The new new deal in Netherlands health insurance by mattsteinglass
July 28, 2009, 8:50 pm
Filed under: Health

It’s come to my attention that if I had moved to the Netherlands from the US this year, rather than 10 years ago, I would have saved less (in percentage terms) on my health insurance premiums. That’s because back in 1999, I was getting a low rate as a then-young healthy person; my premiums were 75% lower in the Netherlands than they had been in the US. But as of 2006, the Netherlands instituted a major systemic reform under which all health insurers must offer everyone in the country exactly the same individual rate for health insurance, regardless of age or prior medical condition. This paper in the magazine Health Affairs by two Dutch health economists explains the details. As of 2007, the average Dutch premium was about 1100 euro, rather than the roughly 600 euro I was paying back in 1999. On the other hand, each Dutch taxpayer (and I was paying taxes) now gets an income-related subsidy from the government to help reimburse health insurance premiums, and that runs up to a 1,464 euro maximum. At the same time, there’s a 7.2% payroll tax to fund the government-run Risk Equalization Fund (more on that below). Employers are required to reimburse that 7.2% fully to employees; but I was self-employed. Of course, in the US, I was paying an equivalent payroll tax for Medicaid and Medicare.

The net impact of all this is kind of hard to figure out. It’s hard to know how much the average 30-year-old would pay for insurance now in the US. The Robert Wood Johnson Foundation says the average cost of an individual policy in the US was $4118 in 2006. But a survey of policies sold through eInsuranceHealth in 2007 showed costs for individual policies ranging from $1200 to $3600 a year. And of course back in ’99 you could get 1.25 euros for your dollar; these days you can get 1.4 dollars for your euro, which makes the idea of moving to Holland to buy health insurance less attractive. And yet, even at today’s exchange rates, and even assuming I could get a decent insurance plan in the US for $2500 a year, I would save almost $1000 a year — 40% — by moving to the Netherlands, even without factoring in whatever government subsidy I got back. (My earnings that first year in Holland were, shall we say, low enough that I feel confident I would have received a substantial subsidy.)


Passing health care reform by mattsteinglass
July 26, 2009, 11:56 am
Filed under: Health

I must confess that I’ve found it increasingly difficult to follow the intricacies of the health care reform debate in the US over the past two months as it’s moved through Congress. (I think I’m for putting Medicare compensation rates in the hands of an independent agency rather than Congress, but since Henry Waxman is against it and the Blue Dogs are for it I feel I may be missing something; in any case it’s clear that without being based in Washington I can’t follow the details closely enough.) But I still think it worthwhile to keep posting occasionally based on my personal experience of European health insurance and health care systems.

The system the US is going to end up with if the current House bill becomes law will look something like the system in the Netherlands: a combination of private insurance plans sometimes linked to one’s employer, a public plan, a mandate that everyone must purchase health insurance, and a mix of public and private health care providers (doctors and hospitals). When I moved from the US to the Netherlands in 1999, I switched from an American HMO to a Dutch health insurance plan. In both cases I was buying insurance as an individual on the private market. My premiums dropped 75%, from somewhere over $2000 a year to a little over $500. During the course of the following year and half, I visited a private-practice primary care doctor three times, which was about three times as often as I visited one in the US. On each occasion I saw the doctor the day I called with no appointment. The cost was somewhere between $25 and $50 per visit, I can’t remember the exact figure. The doctor’s office was a spiffy one located in a gorgeous canal house in the center of Amsterdam.

Since leaving the Netherlands to live in first Togo and now Vietnam, our family health insurance plan has come through private insurers paid by my wife’s jobs. Our current plan is with a company headquartered in the Netherlands and, because my wife is Dutch and works for a Dutch employer, functions within that framework. It initially gave us global coverage everywhere in the world except for two countries where health care costs are so far out of line with the rest of the planet that they demanded a higher premium for coverage there. Those two countries were Switzerland and the United States, which also happen to have the most deregulated and private-sector-oriented health insurance systems in the developed world.

Because we spend several weeks each year in the US and didn’t want to run the risk of bankrupting ourselves in case of an accident, we eventually kicked in the higher premiums to get coverage in the US as well. Our coverage includes full reimbursement for all doctors’ visits and prescription medicine, major dental, the occasional pair of eyeglasses, and various other routine expenses that actually entail rather perverse incentives and perhaps shouldn’t be included in insurance plans if one wants to hold costs down. While on this plan, we have had two children in Dutch hospitals. We have had one very serious medical intervention in which my then 9-month-old son had to be medevac’d from Hanoi to Bangkok for a life-threatening respiratory infection. We have had one other hospital visit and minor operation for him, and various other significant expenses. The cost of our all-embracing gold-plated global coverage is in the range of 6000 euro per year for our family of four — currently about 70% of the average cost of family health insurance in the US. That’s at the historically high level of 1.4 dollars to the euro. If the dollar regains any strength against the euro, the plan will look even cheaper.

