Thursday, July 19, 2007

Paul Krugman, an Eighth-Grader at Princeton

Evidently Princeton University thinks enough of the economist Paul Krugman to employ him to teach in their hallowed halls. Evidently the New York Times thinks enough of him to have him write a regular op-ed piece for them. It was with no small amount of amazement, therefore, that I read his recent NYT screed linked above entitled Universal Health Care Opponents Have no Case.

Back in eighth grade I learned from a very wonderful English teacher and debate coach what an ad hominem attack was and that not only was I never to use this gutter tactic when engaged in argument, that I was, in fact, to allow any opponent who used it to speak freely and at length as they would kill their own side. As briefly explained by wikipedia an ad hominem attack... "is most commonly used to refer specifically to the ad hominem abusive, or argumentum ad personam, which consists of criticizing or personally attacking an argument's proponent in an attempt to discredit that argument."

For instance, if I were to begin the rest of this post as follows, you, my friend, would do best to quit reading... "Paul Krugman, "professor" of economics at Princeton, besides looking like a cheap version of Wolfman Jack, is also well known for spitting on babies and stealing pension checks from the elderly while pushing them down flights of stairs. He secretly hates women, puppies, and eskimos and for all the above reasons can not be trusted when he speaks about economics."

Imagine my surprise when this Princeton professor and New York Times columnist began a recent piece on "Universal Health Care" (again, linked above) with the following quote: "OK, it's not news that (President) Bush has no empathy for people less fortunate than himself. But his willful ignorance here is part of a larger picture: by and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada."

This guy is a famous economist? A Princeton professor? What follows in his article is a confusing mish-mash of pseudo statistics and anecdotal evidence (he cites a "recent Business Week article based on statistics and anecdotes") that our health care system is terrible because sometimes both the insured and the uninsured have to wait a long time for short term care. This is the best I can do at untangling this guy's logic. It seems he's comparing apples to oranges and complaining that the safety net which IS the Emergency Department is overcrowded and sometimes overcrowded to the point that that uninsured and insured alike must wait for a while to be seen. That's right, it's called triage, and thanks for the news flash professor.

To the extent that I can understand the rest of his piece it's no more than a pitiful attempt to gin-up an issue for the upcoming election cycle and confuse the public into believing that "universal health care" will solve all our ills. As has been detailed extremely well on Panda Bear, MD's site there's about a million reasons that this is a terrible idea. Having worked as an active duty military physician, a physician in the Veteran's Administration system, and in the private sector I can not imagine a worse idea than growing a government bureaucracy to administer a single-payer system. Do you enjoy going to the DMV? Are you a vet now? Do you get your care through the VA? Ever read about Walter Reed Army Hospital?

Krugman and his ilk, and pretty much anyone who comments on the current health care crisis neglect to mention what I believe to be the key factor to solving the majority of our problems. Patients, all patients, need to be made to be responsible for their health care. It is not a RIGHT it is a RESPONSIBILITY. Now there is ABSOLUTELY NO MONETARY INCENTIVE for patients to make healthy choices in their lives, to actually get a primary physician, to take their medicines as prescribed, or to get that operation they were told to get three years ago because THEY CAN, in fact, go to the Emergency Department 24/7/365 and have someone like me arrange it all for them.

The economics is simple. People have chosen to drop their health insurance OR have chosen not to purchase it because it is expensive (for me and my family of five we pay $460 a month) OR simply can't be bothered to open a phone book and call a doctor. Under EMTALA it doesn't matter, Emergency Physicians, Surgeons, and other specialists must see these patients in the Emergency Department regardless of their ability to pay, regardless of whether they are wanted by the police, regardless of whether they are in the country illegally, and regardless of the fact that many of them were seen just the day before for the exact same problem. And, as you know by now, the government that brought us EMTALA does not pay us anything for these donated services nor does it allow us protection from malpractice suits related to cases we treat under EMTALA.

When we make Emergency Department visits more expensive than a visit to the local pediatrician, internist, of family practitioner (and I mean collecting a small co-pay with EVERY VISIT) then the Emergency Medicine crisis will vanish. And no, what I'm proposing is not heartless, I'm not asking to bankrupt our underprivileged, I'm merely asking that they forego something, make some contribution towards their care, give up their 1800 minutes/month cell phone plan and settle on the 1400 minutes/month plan, give up their visit to the movie theater this week, don't get their nails done... you know, pony up $50 or so. It's amazing how behaviour changes when money is involved. I would think a brilliant economist like Professor Krugman would understand this, but then again he's just an ivy-league douche bag.


