What Was Wrong With My Last Video

After I posted my last video on wait times for getting a doctor’s appointment in Atlanta, Georgia vs. wait times in Boston, Massachusetts despite the fact that insurance premiums are drastically more expensive in Boston, I received a more mixed response than to any of my other videos.

Fortunately, I have commenters who are much smarter than I am. So I want to take the time to make note of what was wrong with that video.

Things that were wrong:

  • While I didn’t say this, I left the impression that the universal health coverage program in Mass was solely responsible for the expensive premiums. That is not the case. In the study I referenced, premiums were extremely high in Mass, but that was done before universal health coverage (UHC) was implemented. There has not (to my knowledge) been a similarly comprehensive study done since the implementation of UHC, so I cannot say that UHC inevitably leads to higher premiums.
  • Instead of comparing Boston to all the places that don’t have UHC, I picked one place that I liked (I used to live in Atlanta). Atlanta is particularly good on wait times, but it isn’t average. It would have been far better to compare Boston to the rest of the country as a whole.

Things that weren’t wrong, but that people complained about anyway:

  • “The cost of living is higher in Boston. That is what drives the insurance premiums higher”

    This statement was done by people who haven’t actually run the numbers. No one has yet explained to me how a 14% increase in cost of living between Atlanta and Boston explains a 300% increase in health insurance premiums. More importantly, no one has pointed out that doctors in Boston make significantly more than doctors in Atlanta (which would be a far more important data point for investigation).

    Also, it doesn’t explain the difference between Boston and Los Angeles. The Los Angeles cost of living is 22% higher than Boston, but they still have cheaper insurance. And they still have wait times that are half of Boston’s.

To me, the most important point of all of this is the fact that we may not have enough data to say that UHC has actually caused Boston to get a lot worse than it already was, but we do have enough data to say that it certainly hasn’t made things better.

Some people would point out such statistics as “Well, nearly everyone in Massachusetts has health insurance now! It’s been a success!” (In fact, that’s exactly what Mitt Romney does when he says we should, like, totally copy the Massachusetts model.)

But this isn’t a single variable issue, it’s a trade-off issue. If we gave everyone in the country health insurance, but it cost $1 trillion per year, everyone would be against it because the benefit outweighs the cost. Similarly, if we provided everyone with health insurance and kept the cost the same as before, but it took five times as long to get a treatment, most people would still be against it.

It is not self-evident to me that 100% health insurance coverage is a good thing because it depends so heavily on the trade-offs. You could have “100% health insurance coverage” as a matter of statistics, but if that means that it takes three years on a waiting list to get a hip replacement, I’ll stick with the 85% we have today.

And I’ve only mentioned three variables here (cost, insurance coverage and wait times). There is a balance between hundreds of variables that has to be maintained. If you ever listen to the President’s speeches on this issue, you come away with the impression that there will be no trade offs and that it will be cheap premiums, universal coverage and no wait times! And the government will make drugs cheaper.

Also, there will be rainbows and ponies.

Call me a cynic, but that kind of thinking about in the UHC plan strikes me as somewhat naive.

What I would like to see is a comprehensive study of the effects on the Massachusetts plan on the health care system. I don’t know that there are really that many positive effects other than “Look, everyone has health insurance!”


  1. N says:

    I agree with you, it really is all about trade offs. If I needed some surgery I would not like to be put on a 5 year wait list for it.

  2. wranglerdani says:

    “Also, there will be rainbows and ponies. ”

    Best line ever.

  3. Chad Harris says:

    Don’t forget the Tooth Fairy part. When he said it needed to be deficit neutral, he stepped in a huge bear trap. He should have just said, “Hey it will cost a trillion dollars a year but the wait times will be reduced, services will go up and if you do not use the system for that year, you are going to get X number of dollars back on your refund for a total payout of 800 Billion back to the healthy tax payers. Leaving enough to improve the system, but reward good behavior with cash. In other words, run the numbers to make the basket wide enough to cover everyone, raise the payout to the doctors to attract more supply of labor to the market. Then reward people by getting preventative medicine by making that free and no wait times and reward the patient with cash for not using the ER and elective surgery, prescriptions…Cash talks. But he said deficit neutral, that means LOWER THE BENEFITS, PAY PROVIDERS LESS AND WAIT TIMES ARE LONGER. Any 3rd grader can do the math on that. Unless and only unless, you tax the system to the rainbow and pony level then we have a country of well covered poor people that spend all their waking hours trying to figure out how to beat the system. Its stupid. Really enjoy all your stuff by the way. Shocked more people have not found your site, keep it up.

