If only health care were all about economics

David Goldhill’s otherwise astute piece in the Atlantic on multiple reasons for our unsustainable, haphazard way of providing health care in the U.S. has one major failing: his anecdotes and analogies assume that health insurance and insurance for material goods should be analogous. But if someone does not have home or car insurance and loses her house or car through an accident or personal negligence, the rest of us do not have to pay for its replacement. And no one will cry foul when a car or home insurance company kicks someone out who makes too many claims, but most of us believe in (and the law supports) the moral obligation to provide emergency care to anyone, regardless of their ability to pay. Fundamentally, the solution to this problem is so hard because it can never be a purely economic one.

There is nothing wrong with the conclusion he reaches that knowing someone else is paying for our health care makes us push for more potentially unnecessary tests and treatment. The inherent problem with his solution to make people responsible for “routine care,” however, seems to ignore the fact that many – if not most – people who are required to pay for physicals, check-ups, and screenings simply will not attend to their health until it becomes a “massive, unpredictable” problem that has to be paid for by insurance. This brings us right back to the problem of hospitals/insurers having to overcharge responsible users to make up for the irresponsible (or currently, uninsured) users, which is exactly where we are right now.

This issue exists right now for people with high-deductible health plans. Just read the comments on this post at the New York Times’ Well blog to see how many people will simply put off any sort of preventative medicine when they have to pay for it themselves. Goldhill suggests vouchers for occasional checkups, but there is a lot more to preventative medicine than a biannual physical – just think of all the disease-preventing maintenance Americans could do on our bodies for practically free, but do not, such as adjusting our diets or getting a minimum amount of exercise. How many people out there are maintaining their cars better than themselves? Our relationship with our health unfortunately is not based on rational economic decisions. No matter how we decide to pay for it, health care decisions will always be clouded by the issue of moral entitlement, because a productive society supports all its members.

Some commenters on the Well blog are also understandably a bit angry at the idea that they will make better health care decisions simply because they have to pay for their care. Would the elimination of insurance for “routine care” include an instant medical degree? If my doctor recommends a $2000 colonoscopy and I decline it due to cost (which almost anyone with no specific risk factors – and many people with the risk factors – will do), how has putting money in the equation made for better health care than when money was not part of it? Goldhill suggests that “professional health-care agents” would fill this gap. But is an average American really going to pay even more money for a paraprofessional to help make their health-care decisions? Think of the divide between the haves and have-nots we would see then. Poor people will still be a lot sicker than rich people, maybe more so than now. (And yes, I am making the assumption that it often, if not usually, isn’t someone’s own fault they are poor; if you assume otherwise you are blind to reality.) The biggest problem with Goldhill’s economic solutions is that he assumes that a patient can be as much of an informed consumer as someone buying a stereo. Sure, I can come close after a huge time investment because I have a doctorate in biology. Most people, however, must rely on their doctors’ expertise, which you simply cannot buy, now matter how many vouchers the government gives you.

He certainly has a point about elective procedures, but how are we to define them? Lasik surgery, which is already not covered by most insurance, is elective, and absolutely should be paid for by the beneficiary – whether or not you do it will not affect anyone else, and if you can’t afford it, glasses will do. Childbirth could be considered elective as well, and Goldhill indeed lumps this as a predictable event that people should pay for themselves. Except, you then run into the problem that a lack of prenatal care can affect you and me, if it results in a child that has health issues big enough that insurance has to kick in. Is your lifetime of little decisions leading to obesity, diabetes, and heat disease going to result in higher cost for your “unexpected” catastrophic care, the way that points on my driver’s license drive up my car insurance premiums? Figure out how to do that, and get back to me.

Many of Goldhill’s ideas make a lot of sense. But beginning his discussion with the presumption that the health care problem can be solved by economic logic undermines his argument. At least, though, it’s a good place to start, because (like every intelligent commentator who doesn’t actually have to try to shepherd reform through congress) he recognizes the need for a fundamental, ground-up change, rather than the useless, minor tweaks that politicians always seem to come up with to appease idealogues.

My prediction? No substantive health care reform until people in the top 30% or so income bracket can no longer get decent insurance. The tragedy of this is that the dead end road we are on will be harder and harder to get off the longer we stay on it, as our President has tried to make understood over the partisan clamor. Because of the current economics of health care, primary care physicians are an endangered species, and research money goes more to developing new devices and treatments that will make someone money, instead of refining our knowledge of who will actually benefit from the ones we have (which will lose people money). Those issues hardly have even come up in discussions of reform, let alone the proposed bills, but in reality they are the most urgent because it will take a decade or more to change our trajectory on them, once we decide we need to. It’s the politicians’ jobs to understand this, and to realize that as our elected representatives they are supposed to be better informed than their constituents, and therefore can make decisions that might be good for us even if we disagree with them. But because politics is also about money, they are continuing to fail us in every way.

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