Revisiting the Syllogism

I have observed before that when people start talking about health care their I.Q. tends to fall about 15 points. This is from Nicholas Kristof, whose New York Times editorials I often agree with. It’s probably unfair to single him out. The same error in reasoning appears in almost every speech on health care given by Barack Obama and by just about everybody else on the political left as well.

This is almost word for word:

Major Premise: The United States spends twice as much per person on health care as Canada and most European countries and has worse outcomes.
 Minor Premise: Spending twice as much in return for less is bad.
 Conclusion: We should tax the rich and spend even more on health care.

Whoa! Something’s wrong here.


Against the Wind

Whenever I see this type of commentary, I always wonder if there are some implicit assumptions the writer has failed to make clear. Perhaps some unexplained achievement in cost control, quality improvement or increased access are envisioned — even as we spend an extra $1 trillion over the next 10 years.

So let’s be upfront and clear about these issues: [link]

  • If by cost control, you mean someone actually choosing between health care and other uses of money, there is no cost control in the Obama health plan.
  • If by quality improvement, you mean providers competing for patients based on quality — the way producers compete in every other market — there is no quality improvement in the Obama health plan.
  • If by improved access, you mean more people having the choice of doctors and facilities made possible by private health insurance, precisely the opposite will happen under Obama’s plan — as more people move from private plans into public plans that pay below market rates.

In making these observations, I am relying on Obama’s campaign materials and other documents — as explained here.

Comments (20)

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  1. Devon Herrick says:

    But at least some people are rational. Here is Senate Budget Committee Kent Conrad:

    “Some of us have real pause about putting substantially more money into the health-care system when we have already got a bloated system.”

  2. Larry C. says:

    Also the Blue Dog Democrats are starting to make some sense. We can only hope.

  3. Vicki says:

    Do you realize we just went thru a presidential election and no one ever made the simple and obvious point you just made?

  4. Neil H. says:

    If we already spend one out of every five consumption dollars on health care, why do we need to spend even more? What are we going to spend it on?

  5. Robert Blandford says:

    Orszag seems to think that there is money to be mined in the differences between expenditure in the different parts of the country, where there is said to be little differences in outcome. If New York spent the same per/capita as Oregon then we could pick up a trillion or so.

    Effectiveness studies are supposed to show how to accomplish this. I doubt it. How can a third party decide if a CT-scan is needed more in NY than in Oregon?

    What accounts for these differences? Defensive medicine due to tendency to sue? Entitlement attitude of patients?

    Consumer medicine could help a lot, I think. Have the government give tax dollars to citizens for health only. See

  6. miles zaremski says:

    The issue is not spending more, because spending more does NOT produce better health care in this country. The issue is providing ALL Americans with at least some level of basic health care coverage (thus, eliminating the millions uninsured, underinsured and those forced into bankruptcy because medical bills can’t be paid), and if anyone wants more health care they can pay for it out of their private pockets. The solution: establish a public-private partnership, where the government ensures a basic level of care; the private markets still exist because they will be involved at all levels of coverage, and the insurance industry remains satisfied, since they still can stay in business. To this broad outline, add in: (1) pre-existing conditions will not bar coverage; (2) coverage is portable, i.e., across state lines; (3) any reform will include only those immigrants actively seeking citizenship; (4) motivate our doctors AND nurses to stay treating and caring for us; (5) do not discourage those who want to become health care providers; and (6) establish wellness and prevention programs that MOTIVATE us all to stay healthy and fit where we can – – – like, how about a yearly tax credit to remain within certain body weight – – – it is amazing what dollars do to motivate us all.

  7. David R. Weber says:

    What is a basic level of care?

  8. Shannon Cagnina says:

    Wow, John. Your simple logical analysis persuades my daughter, who is an 8th grade Logic student. As the media guideline for an American audience is to aim toward the 8th grade level, I hope your message resonates and travels far and wide. I am afraid many readers glaze over when they see “healthcare reform,” and assume they are wading into arcane public policy dialectic. Your simplicity needs to make headlines. People are finally panicked enough to tune in to spending debates. Keep your clear message coming.
    Thank you.

  9. Steve Robinson says:

    Here’s an even better quote from our friend Henry Aaron —

    “But the United States spends twice as much per person on health care as the average of the ten other richest countries. And our health system is rated as inferior to most of theirs. Patients receive only a little over half of recommended care during typical contacts with doctors or hospitals.”

  10. William Hallman says:

    “Give not that which is holy unto dogs, neither cast ye your pearls before swine…” Matthew 7:6

  11. Uwe E. Reinhardt says:


    Before I respond, tell me this. Did your IQ also drop by 15 points while you were writing this? I may have to adjust the pitch of my comments to the lower level, if it obtained.

  12. Bill Waters says:

    Dear Dr Goodman,
    I sent this letter to the members of Pres. Obama’s health care team with copies of my book, TWO DAYS That Ruined Your Health Care . . .
    I am not waiting to exhale.

  13. Mark Kellen says:

    Excellent summary of our problem. As a physician, I also would like to add anther point to your discussion. Easily 60 – 70% of chronic health conditions pre age 80 are self inflicted, as no one lives forever. I daily tell people in very specific terms how to stay healthy, yet very few actually listen. I also live what i preach, so I am not a 300 pound physician saying do as I say, not as I do. Therefore, I would love to hear Mr. Obama tell us what magic he will use to suddenly convince people to eat healthy, exercise regularly, sleep regularly, maintain healthy relationships, avoid substance abuse, and eliminate promiscuous behaviors.

  14. DoctorSH says:

    Why are physicians sitting back and waiting to be told what will happen to our healthcare system? Physicians are the entry point to the entire system, yet the input of solo private physicians are not being heard.
    More money into the system will only make it worse. We need to find a way to level the playing for field for individuals to obtain insurance, if they choose to purchase it. Individuals need to have some skin in the game if we are ever to bring down costs. The consumer, through their purchasing of care, can bring down costs and spawn major efficiencies, if allowed. The present system has no cost controls by the patient, only by the third party. And where has that led us, but to a system that accounts for 16% of the GDP.

  15. John Goodman says:

    Answer to Uwe: Yes. I most definitely include myself on the IQ deficit when contemplating health policy. I am only today realizing things I should have seen a decade ago — if only I had been more alert.

  16. Frank G. Opelka says:


    I enjoyed your comments at the Brookings ACO panel and wish more physicians could realize the contributions they can make to the value proposition. Great presentation.

    I followed in a later panel that same day to give the specialists perspective of life within an ACO.

  17. Brant Mittler says:

    And while you’re at it, please note that in today’s article about the Massachusetts health care plan, the NY Times did not see fit to quote even one doctor on the progress and outlook for the plan. It’s obvious that doctors- and patients for that matter -don’t count anymore. Health care policy there (and soon everywhere) is being set by policy wonks and politicians and insurance company executives. That’s why very soon your doctor is going to be a nurse at Wal-Mart, highly rated by Zagat.

  18. sam blackman says:

    Mr. Mittler is on the right track. Wal-Marts and fire stations provide the neighborhood clinics/emergency rooms. A 10 week medic training course at the military training facility in San Antonio, Tx provide the first responder/pill dispensers/”nurse”.

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