  4. BCC says:

    You seem to presume that healthcare is on the efficient frontier, where any change from the status quo necessarily involves trade-offs.

    I don’t agree- and I think Gawande’s article http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande provides a good example.

  5. politicalmath says:

    I think Gawande’s article, fascinating though it is, is something of a non-sequitur in this context.

    My point in trade-offs wasn’t to suggest that there are no improvements to be made to the health care system that don’t require trade-offs.

    It was only to point out that there are people who seem to point to high health insurance enrollment is an end in itself. I believe that the evidence seems to indicate that government inspired high levels of health insurance enrollment seem to lead to longer waiting times and possibly higher premiums.

    In the specific context of health insurance enrollment, I don’t see that Gawande’s article really points to anything at all. His piece is more about improving health care outcomes… and specifically on improving health care value. It’s a very different topic altogether.

  6. Patrick says:

    First of all, love your blog! I run one too, and I know what you mean about the benefits of having vigilant readers who keep you in check. I had to make some corrections/clarifications to a post the other day thanks to a smart reader.

    Just wanted to say that I’m glad to know that there’s at least one other person out there other than me who is willing to admit and correct when he’s wrong. Keep up the great work!

  7. Travis says:

    You really improve your reputation by publishing and addressing the (smart) critiques provided by your readers. This is an excellent blog that should be required reading for anyone working in Washington – and for any taxpayers who care where their money goes. Keep up the good work!

  8. Seth Potter says:

    Thanks for the blog, its been informative. I appreciate the corrections and the thoroughness and time you put into it. I’d be interested to see the stats compared to wait times in Canada (I live in Ottawa, Ontario). My mother in law is presently dying of cancer. It took 6 months to get an MRI to confirm she had uterine cancer. It took 6 more months and a two week rescheduling delay before she was able to get a historectomy. Of course by that time the cancer had spread. Now, 2 years later, she’s undergone months and months of radiation therapy and chemotherapy. Due to the radiation her kidneys are failing and she still has cancer. She’ll likely die in a few months from either of those, depending on which one kills her faster. It seems to me that wait times will be the ultimate end of my mother-in-law. I guarantee you that if my wife ever gets cancer I’ll be driving her across the border for treatment asap. I’d rather have $100,000 in debt than lose her to my country’s so-called universal health care. Keep in mind, these are typical wait times for MRIs and surgery. Hip replacements are an average of 1 year wait or more. Also, I’m pretty sure Philadeplphia has or had more MRIs than Canada. Don’t quote me on it, but its sad to think…



  9. Freaking awesome. I appreciate your to-the-point posts and ability to acknowledge when you were wrong.

    Keep up the good work.

  10. Moises Lejter says:

    Your video seemed to imply that the lengthy delays in seeing a doctor in MA were somehow a consequence of the mandate for universal health insurance introduced in MA in 2006. But the exact delay was already present in MA in *2004*:

  11. Anna says:

    I love your videos on youtube. I agree with your assessments. It’s good to give visuals to people so they understand. One thing you forgot is premiums will increase, at least double, because we are forced to take insurance (they got us by one ball). The tax increases on drug companies will be thrown into our court in higher prices for drugs, among other tax increases regardless if you make <$250K, <$150k, <60k, get my point (they got us by the other ball). They took money out medicare, like seniors get live without it (including my mom). Masscare (mass health care) was bailed out by feds a few times, so we never saw the true direction it would go in (down the tubes). I am a woman, but if you wondering where my balls went, you can ask Pelosi. I think she has everyone's, because she was sure bold to say 'we all would save money'. Oh, you forgot Tinkerbell and PeterPan and Neverland.
    I would like if you could show a balance sheet of a few typical family scenarios, before and after this new healthcare bill in one of your visualizations.
    A friend of mine, said, well it's too late, it passed, we'll have to see how it works.' I said it's like buying a house and then seeing if you can afford it. Oh that did happen and look want happened to the country, total financial meltdown. We can blame the banks and everyone, but people should have done their math prior to buying their homes. We did and took into acct my husband is losing his job. And we are not rich.