Map of life expectancy at birth from Global Education Project.

Monday, June 16, 2008

Health vs. Medicine

Yes, there is something not quite right about requiring people to purchase health insurance, or at least there might be or there probably is under the probable forms in which such a mandate might be enacted. This is one of those mildly complicated questions about which we have an extremely idiotic public discussion.

If you will note the URL of this blog -- which is the title of today's post -- you will find there a hint that I have a contrarian attitude about so-called "health care," which is a propaganda term intended to mislead. The medical enterprise does not "care" for our "health," for the most part. Rather it makes money by responding in some way to our ill health. And the sicker we are, the more money it takes in. "Caring" may or may not happen along the way, but it's entirely optional.

And here's another of its secrets: it really doesn't contribute all that much to our health and longevity, at least compared to other factors on which we spend much less money and for which there seems to be much less political support or market demand. We're talking seriously about some form of universal "health care," by which we mean pre-paid access to medical services, while we have malnourished kids, we're breathing polluted air, people can't afford to heat their homes, and there's still lead paint in old houses. How is it progressive to force people who are barely getting by to purchase "health" insurance if that's coming out of lunch?

First of all, it isn't. Any universal insurance scheme is completely immoral if it does not include progressive financing that assures it doesn't undermine people's basic material security and quality of life. But there would still seem to be a libertarian objection. Why should I have to pay for "health" insurance under any circumstances, even if I can afford it? Why can't I make that choice for myself?

And here's where we have to put together all the moving parts and make this dynamic picture understandable. There are two main reasons why the libertarian argument fails. Then there is the somewhat subtler argument about why universal prepaid medical services ("health insurance") is an appropriate social investment in spite of our current overspending on the product.

Why the libertarian argument fails: First, the individual decision about whether to purchase health insurance happens in the context of a society that has a pre-existing moral consensus about what should happen when people have severe but treatable illnesses and can't afford to pay for the treatment. That is, we treat them anyway, we don't allow them to expire on the sidewalk in front of the hospital. What generally happens when people become ill or suffer an injury is that they can no longer work, they spend everything they have, and then they become eligible for publicly funded insurance. So we pay for it anyway.

You could adopt a radical libertarian position that we should not, but once you start defending that position, you're going to find that you have difficulty defending libertarianism as a whole. In the interest of keeping this post to a manageable length, I will leave it at that. If anybody wants to have that discussion, I'll do it later. For now, I invite you to think about it.

The second major objection is that there are important public goods that are produced by "health care." These range from the blindingly obvious -- infectious disease control -- to the only slightly more subtle, such as overall work force productivity. Society as a whole suffers when there are a whole lot of sick people around who don't have to be sick, or whose symptoms can be controlled. There's also a cultural cost: it will just make us all feel bad to know that so many of our family members, friends and neighbors are suffering needlessly, and it would no doubt cause immense social unrest. To the extent it happens now, those consequences ensue in a modest way. Imagine if they were multiplied.

There is a justice issue here as well, if you care about it. Albeit there is much we can do to improve our chances for good health, personal choice is only a part of the story. There's the genetic lottery, followed by an evironmental lottery. If I'm hit by a car, I might have been careless crossing the street, or the driver might have run a red light. How does Ron Paul feel about leaving me to die because I can't afford trauma surgery? Finally, I might have dependents, who will become wards of the state, or I might be a dependent in the first place and have no control over my guardian's decision about whether to buy me health insurance. So for all these reasons, the liberty argument against some form of universal medical insurance fails.

And that's why all of the free, democratic countries of the world, other than the United States, have it. The citizens of the United Kingdom, France and Norway, do not feel oppressed by their various systems of universal health care. They do not feel that they have sacrificed their freedom for it. And you can ask them, if you don't believe me: polls consistently show that they are far more satisfied with their health care than we are.

Why the cost argument fails: We spend too much on medical services, no doubt about, anywhere from 50% more to twice as much and up compared with the other wealthy countries, and oh yeah, see above: they're happier with what they get. They are also healthier than we are, and they live longer.

So doesn't extending universal health care mean we'll spend even more than we do now? And how can that be good? (And doesn't that sort of contradict everything I've said above?)

Well, look at those countries with universal health care: they spend less than we do. How do we resolve this paradox? The answer is that they spend more rationally, in other words, they have rationing, which means allocating rationally. This happens in a lot of ways.

First of all, true single payer systems -- such as Canada's -- and true socialized medicine systems, such as in the totalitarian dungeon called Britain, can directly control spending to whatever extent the social consensus will allow. If they calculate that the amount a particular treatment costs for a person of a certain age and condition is not worth the likely benefits, they just won't pay for it. And yes, that means they have to decide that a quality adjusted life year is worth a finite amount of money. Americans seem to have an allergy to that idea. "You can't put a price on human life!" But in fact we do, all the time, when people work in hazardous occupations, when children in Africa die for lack of a $2 mosquito net or clean water, when we decide to defer maintenance on a bridge and take a chance it will collapse, or when we allow working people to go without medical care for that matter. And remember, we're already spending more, but we're getting less, so if they're putting too low a price on human life, they're still getting a better bargain.

Second, they drive a bargain with the drug and medical device companies. The drug companies claim that's going to kill the goose that laid the golden egg, by depriving them of profits to invest in research and development, but the technical term for that is that they're full of crap. They spend more on marketing than they do on R&D, and most of what they spend on R&D is directed toward drugs they can market effectively, not toward meeting the health needs of the population. Medical research is a public good and it should be publicly financed. Uh oh, more creeping socialism. Well of course it already is publicly financed to an extent. We should do it more. The money we save on buying drugs will pay for a lot of NIH-funded research.

Oh yeah, their physicians make less than ours do. But most of those countries have free or highly subsidized access to higher education. Doctors don't come out of medical school with a lot of debt, so they don't need such huge incomes for that reasons. The societies are more egalitarian in general, and offer more public goods and amenities -- such as subsidized higher education for your children, and paying for college is one of the main reasons American families feel pressure to have enormous incomes. Not to mention health insurance and long term care.

But even more telling, the really big bucks for U.S. docs are in high tech specialties. Primary care doctors here are comparatively underpaid, and their incomes are much more comparable to the incomes of physicians in Europe. And it's the primary care doctors who actually contribute the most to population health, and who keep people out of the clutches of those highly paid specialists in the first place. So it's actually the specialists' incomes we need to knock down, and we should pay primary care doctors more, because they work extremely hard, have huge responsibilities, and could do a better job if they carried smaller caseloads.

So here's the problem: the plans that are floating around, including the Obama plan, won't get a handle on costs because they won't fundamentally change the system. I'm willing to support them because they may be a step toward the needed changes, and might make the truly needed reforms more politically feasible. But if costs keep going up, these schemes will ultimately fail, because people just won't be able to afford to pay what they're being asked to pay. And that's asking for big trouble.


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