Wednesday, November 21, 2007

Mankiw versus Krugman

It's beginning to look like Prof. Mankiw is going head to head with Prof. Krugman but they're not really facing off but through blogs and pres articles. Prof. Mankiwlinked to this article in the Washington Post, I assume to illustrate the inconsistencies in Prof. Krugman's position on whether Social Security is in crisis. As usual I can always rely on Mark Thoma to elucidate Prof. Krugman's position. As he explains, Prof. Krugman was talking about Social Security in relation to the Bush tax cuts. Prof. Mankiw is also taking on Prof. Krugman on health care. Prof. Mankiw links to an article by John Ford from UCLA. This sounds a lot like a face off to me (but by letting a third party do the talking, just as Prof. Krugman is letting Mark Thoma do his bit). It's starting to look like a showdown.

N. Gregory Mankiw fired the opening salvo on misinterpreted health care statistics when the New York Times published his op-ed entitled Beyond Those Health Care Numbers. Paul Krugman, also writing for the Times fired back with Health Care Excuses. Although he doesn't explicitly address Mankiw's piece, it seems clear that he intended to correct the record.

Krugman explains that the U.S. spends more per capita on health care than any other country despite lower life expectancies and a very high proportion of uninsured patients. He feels that those who suggest more measured interpretations of these facts are little more than "apologists for the status quo".

Accordingly he offers his take on their misguided statements (which he calls excuses):

Excuse No. 1
He cites the standard 47 million uninsured in this country as exhibit one. People have argued (Mankiw, for example) that this number is misleadingly high because it includes illegal aliens (10-20 million) and that many of the Medicaid-eligible simply don't apply until they get sick. These are both excellent points; but Krugman diminishes the latter (and pointedly ignores the former) by suggesting that "showing up in an emergency room isn't at all the same thing as receiving regular medical care".

This may be true, but to some extent it really represents a matter of choice. Most of these patients are generally healthy and don't attach much value to seeing a doctor when they are well. Well-insured patients often make the same decision. It's hardly the health care system's fault that patients don't take advantage of resources made available to them. Certainly as a nation, we can do a better job of educating citizens about their benefits; yet to do so hardly requires the drastic overhaul Krugman would like to see.

Moreover, Krugman doesn't seem to know that much of preventive medicine falls into the category of dogma and has yet to be validated by well-executed studies. Many of the components of the highly vaunted "annual physical exam" fall into this category.

This is not to say that pap smears, mammograms, cholesterol screening, etc. are not useful (quite the contrary), but that much of "well-patient care" hasn't been shown to lower morbidity or mortality.

Excuse No. 2
People have argued that the reason our life expectancy is lower than Canada's , for example, is because we have much more obesity. As such this factor (which is largely out the hands of health care providers), leads to more disease, more mortality and therefore shorter life expectancy.

Krugman makes the legitimate point that the connection between obesity and mortality is probably overstated. However, to some extent, this is a straw man argument. Few people really believe that obesity is the cause of our reduced life expectancy. What Krugman fails to mention is that trauma, homicide, and teen pregnancy (with its concomitantly higher infant mortality) have a much greater impact.

Life expectancy is calculated by dividing the total number of person-years lived by an imaginary cohort by the size of that cohort. A teenager killed in a gang shooting or a premature infant who dies in her first year of life costs society far more person-years than the septuagenarian who passes quietly away in his sleep. When the young die, a country's life expectancy takes a much bigger hit.

Certainly, it is an indictment of our society that violent death and the high infant mortality associated with teen pregnancy are more common in the U.S. than in other developed countries. The reality is however, that medical care itself cannot be blamed for this nor for the consequent lower life expectancy.

Excuse No. 3
Krugman reports that people assert that health care is better in 2007 than in 1950. He points out the irrelevancy of that position in supporting current policy practices. If some people do make this argument then like Krugman, I don't find it very compelling. However, I don't ever recall anyone seriously raising this straw man point as an entire justification for our system.

Excuse No. 4
Krugman claims that those advocating change short of a government single payer are fear-mongers when they point out inadequacies of other countries in their delivery of health care. He describes Rudy Giuliani's reference to higher prostate cancer mortality in Great Britain compared to the U.S. as "fake numbers". They constitute one more example "in a long, dishonorable tradition of peddling scare stories about the evils of 'government run' health care".

Unfortunately, he offers no other such examples nor does he offer a scintilla of proof that Dr. David Gratzer, who supplied Giuliani with this information was actually wrong.

In a
previous column, Krugman's idea of "proof" takes on this form: "The details are technical, but the bottom line is that a man's chance of dying from prostate cancer is about the same in Britain as it is in America" (my emphasis). Read it. His analysis doesn't get any more penetrating than this.

Contrast this with Gratzer's reasoned response to mainstream media criticism of his methods. Gratzer, like Krugman is a scientist and deserves a cogent, logical argument. Failure to offer that serves no purpose but to obfuscate reality and cheapen the discussion.

In the end, Krugman builds his op-ed to this conclusion: "So now you know how to answer the false claims you'll hear about health care. And believe me, you're going to hear them again, and again, and again."
Perhaps, but only to the extent that people continue to make the original claims without appropriate context.
John S. Ford, MD, MPH is Assistant Professor of Medicine, David Geffen School of Medicine at UCLA. You can find more of his writing

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