At some level, I’m not sure why I care whether the US finally gets a sane health insurance system. If people who live in the US want to waste 5% of their annual income on a full employment program for health insurance company call center workers and pharmaceuticals executives’ golf course memberships, that’s their prerogative. But my passport says “United States of America”, I vote in the State of New York, and to make a long story short, it’s my country and I love it. The insanity of the US’s health insurance system, and the inability of the US’s political system to get a handle on problems caused by corporate interests that run against the public welfare, is wrecking the government’s budget and rendering the country unable to act on issues of global urgency. The US needs that money to fight climate change and to fund development aid in Afghanistan. And more broadly, I don’t like it when people from other countries consider my country stupid, and are right about it. It feels much better having a president who people from other countries respect. It’d be nice if on this issue too, when people from Vietnam asked how health insurance works in the US, I could explain it to them as a positive model, not as a warning of how not to do things.

God: exists in the sense of being reliable click-bait by mattsteinglass
July 25, 2009, 5:49 pm
Filed under: Religion

There really isn’t anything at all interesting to say anymore about atheism vs. religion, and hasn’t been since at least the 1950s, if not the 1850s. So instead I’m going to catalog a few of the more spectacularly uninteresting things people are saying on Andrew Sullivan’s atheism vs. religion thread. From Patrick Appel’s post today, reporting some reader responses:

Lots of atheists broadly reject the existence of any God, but casually embrace concepts such as ‘luck’

Name one.

I have seen people who were losing or had just lost loved ones, and been with them when they heard words from their faith tradition that spoke of all things being in God’s hands, and seen them draw strength from that to deal with their loss.  So, yes, religion has to answer for the crusades.  And atheists have to answer for having no meaningful words of hope to provide in crisis.

Funny, my dad is an atheist, and I’ve always found him to be full of meaningful words of hope in times of crisis. I mean, I think he’s an atheist; I actually don’t know. Put it this way: Both of us are occasionally practicing but non-believing Jews, and in all the conversations we’ve ever had about moral significance in life, never once has any mention been made of the will or existence of any kind of supernatural being.

I’ve always had room in my head for the acceptability of belief in the existence of some kind of deity, as long as one doesn’t believe that deity has any actual physical influence on the really existing material universe, which would just be ridiculous and superstitious. But recently I was taking a shower, and it occurred to me that saying you believe in the existence of something that doesn’t have any material reality or observable consequences is a pretty empty statement. If something has no effects whatsoever, if its absence would have no consequences, what does it mean to say it exists? One might I suppose place it in the category of values or qualities, which are things we believe in that often have no material existence and in a sense no observable consequences. “Nobility,” for instance, is something I believe in but that doesn’t have any material existence, and one could imagine people from other cultures who didn’t even understand what you meant when you said “nobility”; the world they see is no different from the world I see, but they are not wrong when they fail to perceive any such thing as “nobility”, nor am I wrong to perceive it. In a slightly different way, there are people who argue there’s really no such thing as “altruism” on various emotional or philosophical grounds, whereas I believe there is such a thing. This is an interpretive difference about the nature of the world, and one can argue for the existence or non-existence of these qualities without having to believe in a different material reality, much in the same way that I believe there is much that is good in Stanley Kubrick’s Eyes Wide Shut while others deny the existence of anything good in the same movie. But I’m not exactly sure what a belief in God as a value or quality would look like, and I really doubt it would look much like the religious faith practiced by 99% of the people who identify themselves as believers. Another plausible option would be to believe in God as a fictional character, which is I think what a lot of people are doing when they ask themselves “What would Jesus do?”

Being polite to virulent reactionaries by mattsteinglass
July 25, 2009, 12:17 pm
Filed under: race

Conor Friedersdorf is, as I’ve had occasion to experience, polite to a fault. But in this case I mean that literally: he’s being much too polite to this piece of garbage written by one of the National Review’s indistinguishable hackbots, this one apparently labeled “Jack Dunphy”. Dunphy generated the following bit of hatethink:

The real tragedy of [the Gates arrest] episode is that the genuine danger faced by blacks in America is not posed by racist police officers but rather by other blacks, particularly blacks armed with guns and lacking any moral constraints on using them….But such facts just aren’t “box office” for Mr. Gates, who feigns indignation at his arrest but must be inwardly gleeful that his victim ticket has now been punched, courtesy of the Cambridge Police Department.