  1. Your last paragraph said it all.

  2. This guy is as big a loser as most college professors (history and political science, and sometimes even English-usually less so in the physical sciences). He probably just wants universal health care so the gov't will pay for his surgery to fix his "gender identity" problem. This usually involves a fear of REAL MEN, hence his ad hominem attack on Bush. My dad told me a long time ago "those who can do, those who can't teach", and the "university" of today provides endless examples of this. Someone should take that bottle of Courvoisier he keeps in his purposly messed up desk, made to look like he actually dose something, and stick it up to his already generously wide dentate line. Adicus hominemicus.

  3. How about two triage lines. Those that have been to the ER in last week go in one line, and those that haven't been to the ER in the last 5 years in the other line.

    I don't even know anyone who's been to the ER in the last 5 years.

    Typically it's the poor management of the few people abusing the system.

  4. Seems to me there's been a concerted effort for several decades to infantilize the public. I know many middle-class and upper-middle class folks who tend to vote for politicians who promise to get something free for them, something they can well afford to pay for. It's like -- they've became jealous of the down-and-outs and deadbeats and the truly poor getting services free or cheaply. They don't get it that nothing is 'free', that their taxes go up to pay for 'free', but then they say (!) it'll be the federal government paying! Like the federal government doesn't tax us! Money from Washington is 'free', I kid you not. The politicians know their constituencies, alright.

    When I say the public is being infantilized, I mean Americans are being dis-empowered. They are encouraged to become lowly demanding infants who are stupid, ignorant and helpless and require someone smarter and 'richer' to take care of them -- the government bureaucrats, of course. Oh, and doctors, are really smart and rich. They're part of the grownup bunch that won't give the babies whatever they want, whenever they want it and for free.

    The hook Krugman and others like him know to use is that almost every American gets 'freebies' of some sort from the government and feel entitled to it and will never give it up, even while sneering at others who are getting some other 'freebie'. Politicians know this to be true. It keeps them comfortably in power.

  5. First off, ad hominem has no role in a serious policy debate -- you are right. It does have a long and time-honored role in the realm of politics, which is where Krugman is operating here. Just read George Will, whom I personally detest but also revere as the best and most eloquent crafter of subtle and devastating rhetorical attacks. I don't complain about Will's mischracterization of 'liberal's' motives, nor does it make much sense to complain about Krugman's.

    And you yourself engage in similar rhetorical tricks -- like setting up the strawmen of the DMV, and conflating the potential drawbacks of single-payor with universal healthcare, and the other strawman of the mythical "welfare queens" driving their cadillacs and talking on cellphones who surely must have $50 stached somewhere in their purses.

    Finally, where do you get your insurance through? We pay $890/month per family. I want to get on your plan.

  6. shadowfax,

    again, we must work in completely different EDs as just today we saw, for the fifth time in five days, an uninsured patient who rode the ambulance in for a valium refill and had a nice motorola razor in her purse. here, the queen's are not mythical but commonplace.

    secondly i fail to see how comparing a government directed system of health care (which, as i state, i have personally been a part of in the past) with the efficiencies of another government system, namely the DMV, is a 'straw man' argument.

    also, krugman's piece is, of course, political, so what? he's lying and doesn't even do it well.

    finally, i have blue-cross, blue shield purchased through my local farm bureau.


  7. "Do you get your care through the VA? Ever read about Walter Reed Army Hospital?"

    I'm on your side, but be warned: health care socialists love to swarm on people who associate Walter Reed with the VA, which does not operate it (the DoD does). They will insist that you ("obviously") don't know what you're talking about and therefore the rest of what you have to say is ("obviously") misinformed.


  8. point taken. i've worked military and va and the military facilities i have worked in, all major centers, were excellent. also, the combat hospitals are the best in the world. once, however, you get outside the major centers into the branch clinics the paper-pushers rule and the care suffers.

  9. A friend of my daughter's, with a job, with insurance, was suffering from a small case of bronchitis. She was having a little trouble breathing and had a rather harsh cough. She had called nearly every Primary Care Physician in town in an attempt to get an appointment for her ailment. She was repeatedly referred to the ED. She told them numerous times, "Hey look, I'm not dying, I don't want narcartics, I just need seen to see if I need something to help me feel better." After two hours of phone call after phone call, she found a doctor who would see her. Gives me a whole new look at why ER's are over crowded with nothingness.

