Map of life expectancy at birth from Global Education Project.

Thursday, March 15, 2012

Health care reform for dummies

One of my great and enduring frustrations is that the problem of health care organization and financing, and the reasons why 90% of what politicians say about it is baloney, are just too complicated for a sound bite or a bumper sticker. I wrote a long series on this subject a while back. You can start here and then keep clicking the "newer post" button to continue. There are also two essays in the new NEJM, which they have kindly made available to the Great Unwashed. Victor Fuchs discusses the history of the U.S. health economy since 1950, and Harvey Fineberg discusses why our health care non-system is messed up and what he would like to do about it. Both of these assume that you already know and understand what most politicians don't want you to know and understand (assuming they understand anything themselves), so let me lay out what I would say if I were running for office.

Health care isn't like most goods and services. Everybody needs approximately the same amount of food, clothing and shelter, and other basic goods. Beyond that, if you're lucky enough to be able to afford it, you might by more and better stuff and exactly what you buy will be according to your own taste and desires.

Your need for health care, on the other hand, goes up and down throughout your life and is much different from other people's need. That might have something to do with choices you have made (i.e. tobacco or chicken fat) but it also has a whole lot to do with circumstances completely beyond your control, such as your genetic endowment, the family you were born into, where you live, being hit by a bus, and just plain luck, not to mention how old you are. So you may just end up with a need you can't afford to pay for, and that can happen to just about anybody except really, really rich people.

Second, the reason you go to a doctor is because the doctor is an expert about medical care and you are not. You don't know what you need, the doctor has to tell you. If you are lucky you may meet a doctor who explains what's going on in a manner that you can understand, and makes clear the alternatives, and empowers you to make an informed choice in your own best interest. As I say, if you are lucky. But a) that probably won't happen, at least not in 2012, although we're working on it; and b) even so, you still might need something you can't afford.

That's why the whole idea of a hypothetical "free market" putting you in the driver's seat is utter nonsense. The only way to make the world more just is for everybody to have health insurance that makes it affordable for them to get the care they need, should they happen to need it. And making people pay out of pocket till it hurts won't cause them to make the right decisions about their health care because they don't know how. On the other hand, not having to pay isn't going to cause you to get health care you don't need, because medical procedures are generally unpleasant at best. I'm not going to check in for a triple bypass just because my insurance will pay for it. What will make you get health care you don't need, however, is your doctor telling you that you do need it.

Unfortunately, doctors do that a lot, because they get paid to do stuff. It's usually an unconscious bias, but it has been proven again and again that it exists. So we have two problems: people who don't get care they really do need, because they can't afford it; and people who get care they don't need, because there's an economic incentive. There are many other sources of waste and inefficiency in the system, as Fineberg details, but those are the core problems.

Republicans want to control health care costs by just not paying for health care that low and moderate income people can't afford. They're the real death panel. Democrats are all confused and conflicted, in part because hospitals and doctors and drug companies all give them money to keep the gravy train flowing.

What we really need to do is:

1) Make sure everybody has adequate, affordable health insurance. That requires:
a) Regulation of the insurance market so that insurers compete by offering better benefits and friendlier service, instead of by only enrolling the healthiest people. (Single payer national health care would be much better but I'm not dreaming right now.)
b) Providing subsidies for low income people who cannot otherwise afford the above. And by the way, however smug you are about being successful and well-to-do, and however much you think that poor people are moochers and should drift off on an ice floe, if you should happen to get seriously ill you might just find yourself among them. Yes you can.

The affordable care act does that. It can't do it without the individual mandate because otherwise, (a) could not happen.

2) Change the way doctors and hospitals get paid so that they make money by keeping people healthier at lower cost. Yes, both are possible.

The affordable care act makes a modest start in that direction, but doesn't go far enough because of the Death Panel horseshit. If Democratic politicians (and that includes the president who for some reason has no interest in defending his signature achievement in public) would start making an effort to explain this, the world would be better.


Daniel said...

Two thumbs up

Unknown said...

Love you! And though I wish that logical reasoning could be persuasive--even the NYT had an editorial today headlined, "Hospitals are not Hotels,"--people don't seem to want to hear/read anything that might change their minds. Kudos to you for putting this out there.

Anonymous said...

I enjoyed this article. Logic and Common Sense are unfortunately not part of the political vocabulary.

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