Friedersdorf points out politely and accurately that there is no reason on earth why Skip Gates, angry at being, on his view, wrongfully arrested on his own property, should suddenly decide to decry the irrelevant issue of the relatively high rate of violence between black Americans. And to stay polite, Friedersdorf pretends not to understand why Dunphy raises the issue.

But obviously Friedersdorf knows why Dunphy raises the issue. French conservatives, criticized for their country’s colonialist record in Africa, will reliably raise the irrelevant issue of poor post-colonial governance by black African regimes; Russian conservatives, criticized for their country’s behavior in Georgia or Chechnya, will raise the irrelevant issues of Georgian mafias or Chechnyan religious fundamentalists; Serbians, criticized for oppressing Kosovar Albanians, will find all sorts of irrelevant things to say about how awful Kosovar Albanians are; Chinese will talk about the barbaric feudalism of pre-invasion Tibet or the ignorance and sexual rapaciousness of Uighurs; Israelis will point to Palestinian factional fighting; and so on. This is a rhetorical strategy for perpetuating ethnic in-group solidarity and dominance and for deflecting any accusations against one’s own group: “Those awful (blacks, Palestinians, Tibetans, Kosovars, Georgians etc.) have only themselves to blame.” It’s a disgusting form of ethnically divisive discourse, and people who engage in it deserve scorn and vilification. In fact, Friedersdorf’s modest and polite bafflement is probably a more effective response, but I’m choosing not to restrain myself.

Paying for kidneys by mattsteinglass
July 24, 2009, 9:48 pm
Filed under: Health

Megan McArdle thinks the legal prohibition against paying for kidneys is indefensible, and challenges anyone to provide a defense of it which does not involve the following:

  1. Huffy declarations that anyone who disagrees with you must be amoral
  2. Appeals to the fact that many other people are also against organ donation
  3. Invoking the infamous “ick” factor involved in selling a body part

I am determined to exercise one of our most important rights on this issue: the right not to have an opinion. But this pretty standard argument from a 2002 article in the New England Journal of Medicine opposing payment for organ donation doesn’t seem to me to involve any of the above shibboleths:

The fundamental truths of our society, of life and liberty, are values that should not have a monetary price. These values are degraded when a poor person feels compelled to risk death for the sole purpose of obtaining monetary payment for a body part.

I don’t consider this to be an overwhelmingly convincing argument in the case of kidney donations, particularly because they don’t involve much risk of death, as Megan points out. Kidney donations are a unique case among organ donations in that they don’t entail much impairment of the donor’s health. Meanwhile, there are a huge and growing number of people with chronic kidney disease, and it seems implausible that the pool of voluntary donors could ever be made large enough through non-financial incentives. There are estimates that thousands of people die every year due to shortage of kidney donors, and this paper argues that kidney transplants save society at least $90,000 per patient over dialysis, not counting the increased quality-adjusted life years for the patient.

But to see why the moral case against paid organ donations isn’t as content-free as Megan paints it, consider this argument for a market system for kidney donations, from Drs. EA and AL Friedman in the journal “Kidney International”:

The case for legalizing kidney purchase hinges on the key premise that individuals are entitled to control of their body parts even to the point of inducing risk of life.

This premise seems to me to be utterly wrong. A society in which rich smokers went around buying poor people’s lungs would be contemptible. When you get to the point where market forces allow some people to take physical possession of vital, irreplaceable parts of other people’s bodies, you are entering the territory of slavery. It’s a territory in which some of the inalienable rights that underpin a liberal democratic society — and the inalienability of one’s possession of one’s own body, as in habeas corpus, is fundamental to all other rights — can disintegrate in the face of inequalities of wealth. That’s the moral basis of the anxiety over paying for organ donations in general, and it is warranted.

In fact, the case for legalizing kidney purchase hinges precisely on the fact that it is not like other organ donations: having just one kidney does not seem awfully risky to the donor’s life. (Further, one can mitigate the risk by placing the few kidney donors who subsequently develop renal disease at the top of the list for transplants, a measure that has been advocated as a non-market way to encourage donations.) As the harm to the donor goes down, tissue donations become more similar to donating blood. Donating blood has long been (slightly) financially compensated without fear of a “slippery slope” to a paid market for, say, eyes. But that’s not to say we should allow people to sell their eyes. It’s to say that perhaps donating blood and donating kidneys are special cases, and should be treated individually rather than as part of a blanket policy towards donating “organs” or “tissue”.

