Map of life expectancy at birth from Global Education Project.

Saturday, August 30, 2008

Hey Bub, do you know where you are?

This is Stayin' Alive, and of all the blogs, web sites, regular columns, and street corner ranters in all the world, this is the one place where you are guaranteed to have it driven relentlessly like a spike into your brain, that the United States spends too much on medical services and that much of that is for useless or counterproductive procedures and pills and devices. That includes a lot of services that are labeled as preventive. I have even bored my readers half to death with endless mathematical wonkery to support my assault on preventive medicine. Check out the URL for this blog. What do you think it means? Read the mission statement at the top.

So we get the problem, we definitely do. Now Republicans, including the formerly mavericky John McCain, say that the reason we spend too much on stuff we don't really need is that we have insurance. If people had to pay out of pocket, they'd spend less. Voila! Oh sorry, that's in the language of the enemy.

Anyway, here's what you need to do. Remove your head from the anus of Milton Friedman to look around you. What do you see? That wonderful, wacky world called reality, which Dr. Friedman's theories, however wonderful and wacky they may also be, do not describe.

It turns out that in this world, unlike the world of Dr. Friedman's imagination, the United States spends more, far more on medical services than every country which is comparable in terms of wealth. And yet, and yet -- in all those other countries, everybody has health insurance, whereas here, around 45 million do not. And here, of those people who do have insurance, most already pay quite a bit out of pocket, for copays, deductibles, uncovered services, and a share of the premiums; whereas in all those other countries, the people have good, comprehensive insurance and they pay little or nothing out of pocket. And the country which is most like the U.S., where the people do pay substantial co-pays and deductibles -- that would be the land of the yodel and the holey cheese -- has the second highest spending, after the U.S.

Okay, you're a Republican, so I know what your response is already: my ideology doesn't predict that, so to hell with reality, I'm going with my ideology. But for those of you willing to be swayed by facts and logic, read on.

One of the most common fallacies is the ecological fallacy, in essence that means deducing the part from the whole. On the whole, we spend too much. But that doesn't mean that we should just spend less. In fact, some of what we spend is wasted, some is well spent, and on some things, we should probably spend more. But simply throwing costs onto consumers does not achieve wiser spending, in fact it does the opposite. Rationing by cost is not "rationing" at all, it's totally irrational. People who just can't afford it may not get some services that would be wasteful, but they also won't get the ones they need; whereas people will still end up digging deep into their pockets and giving up fresh vegetables to pay for stuff they'd be better off without, because they don't know any better.

This is a huge subject, and I haven't written the book yet. But consider the case of prostate cancer screening. I believe that it is not in the best interest of society to routinely screen all men over a certain age for prostate cancer. That does not mean that no man should ever have examinations or tests for prostate cancer, it means that doctors should not routinely, during office visits for other purposes, do DREs and PSA tests on men who do not have particular risk factors.

And yet many of them do. My doctor is one of them, but I refuse to be screened - which by the way makes him quite unhappy and it's a continual struggle. As it happens, I have a co-pay for an office visit but not for prostate cancer screening specifically. However, I'm quite sure that most men, if their doctor told them they should get a prostate cancer screening because it might save their life (which is true, BTW, but that's insufficient reason), would go ahead and cough up ten or fifteen bucks. I'm very highly unusual in having more and better information about this than my doctor does, and in making what is a highly unusual decision.

The reason my doctor wants to do something that is probably not a good idea is not because "I'm not paying for it, so what the hell." It's because his interests are not aligned with mine. The recommendation for screening was developed by a committee of oncologists -- doctors who make their living treating cancer. My doctor works for a community health center which is owned by a big, fat famous teaching hospital that has all kinds of equipment for treating prostate cancer that cost 8 figures and they need to pay for it. Once somebody is diagnosed with prostate cancer and they get into that labyrinth, even their high deductible, high co-pay insurance will be fully engaged. And guess what - if it wasn't, there would be a howl from the middle class that would make the Chinese revolution look like the College Republicans withholding their student activity fees.

So y'all have the wrong diagnosis. More to come.

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