In the August 29 issue of the New Yorker, Malcolm Gladwell makes so many errors in discussing national health insurance, it’s hard to believe the piece was reviewed by an editor. To fisk it all would mean to delete it.
Arnold Kling does an excellent job junking Gladwell’s misguided notion of “moral hazard” (and the notion that American health care economists are mistakenly “obsessed” with the idea).
And Slate’s Mickey Kaus nicely rips Gladwell’s claim that health care copayments are a bad idea.
But Gladwell begins his piece discussing how the lack of dental care among the poor demonstrates the need for socialized medicine.
“People without health insurance have bad teeth because, if you’re paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury.”
Curiously, he does not follow up and tell you whether this method succeeds in producing better teeth in the UK, Canada, or elsewhere.
In the NHS, dental care is free at the point of use. Almost all dentists in the UK are self-employed and see both NHS and private patients. As of 2002, 22,194 general dental practitioners worked in Great Britain, or 0.386 dentists per 1,000 population. According to 1998 OECD data, this figure is low compared to many other countries. For example, the corresponding figures of are 0.5 for Austria, Canada, Italy and Poland, 0.6 for the Czech Republic and the United States, 0.7 for Belgium and Germany, 0.8 for Norway and 0.9 for Finland. The 1995 figures are 0.5 for Denmark, Hungary, Netherlands and Switzerland, 0.7 for France and 1.0 for Greece and Sweden.
The shortage of dental care in Wales, for example, was described by a local health spokesperson thus: “He likened the queues to register for NHS dentists to “those queues outside food shops in Eastern Europe during the dying days of communism”, adding: “This is an absolute disgrace and this small amount of cash will not solve the problem”
In 2003, when a dentist in Wales announced that it would accept 300 NHS patients, some 600 queued to get on the list. After waiting 11 hours, some 300 were turned away. Money quote: A few hundred miles east, in Essex, a friend has been told that she can only become a national health dental patient “if someone dies”.
Indeed, due to the “continuing lack of access to NHS dentists ” the private dental care market in the UK is large and growing. As a result of low reimbursement, many NHS dentists are converting to private practice. The value of private dentistry grew from £289m in 1994-95 to just under £2bn in 2001-02. According to the New Statesman article above, the “most recent figures show that just 48 per cent of the population in Britain is registered with an NHS dentist. Roughly 1.5 million fewer people have access now than in 1998, and five million fewer than in 1994.”
According to the WHO, inequality in oral health appears to be universal, even in countries with a long tradition of oral health promotion, preventive oral care, outreach dental health services and high utilization rates. In Denmark, for example, socioeconomic status greatly affects the risk of dental caries in young children, despite the fact that they are covered by comprehensive public oral health programs. Multivariate analyses show more frequent dental caries in cases when sugar consumption is high, regardless of payment type.
Finally, dental care is not covered by public health financing in Canada, France, Australia, or Austria.
Gladwell also repeats the common error that the US health care system is fundamentally a free market with its “ruthless commitment to efficiency and performance “. Although more competitive than in many nations, the current US health care system does not operate as a free market. According to OECD data from 2001, health care accounts for 13.9% of GDP, and 44.6% of health care expenditures in the US were paid by public systems such as Medicare, Medicaid, the VA and other military care, public health clinics, and other programs. However, when one includes tax subsidies and public employee benefits, the current tax-financed share of health spending is nearly 60%. Government mandates and regulations add another layer of public expense to health care in the US. From 1970 to 1996, state and federal mandates increased 25-fold, an annual growth rate of 15%. It is estimated that 15 percent of the total increase in health care costs (representing $10 billion in 2001) is attributed to government mandates and regulations. Indeed, the Health Insurance Portability and Accountability Act (HIPAA) alone is expected to add billions of dollars in new compliance costs to the healthcare system. A recent analysis estimates that the 12 most common mandates together increase the cost of insurance by as much as 30%. Moreover, individual state insurance regulations serve to restrict the number of providers able to operate in their States, further limiting competition. Not surprisingly, as many as one in four Americans lack health insurance because of benefit mandates.
No, not a free market at all.
Gladwell’s article is so wide of the mark, its conclusions unsupported by evidence, and beset by internal contradictions, one wonders whether he suffers from “bad rapid cognition” .