  10. my dear M.O.W.
    sadly you are correct in that trying to get an acute appointment with a primary care physician is increasingly hard to do. i think this is multifactorial, but, as was pointed out in the prior post "whither the generalist" i believe that primary care providers have taken themselves out of the game for even the mildly ill. nurse practitioners are filling the void in my area of the country and i think that's fine. the fact is that reimbursement is so low for physicians in primary care that their clinics are routinely packed so they can see their forty patients per day. gone are the days of the in depth physician visit UNLESS you establish care with a good doc and maintain the relationship. even then it's hard to get an appointment and it's easy to default to the E.D. since we may not refuse anyone without running the risk of an EMTALA violation. theoretically, we can turn away the non-emergent cases but since doing this entails risk and we do not have doctors or even mid-level providers in triage we basically see everyone. you can, in fact, always 'just go to the E.D.". i'm fried.

  11. From Krugman's article-"and I suspect that France, which wasn't included in the study, matches Germany's performance."

    Hehehe. Ever heard of WWII?

  12. From a responsible patient.
    You have omitted the fact that it is nearly impossible to find out the cost of any medical procedure.
    Small rant/story
    I was told by my PCP to have a test done. Well I'm not completely convinced that this is useful but if it did not cost too much I'd do it.
    I call the facility. In a difficult to understand accent, the response is "no they have no idea call the insurance company". I call BCBS, they have no idea. I must have the CPT code and ICD9 plus the physicians ID number. Call the facility back and ask for the numbers. No they don't have them. Through research on the web I find the probable procedure I will supposed to have. AH ,but CPT codes are licensed by the AMA. I can not look them up. ICD9 code really should have no meaning in this case since I must have the test to have a diagnosis but knows what the logic of BCBS.

    More web browsing "Google is your friend" I find the CPT code from a web site that obviously the AMA has not sued yet. I discover ICD code from another web site.

    Call facility back, get another person of course, a little social engineering and I get the normal charge they will bill for the procedure. No, they have no idea what the allowable amount is.

    Use web site to find names of principals at facility. Call hospital to get physician ID based on name of big boss.

    Back to BCBS. Different person. I give the CPT code, the name and location of the facility. I given the usual they 80% of the allowable charge. So What's the allowably charge amount. Get nowhere. Hang up and call again different clerk with only a little persuasion I finally get the allowable charge.

    Call facility back just to confirm previous numbers now I am told oh there is a initial consult before the procedure $130 then a follow-up consult $300 after the procedure. Of course who know what I will be charge.

    The Medical system is designed for those who go to a medical establishment, open their wallets and say here keep taking until you're through. Oh there's not enough in here ? Use your credit card..

    I'll be damned if I do that unless I feel I am in severe pain or think I'm dying.

    My wife's PCP Knows how much drugs and medical procedures cost. She tells my wife in advance ball park figures. She know how much she costs. We can plan for the expenses.

    I understand there is no point in knowing for a big ER serving sumdude but for those of us who I think you're complaining about

    What's the matter with you that you don't find out a ballpark figure.

  13. dear mr. hawkins,
    please see my response to this comment posted under ''customer or patient (part deux)''.

  14. Was Paul Krugman the neat guy or the messy guy? I always get them mixed up.

    /lame joke

  15. Happy Sunday the 22nd to you ! Just came by to say hello and see what was new !

  16. Great post. Keep up the good work.

  17. I am researching health care to teach the issue as a topic for argumentation for college freshman English students. I am looking for serious arguments that provide an alternative to Krugman's views, but the Emergency Room alternative is a joke, a bit of straw man fallacy, that is clearly not a worthy rebuttal. When the uninsured baby boom hits the emergency room without insurance, and that appears to be looming ever more closely, the costs to the average American for health care will skyrocket so far beyond what it is now, that it could threaten to wreck our national economy and create a class of elder poor, not to mention bankrupt families across the nation.
    I would like to see alternatives presented, but the Emergency Room is not a viable alternative.

  18. Single payor is frequently confused with government based health care: the VA and the military are not the appropriate analogy. Medicare is. The type of single payor system that Krugman and others advocate is simply one that would eliminate the myriad insurance companies that suck so much money out of the system. Far from perfect, most people agree Medicare has a much lower overhead than any other insurer. So we should be arguing about it at that level, not at the level of VA and military medicine, in both of which, like you, I've worked.

  19. thanks dr schwab for pointing out the distinctions that you do.

    anonymous, would be happy to reply but i'm confused by your post. could you restate your question to me if you have one?

  20. A bit on the NYT editorialists:

    I'm not a NYT basher - it is an excellent paper. The non-news (editorial page), however, is embarassing. Krugman, Thomas Friedman (whose book "The World is Flat" is so self-serving and weakly argued that it is a testament to the power of The Times that it is a best seller), and Maureen Dowd are painful to read. When they try to be cheeky, they come off as adolescent; they try clever, it becomes sneering; criticism becomes unsupported attack.

    For commentary with brains and cheek, read The Economist, Camille Paglia or this blog (talk about self-serving...).

    Out bitches,