Health care spending on people vs. animals by mattsteinglass
July 20, 2009, 11:42 am
Filed under: Health

[by Matt]

There’s been a lot of attention paid to this chart from AEI’s Andrew Biggs, which conservative-leaning bloggers (Megan McArdleTyler CowenJim ManziArnold Kling, Greg Mankiw) argue show that the reason for rising health care spending is that people have more money to spend on health care:

Conor Clarke wrote a good riposte on this issue. I just have two points to add. First: Do we believe that rising expenditures on veterinary care for pets largely reflect a major increase in quality of life and longevity for pets? Or do we believe they largely reflect vets’ increasing success in convincing pet owners to pay for expensive treatments which they and their pets don’t need? I would tend to think that most expensive health care for poodles falls into the latter category.

I am, of course, not a poodle. But then again — here’s the second point — neither are the people who are making purchasing decisions about health care for poodles. In this sense, one of the points made by conservatives about the above chart — that unlike human health insurance, the vet care market is not complicated by third-party payers (i.e. insurance companies) — is quite wrong. In fact, veterinary care is always paid for by third parties (i.e. pet owners). No poodle has ever had to assess whether the cost of a hip replacement was worth the benefit.

Is China an ideological alternative? by foarp
July 19, 2009, 10:40 pm
Filed under: China, Development


A couple of weeks back Matt wrote a piece asking whether the Chinese political/economic system (i.e., a single-party dictatorship combined with relative economic freedom) should be considered an alternative to liberal democracy and the free market which might appeal to people in other countries in the third world where democratisation has seemingly brought little benefit. I have a few problems with this.

First off the current Chinese political/economic system is one that has been formed pretty much accidentally after the death of Mao. There is no way that any sane person would wish to put their country through the various stages of political oppression, strife, and brainwashing, merely to arrive where China is now. Basically only countries which have already suffered under a single-party system can hope to reproduce China’s current system. The Chinese Communist Party even tacitly admitted this in its recently promulgated “6 Whys” saying (in what is also obviously a classic expression of the Marxist dialectic) that:

“The guiding role of Marxism in China has not been decided by any certain person or by the will of one party, rather it is a choice and circumstance of history”

The whole point of the Chinese system is that it is supposed to be suited to China and not transferable to other places, and that examples from other countries are not applicable to China. The Chinese leadership has long abandoned support for communist rebel groups in other countries using this exact excuse. The current Chinese system is in fact an increasingly-obvious anachronism rather than a new and revolutionary development.

Secondly, whilst it is fashionable to talk of China as almost a former-communist country now under a new system of its own devising, this ignores the way in which communism is both an economic system and a political system. Essentially whilst socialism has been abandoned, Marx-Leninism is still the basis of the political system. China is still run by the ‘democratic centralism’ of the ‘revolutionary vanguard party’, or, in plain speak, a single-party dictatorship. As such there is nothing new about China’s political system, and for this reason it is unlikely to be attractive to people who have not grown up under such a system.

Thirdly, this ignores the essential glue that holds together the Chinese state under circumstances not dissimilar to those which tore Yugoslavia and the USSR apart: nationalism. Firstly under the nationalists and now under the communists China has been subject to the greatest and most successful program of nation-building ever seen. Whilst in India there are reportedly still whole villages in which nobody has ever heard of the country ‘India’, since 1912 the Chinese nation has steadily been built up, with ethnic and regional loyalties largely subsumed into the Chinese identity or race (中华民族). Whilst it is generally believed in China that this identity has existed for thousands of years, it is in fact an invention of nineteenth century theorists like Liang Qichao (梁啟超), intended to replace an imperial system fairly similar to the one that existed in the Austro-Hungarian or Russian empires. This has largely succeeded, and it is only in those areas with ethnic identities so entirely different to that of the majority as to be incompatible (such as Tibet and Xinjiang) that it has failed. The high level of nationalism in China (Australian China-hand Ross Terrill described it as “the nearest thing China has to a national religion”) has allowed the Chinese state to survive pressures which would shatter other countries, as such the Chinese model cannot simply be transplanted to countries with strong regional identities.

A far more important question to ask, therefore, is what system will be adopted once the anachronism of communist rule is finally done away with?