Newsgroup: it.politica.internazionale
Titolo: Il sistema sanitario negli USA

http://www.newyorker.com/fact/content/articles/050829fa_fact
In the rest of the industrialized world, it is assumed that the more
equally and widely the burdens of illness are shared, the better off the
population as a whole is likely to be. The reason the United States has
forty-five million people without coverage is that its health-care
policy is in the hands of people who disagree, and who regard health
insurance not as the solution but as the problem.
-- 
ciao,
Marco

 
http://www.newyorker.com/fact/content/articles/050829fa_fact

provocatore! questa notizia e' politica interna USA e quindi secondo i
sacri dettami di charlie-castagno (e dei suoi fiancheggiatori alla
tonibaruch) sei OT. Comunista!
-- 
cocktail maisele: 1/3 arduino, 1/3 debora faith, 1/3 S. De Ce' . Agitare.
questo articolo e` stato inviato via web dal servizio gratuito 
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C'è un articolo su Techcentralstation di Arnold Kling che rispedisce
al mittente le accuse.
How Economists Really View Health Insurance
http://www.techcentralstation.com/082605E.html
s there such a thing as a class-action libel suit? In his
much-discussed recent article in The New Yorker, Malcolm Gladwell made
malicious, false, and defamatory statements about the economics
profession.
Gladwell blames economists for the fact that millions of people lack
health insurance. However, like most economists, I support everyone
obtaining insurance against catastrophic health care costs. In fact,
this is one area where I have thrown my libertarian principles out the
window and advocated mandatory catastrophic coverage.
The main point of Malcolm Gladwell's article is that he believes that
comprehensive health coverage is better than catastrophic insurance. He
believes that without comprehensive coverage, people will undertake too
little preventive health care, such as routine dental cleaning. This
may or may not be correct. But the reason that economists disagree with
Gladwell on this point has nothing to do with the concept of "moral
hazard." In fact, "moral hazard" means that insurance companies would
want to try to encourage more preventive care.
Gladwell's article is confused and distorted. Here, I will attempt to
set things straight.
Two Issues Regarding Health Insurance
Gladwell's primary confusion, which is deliberate on his part, is
between two issues regarding health insurance.
1. Should everyone have health insurance?
2. Should health insurance be catastrophic or comprehensive?
Catastrophic health insurance is a high-deductible policy that pays
benefits only if someone suffers from a very expensive illness. It does
not pay for smaller items, such as routine doctor visits, vision care,
or for low-cost treatment of minor illnesses and injuries. In contrast,
comprehensive coverage pays for all services from all health care
providers, whether for major illnesses or not.
On issue (2), many economists favor catastrophic coverage as opposed to
comprehensive coverage. Gladwell confounds this with issue (1), and
accuses economists of opposing the idea that everyone should have
health insurance. I have never seen an economist confuse these two
issues. I have never seen an economist who was opposed to the whole
idea of health insurance, which is what Gladwell implies.
Moral Hazard vs. The Law of Demand
Gladwell mixes up two economic concepts. One concept is moral hazard.
The other concept is the law of demand.
The law of demand states that if you reduce the price of a good or
service, then people consume more of it. Comprehensive health care
coverage reduces the price that people pay for routine health care. The
law of demand states that this will increase people's use of it.
Gladwell quotes Uwe Reinhardt, a well-known health care economist who
occasionally gets carried away with his own rhetoric, as effectively
denying that the law of demand applies in health care.
Uwe Reinhardt says. "You always hear that the demand for health care is
unlimited. This is just not true. People who are very well insured, who
are very rich, do you see them check into the hospital because it's
free? Do people really like to go to the doctor? Do they check into the
hospital instead of playing golf?"
In the very next paragraph, Gladwell cites a famous study which showed
that the law of demand applies to health care, and in fact people do
spend less on health care if they have to pay for it themselves.
Gladwell writes, "As you might expect, the more that people were asked
to chip in for their health care the less health care they used."
In fact, if the law of demand did not apply to health care, then
everyone would obtain whatever health care they needed, regardless of
cost, and regardless of whether or not they had insurance. Frankly, I
believe that even Uwe Reinhardt would, if pressed, agree that the law
of demand applies to health care.
The term "moral hazard," narrowly defined, means the reduction in the
incentive to mitigate risk that comes from having insurance. If the
