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  • Malcolm Gladwell Responds

    Posted by Kevin Fleming on September 1st, 2005 (All posts by )

    In response to my previous post, Malcolm Gladwell (it appears, one cannot be too certain) wrote in the comments:

    “Can i suggest that before attacking my article, you first read it? I never once say that I’m in favor of dental insurance. I merely point out that people without general medical coverage can’t afford to pay for preventative dental care. And nor do I saw that the health care system is an efficient free market. I say–quite the opposite–that the amazing thing is that a country that is otherwise committed to economic efficiency would tolerate such a grossly inefficient health care system. Trust me. It’s not that hard to read a 4000 word article.”

    I am certain that Mr. Gladwell is not seriously suggesting I had not read his article, but rather uses this cute device to imply that my interpretation was so far afield from his intent, one could only assume the critic (that is, I) had not in fact read the piece at all.

    But it was indeed read, and several times, mostly in astonishment that such a slightly argued discussion was published in a major magazine. It appeared to contain virtually every canard supporting nationalized health care I have ever seen in print.

    Others have, as I had noted, already critiqued several of its deficits. My main concern was that the initial argument introduced in that article, that:
    “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.”
    was never in fact demonstrated in the article.

    Read on.

    Is it true that people without health insurance have bad teeth because of health care spending?

    First, he repeats the unverified-but-now-canonical statement: “The leading cause of personal bankruptcy in the United States is unpaid medical bills.”

    This Health Affairs article he references was debunked by Gail Heriot in the National Review. It was similarly refuted at Volokh.com by Todd Zywicki here and here.
    In short, a rather expansive if not dishonest definition of ‘bankruptcy due to medical bills’ permitted two longtime leftist authors to introduce a meme that has held firm, despite its weak evidence. David Himmelstein and Steffie Woolhandler, authors of the 2003 Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance and co-founders of Physicians for a National Health Program (1989) have long pushed for nationalized health care. Their studies’ conclusions are both biased and questionable, to put it mildly.

    Even if that claim were true, it does not follow that people do not get their teeth fixed because they spend their income instead on health care. The poor already have health care covered by Medicaid, so he cannot mean that group (one hopes). If he means the uninsured but non-poor, he does not say so, or prove that either. His anecdotes suggest the working poor as well as those on the dole were interviewed, but we must assume their self-reported status of non-insurance is accurate (which is not often the case, as any social worker could confirm). Undoubtedly this group finds dental care too expensive, but why? Their spending choices? Other fixed costs? Preferences? That answer is simply unknown. He is not permitted to assume that because (a) one is uninsured that (b) one’s teeth go uncared-for as a result.

    In the comments, Mr. Gladwell takes issue with other things:
    “I never once say that I’m in favor of dental insurance. I merely point out that people without general medical coverage can’t afford to pay for preventative dental care. “
    Well, no. In fact, he quotes outright from the book:
    “Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow,” Sered and Fernandopulle write, “the immediate answer was ‘my teeth.’ ”
    So he meant national health care, but no dental care? Something else? Then why that quote? And how were we to draw any other conclusion than that a national dental plan was needed?

    And he comments further: “And nor do I saw that the health care system is an efficient free market. I say–quite the opposite….”
    From the New Yorker again (ellipsis mine):
    “A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy … has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.”
    I see. Was he instead saying that we should promote a “ruthless commitment to efficiency” for health care? Is it insufficiently ruthless? Or simply inefficient?

    It appears that his comment (“nor do I sa[y] that the health care system is an efficient free market”) means that it IS a free market, just an inefficient one. I think. Or not; it’s hard to tell. (Unfortunately for us, the fact that nationalized industries are among the most inefficient of economic arrangements, marked by historic failures across the globe, seems to have escaped Mr. Gladwell’s research.)

    The original argument, then, that poor dental care results from a lack of funds caused by a lack of health insurance, remained unexamined and unproven. A long trip through the talking points for Himmelstein’s national health care proposal is not proof thereof, but is itself another uncritiqued proposal (look it up: there has never been a follow-up article in JAMA rebutting her proposal.) A wish list is not evidence.

     

    6 Responses to “Malcolm Gladwell Responds”

    1. malcolm gladwell Says:

      It is reasonable to assume, I think, that if the burden of paying for their own health care were removed for the working poor, they would find it easier to afford preventative health care (among other things). It also seems to be the case (according to the book I reviewed) that many working poor would love for dental care to be included in a comprehensive health care system. I am interested in that because I’m interested in the notion that teeth have become a class marker. But only the most tendentious and wrong-headed readings of my piece could conceive it of it as a piece about the need for universal dental care.

      Now, speaking of wrong headed and tendentious readings, let’s talk about the paragraph that appears to have so completely befuddled you. I quote:

      A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy—a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper—has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.

