and a Food and Drug Administration that has to fend off the lobbyists with every move. And who bears the costs of bad diets? Lots of people, but in a dispersed and not easily organised way. And who's telling Americans to eat less healthy diets? Turn on the TV or open a magazine. It's big money.

With national healthcare, there is one single entity that sees all the cost: the government, because it's paying for it. Then the playing field between public health and the food industry is a bit more level and the levers for reaching some of the people on the fringes on the system are wider than they are now.

For one thing, countries with single payer health systems seem to understand that contraception in secondary schools is not just grist for the mill for talk radio ranters, but something that actually improves public health. Saving everyone in the country a little bit of money. It's called a "collective action problem". It might even be on the syllabus at Harvard.

UPDATE: Additional links on the Mankiw piece (after the self-reference, go to the economistsview one).