Not much has changed.

I just rediscovered something I wrote ten years ago. Other than the anecdote, which is old but could still happen today, it's completely current. 

And btw, why is it ridiculous to say that the most likely use for a firearm stored in the home (other than hunting or target practice) is suicide? It's just a fact. Maybe it's a fact you don't like, but it is, you know, true.

Hed: How to Buy a Miracle Cure



Dek: To make cures like gene therapy possible, the US will have to overturn everything we think we know about Economics 101



In 2014, Charlene Dill, a mother of 3 from Orlando who was estranged from her husband, was trying to make ends meet by selling vacuum cleaners. She had a heart condition for which she needed medication, but when Florida rejected the Affordable Care Act Medicaid expansion, she fell into the gap between Medicaid and subsidized insurance, and was forced to go without.



But some other chronic conditions, such as cystic fibrosis, may one day have a quick fix. This isn’t science fiction; gene therapy may soon make cures for such congenital diseases possible in a single treatment. However, to recoup the high cost of developing treatments for comparatively rare conditions, companies will have to slap on a price tag on the order of a million dollars. Since that’s actually less than the life-long cost of treating cystic fibrosis, one can imagine that an insurer might want to pay for it. But there’s a catch: the insurance company might not recoup the cost because the same insurer won’t necessarily be covering that person in the future.



Though we might not realize it, this dilemma is one we already face. Take some new cancer therapies, which offer only a few weeks of added life for most patients at a cost of more than $100,000. Established therapies such as organ and bone marrow transplants are comparably expensive, as much as a half million dollars, and are often unsuccessful, or leave patients with diminished quality of life. We’re all paying for these treatments, as taxpayers or through our insurance premiums, and most people support these expenditures; people will typically say that “You can’t put a price on human life.”



But we put a price on human life all the time, or nobody would ever ride in an automobile. And we certainly wouldn’t let three million children under five die every year from causes such as malaria, or vaccine preventable diseases that would only cost a few dollars to prevent. (http://www.who.int/mediacentre/factsheets/fs178/en/) And we still let some people like Charlene Dill, in our own country, go without health care entirely.



Paradoxically, though we spend more on health care than any other country on earth, our health status and life expectancy are well down the list. The problem is, we aren’t allocating our resources to get the most out of our health care spending.



We often hear that our country’s “free market” solutions constrain costs, improve quality, and give consumers more control over their own health care. A common argument is that when people are insulated from health care costs by insurance, they don’t shop wisely, as they would for other goods and services.



These claims have superficial appeal, but the truth is that health care doesn’t work anything like the idealized “free market” taught to beginning economics students. Here are some assumptions underlying cartoon Economics 101: All costs and benefits to society are captured in transactions between buyers and sellers
Buyers have perfect information, and know everything about the product and alternatives
Consumers have sovereignty, and consumer choice drives demand

And a grand conclusion: “Free markets” are self-regulating and efficient.



However, these postulates are always false, and so must be any theory based on them. Anyway, the theory does not tell us anything about whether outcomes are fair and just. Yet many politicians and pundits go from the supposed "is" -- that this fictitious "free market" is the natural state of affairs -- to an "ought" -- that whatever outcomes it produces must be the right ones.



Let's start with that first assumption: that all costs and benefits of a transaction affect only the participants. A person who receives health care might indeed benefit. But benefits are conveyed to others as well.



An obvious benefit is communicable disease control. If you cure or prevent an infection in one person, you protect a whole lot of other people. Furthermore, the good health of one may contribute to the prosperity of all. Good health allows people to care for children and disabled relatives, to volunteer – all sorts of good works that aren’t part of the money economy. Some might even feel bad about suffering in general, and enjoy being part of a society that provides basic, compassionate care for everybody. If that doesn’t apply to you, you might at least find it unpleasant to have to step over sick and dying people in the street.



So health care is, in fact, in part a public good. If we had to depend on people to buy only as much as they could afford, it would be under-produced – all of us would be losers.



Next up: as patients, we don’t have perfect information. That’s why we pay doctors – they know more than we do. The result is called “provider-induced demand.” For the most part, people don’t consume health care because they want it, but because a doctor tells them it’s what they need.



Lastly, the need for health care differs radically among consumers. It’s just bad luck if you develop rheumatoid arthritis, but few could pay for the needed medical services out of their paycheck. Meanwhile, for sane people, getting medical interventions is generally unpleasant; we undergo them out of necessity. I might have a lobster dinner because somebody else is paying for it, but I’m not going to have an appendectomy just because it’s free.



Therefore, every other affluent country provides universal health care, and makes it affordable for everyone by some form of progressive financing. But how is it also cheaper for them? There are a few reasons, including negotiated drug prices and lower physician salaries. I’ll leave that aside for now and focus on this aspect: Countries with universal systems allocate resources more cost-effectively than in the U.S.



The United Kingdom has a National Health Service (NHS) that takes care of everybody (although it’s currently underfunded by the Tory government and struggling); it also has the National Institute for Health and Care Excellence, or NICE, which decides what treatments the NHS will provide, in part on a cost/benefit standard. If you’re rich enough, you can buy unapproved treatments, but the taxpayers won’t.



This isn’t the “death panel” concept that was (falsely) claimed by certain politicians to be hidden in the Affordable Care Act. NICE doesn’t review individual cases, and they don’t value one person more than another, although age is sometimes a factor. But so is cold cash. NICE needs especially compelling reasons to approve a treatment that costs more than 30,000 pounds per “Quality Adjusted Life Year,” which is a way of combining length and quality of life in a common currency. The fictive “free market” can’t do that.



NICE decisions are often controversial, but Britons generally accept the necessity of making them. There is ample public participation in NICE decision making, and the basic philosophy and standards are subject to robust public debate.



How will NICE treat gene therapy? Since one treatment will probably be cost saving over a lifetime, it will presumably be approved, in spite of the high cost. However, some cancer therapies with limited benefits might not be.



Now imagine these same treatments being weighed in the US. Treatments like gene therapy may soon be a reality—however, a discussion about their relative value in our country still remains science fiction. And while we were waiting for that discussion, on March 21, 2014, Charlene Dill collapsed and died on a stranger’s floor while trying to sell a vacuum cleaner.