      That paragraph was read by several layers of editors, proof-readers and copy-editors at the New Yorker, not to mention many hundreds of thousands of readers of the New Yorker, and I have yet to hear from a single person who thinks that it means that i think the health care system is efficent or a free market. That is, except you. The word “other” is implied here, surely, by the structure of the sentence. The point of the sentence is to highlight the incongruity of the fact that we tolerate a health care systems as we have DESPITE our normal committment to efficiency and free markets. I feel like we’re in eight grade here. Is this really so hard? And by the way, a single payer system is not “nationalized” medicine. Medicare is a single payer system, as is Medicaid and the VA. Are those natinalized systems?

    2. z Says:

      Malcom’s comment is barking mad. “Preventative care” for teeth is 1) brushing, 2) flossing, 3) not eating sugar. If people don’t do this it is not because they are poor nor because they are uninsured.

    3. Kevin F Says:

      Thank you to Mr. Gladwell for the reply, and I apologize if my writing is less than clear.

      To be sure, general dental appearance is, and always has been, a sign of several things. Those who look for class lines tend to see a “class marker”. Other explanations, as your article noted, exist, among them poor parenting, mental illness, bad food choices, simple neglect, and lack of access to restorative care.

      I cannot agree that it is “reasonable” to assume “…that if the burden of paying for their own health care were removed for the working poor, they would find it easier to afford preventative health care (among other things).”
      If by this you mean they could then afford preventive dental visits, check out these prices for dental visits:
      Average Charge per Dental Cleaning Visit (2000)
      California $66
      New York $66
      New Jersey $60
      Mississippi $41
      Not cheap, but neither is it prohibitive, compared to other common expenses. Again, those existing at poverty level are uniformly covered by Medicaid, so your argument must be intended for the working poor. But you have in fact made an assumption that the very reason they do not spend $120 a year on tooth cleaning is their medical costs are high enough to dissuade them, a point you did not demonstrate or prove at all. It might be true, it might not. How would one know from your article? You have simply assumed it to be true, but that is not proof by any means.

      The question remains: do the medically uninsured have poorer teeth than those with such insurance? And do these medically uninsured skip routine dental cleaning because their out of pocket medical spending is too high (as opposed to other spending choices)?

      As for the statement “I have yet to hear from a single person who thinks that it means that i think the health care system is efficent or a free market.”
      Then I am truly at a loss. It is clear you find our system inefficient, as you have so stated. But now it appears you are also stating it is not a free market. I agree, it is not (as my previous post detailed).

      And further “… the incongruity of the fact that we tolerate a health care systems as we have DESPITE our normal committment to efficiency and free markets.” OK, so we should not tolerate it. Agreed. I just have a hard time believing you are simultaneously arguing for a free market AND a single payer system, as they are economically opposite conclusions. It makes no sense at all, frankly. So which are you supporting, a more efficient system, the free market, or the even less efficient single payer program? (Single payer is inarguably less efficient than the free market)

      Re: “…a single payer system is not “nationalized” medicine. Medicare is a single payer system, as is Medicaid and the VA. Are those natinalized systems?”
      In advocating the dominance of government allocation over market principles in the organization of the US health system, a single payer system is by definition a socialist endeavor. You are correct in stating that businesses owned outright by the country are ‘nationalized’, but economically there is little difference when a single payer exists as a monopoly purchaser, dictating price, volume, level of service, and choice. It is a false or useless distinction; effectively they are identical in being socialist, and anti-free market. The VA health system, because it is in fact owned and run by the government is a nationalized health care system, but limited to a subpopulation of recipients.

    4. Kevin F Says:

      P.S. It is quite possible, that you and “several layers of editors, proof-readers and copy-editors at the New Yorker, not to mention many hundreds of thousands of readers of the New Yorker” misunderstand some aspects of economics, including the smaller subset of health care economics.

      I am not an economist, as is quite plain to readers here, but I know enough to see that there is little to support your line of reasoning (except perhaps Krugman, which isn’t a defence at all).

      [modified for civility]

    5. Sandy P Says:

      –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.”–

      Britain’s had national dental care for about 60 years, and they’re notorious for their bad teeth, so I don’t think I can agree w/his belief.

      I’m not taking credit for that observation, I think it was Iain Murray on his blog a couple of years ago, since he’s British and all.

    6. Ginny Says:

      I don’t floss with regularity; I have dental bills. I assume that some of the poor are like me – that is, somewhat sloppy about some points of dental hygiene. I would point out, however, that my dentist suggests cleaning once a year except for people like me (and he then eyes me critically) and my peridontist is in his fiftiss and has never had his teeth cleaned. I think he’s a bit of a nut – he spends his whole day with his hands in people’s mouths but contends he can’t stand the thought of someone’s hands in his – so he flosses faithfully and perhaps compulsively.

      I am in no position to criticize anyone for not flossing but I’ve always figured a good percentage of my bills were due to my own slovenliness. This guilt is an attitude we want to encourage. I’m no economist but isn’t that the moral hazard?