fact that you have auto insurance makes you feel relaxed enough to
leave your car sitting outside with the doors open and the keys in the
ignition, then that is moral hazard. Another example, which Gladwell
gives, is that with fire insurance "you may be a little less diligent
in clearing the brush away from your house."
Gladwell argues that the way that insurance companies mitigate moral
hazard is by raising the deductible on insurance, but that is not
really the purpose of high deductibles. High deductibles are used
primarily to reduce the costs associated with non-catastrophic claims.
Instead, the most important way to mitigate moral hazard is through
"riders," or provisions in the insurance contract. For example, the
auto insurance company may include a "rider" that states that if you
leave your car with the doors open and the keys in the ignition, then
the insurance company will not compensate you for theft. Another way
the auto insurance company fights moral hazard is by offering discounts
to owners who install anti-theft devices. A fire insurance policy could
include a rider that says that claims will not be paid in case of
negligence, such as smoking in bed or failure to remove brush from
around the house.
In health insurance, moral hazard means that if you believe that major
expenses are covered, you have less incentive to obtain preventive
care. In order to mitigate moral hazard, the health insurance company
might want to include a rider that requires you to obtain regular
checkups -- and even dental cleanings. It might offer discounts for
non-smokers, people who exercise regularly, etc.
Thus, moral hazard would lead an insurance company in the direction
that Gladwell presumably would favor -- to provide incentives for
preventive care. I think that such incentives would be more widespread
if health insurance contracts were more long-term and were designed by
consumers and insurance companies with less interferences from state
regulators.
Gladwell indicates his confusion on the issue of moral hazard by
offering as another supposed illustration, "If your office gives you
and your co-workers all the free Pepsi you want -- if your employer, in
effect, offers universal Pepsi insurance -- you'll drink more Pepsi
than you would have otherwise."
That is not moral hazard. That is the law of demand.
Insulation vs. Insurance
The real disagreement between many economists and Gladwell concerns the
concept of insulation, not insurance. It concerns the law of demand,
not moral hazard.
Economists support the idea of health insurance. However, many of us
believe that policies that pay for all health care services are not
real health insurance. Insurance should protect people against
catastrophic loss, but it should not insulate them from the cost of all
health care.
Gladwell tries to simultaneously argue two points, which are mutually
contradictory.
1) People have to obtain health care, so that raising the cost to them
will not reduce their demand. Therefore, insulating them from the cost
of treatment does not distort their use of medical services.
2) If people have to pay for their own preventive care, then they will
not obtain sufficient care.
The first statement denies that the health care obeys the law of
demand. The second statement applies the law of demand to health care.
As an economist, I believe that the law of demand applies in health
care. I believe that if patients are insulated from the cost of health
care, then they will err on the side of obtaining unnecessary CT scans,
MRI's, and visits to specialists. They also will "err" on the side of
obtaining useful preventive care.
In the United States, over 85 percent of health care expenses are paid
for by insurance companies or governments. This is one of the highest
rates of insulation in the world (based on OECD health data, but this
particular table is not available on line). Even in Canada, the percent
of health care costs paid out of pocket is slightly higher than in the
United States. Americans' high rate of insulation, combined with the
abundant availability of trained specialists and the latest equipment,
accounts for the high level of health care spending in this country. I
hope that for the most part this is cost-effective, but I believe that
the issue deserves careful study.
Do people need to be insulated from the cost of preventive care in
order to encourage them to get the appropriate amount of check-ups,
dental cleanings, etc.? I believe that health care programs for the
poor, such as Medicaid, ought to be structured to encourage preventive
care. However, I do not believe that the rest of us have to be
insulated from the cost of health care in order to choose to have our
teeth cleaned.
People who want to see everyone in this country protected from
catastrophic loss due to illness or injury should listen to economists.
Not to Malcolm Gladwell.

 tonibaruch) sei OT. Comunista!
Tanto per cambiare, hai sbagliato. Il passo citato raffronta il sistema
sanitario USA con quello del "rest of the industrialized world",
portando de facto la discussione nell'ambito della politica
internazionale.
Raffaele