Puzzle pieces

To get meaningful, postitive health care reform we're going to have to clear away a lot of brambles. Oh sorry, I guess I've already mixed my metaphors. I was also going to say something about lots of moving parts.

Anyway, our great difficulty is that we've waited so long to fix this mess that it's grown into a tangle that's as difficult to describe as it is to dig up and replant. There's no way to get the necessary concepts onto a bumper sticker and it's very easy to confuse the public. I wish I had the magic simple explanation but I don't. Let me at least see how succinctly I can lay out the pieces, and maybe connect them later.

• Medical services satisfy none of the criteria required for the idealized free markets of faith-based economics to work. Consumer sovereignty is utterly meaningless in health care and can never be achieved. Efficient allocation of resources has little relation to consumer preferences; demand is generated principally by providers, in response to some combination of their financial and other external incentives; the merciless generation of disease and risk by genetics, environment, behavior, and chance; the state of medical knowledge and standards of practice; and the individual provider's grasp of said knowledge and standards.


• People's need for medical services, and just claim upon them, is if anything inversely related to their income and wealth. Elementary considerations of equity require that people have some form of guaranteed health care as needed, to which they contribute financially as they are able. Anyone who disagrees with that should try getting oh, kidney failure or lymphoma. Then come back and argue your case.


• Private markets for insurance actively misallocate resources and work against justice because insurers have strong incentives to charge more to people with greater needs, or to exclude them entirely. Insurers individual incentives are further misaligned with social benefit because they do not expect the people they insure to be their responsibility in the future, therefore they underinvest in preventive measures. Finally, they spend a substantial portion of their income on excluding people, denying benefits, marketing, and executive salaries and profits, none of which have any social benefit whatever.


• In medical care, more is not better. The U.S. spends twice as much on medical care as other wealthy countries, and has the worst health status. It is nonsensical to decry the "rationing" and other putative crimes of the United Kingdom and Canada when their people are healthier than ours and spend something like $4,000 a year per capita less on health care.


• The dysfunctionality of our current system is evident in numerous ways. These include:
  

  * Insufficient numbers of primary care practitioners, insufficient access to primary care, and insufficient time and other resources available to primary care providers for individual patients. About 30% of U.S. physicians practice primary care, compared with 50% in most industrialized nations.
  * Overutilization of expensive and useless or dangerous procedures. We do too much back surgery, too many imaging procedures, and too much on worthless drugs that are heavily marketed, for example.
  * As a tragic subset of the above, too many people die in hospitals attached to machines and attended by stranger technicians, kept alive well past the point of hope or purpose.
  * 45 million Americans have no health care insurance at all; medical costs are the leading cause of bankruptcy in the United States; people end up stuck in jobs they would prefer to leave because they can't afford to lose their health care; people on Medicaid who have the opportunity to work often have to turn it down; and so on.
  

In order to solve these problems, several things have to happen all at once. More on that anon.