You might be interested in reading this interview at Vox. In it Sean Illing, playing the role Alcibiades without the self-awareness, discusses health care with economist Craig Garthwaite taking the role of Socrates in the dialogue. Armed only with the sword of self-righteousness and the impenetrable armor of ignorance, Mr. Illing opens the conversation with the confrontational and argumentative statement “I think health care is a right. Tell me why I’m wrong.” Dr. Garthwaite responds patiently and temperately. Read the whole thing.
As a matter of public policy health care presents many challenges. I agree with Dr. Garthwaite in that I believe that it is better to treat health care as a benefit rather than a right. I disagree with him in that I believe that while the matter should be approached in full recognition of the implications of eschewing a market-based solution, no market-based solution is acceptable for the simple reason that none of the stakeholders, by which I mean patients, physicians, hospitals, insurance companies, pharmaceutical companies, taxpayers, and politicians (just to name a few), would find an actually free market in health care tolerable. Free markets are like the old joke about “a little bit pregnant”. Either a market is free or it isn’t. When it isn’t a free market some participants gain advantages while others incur penalties.
Unlike negative rights like, say, freedom of speech, when health care is construed as a right, in this case a positive right, you must dilute the notion of right itself out of any real meaning. There are just too many conflicting interests. These include
- Health care as a right.
- Physician autonomy.
- Access to health care.
- The right to property.
- The corpus of common law.
If health care is a right that belongs to the patient, how can physicians be allowed to prescribe courses of treatment? How can taxpayers be protected from excessive demands? How can physicians be assured of earning a living? The list of such questions is nearly endless.
Under the Affordable Care Act a carefully balance but risky solution to the problem of health care was chosen. Unsurprisingly, it has met with substantial resistance and without additional subsidies may collapse of its own weight. Under the Republicans’ version of health care reform yet another strategy would be implemented, no less tenuous or risky and also, unsurprisingly, meeting with substantial resistance.
I think that the preferred strategy should be to treat health care as a benefit and to exert substantial efforts to decreasing the cost of health care. The provision of the vast array of subsidies that we apply to health care should be tied directly to cost reduction. My strategy would have the advantages of being sustainable and as effective practically by definition as possible. I’m accustomed to disappointment.
“Just to name a few”. Heh
I find myself largely in agreement with the conclusion, but truly wonder what tying those subsidies driving cost reduction would look like.
Issues I have with earlier portions of the piece are probably of only academic interest:
Absence of perfect markets should not be disqualifying. I know of no perfect markets with perhaps the exception of modern trading in securities, commodities etc. I don’t think it’s fatal to health care, and pales in comparison to interference in health care markets.
Whether the ACA was balanced seems dubious. But as it swirls around the toilette the predictable, and predicted, financial failure has become real. What a disaster.
I would intentionally set up a non-free market structure. The disabled, the very poor must be dealt with somehow. We do it with food. The issue is always the capping process (and why should we have perfect equality when being gifted a benefit? And when it exists nowhere else in society or history) and in the case of health care, free riders as we don’t turn away people at the ER. But we manage to deal with it with car insurance. And our IT capabilities must offer some sort of tracking capability for abuse and even partial remuneration. But we are way, way past humanitarian considerations when we have successful and relatively well off authors cheering on the ACA to pay for their statins.
But politicians and do gooders being what they are, I, too, am accustomed to disappointment.
Te Veo.
“Imperfect” would really be an understatement. The supply is capped and demand isn’t. 50-70% of spending is subsidized. Localized monopolies are the norm not the exception in many aspects of the sector.
Relative prices are set by commissars; not only are patients unaware of prices, there’s no practical way to determine prices; producers control most of the demand; producers are exempt from ordinary liability. The list of imperfections in the market is so enormous you have to squint to see any sort of market.
I can think of any number of forms that would take. Here’s one, right off the top of my head. Physicians and hospitals would be free to charge whatever they cared to and earn whatever they cared to. Only physicians and hospitals that consented to wage and price controls would be eligible for Medicare or Medicaid reimbursement.
Once states could opt out of the Medicaid expansion and the employer mandate was delayed it upset any balance the ACA had. There are other issues. The penalties for not carrying insurance are too low. Eligibility for subsidies is too expansive. The list goes on.
I guess I wasn’t clear. Today’s market is anything but perfect, or near perfect. It’s a mess. But a “market based solution” need not be perfect to be considered.
And as for balance. It may have had balance on paper, but the defects you cite, IMHO, were inevitable all along. They were latent features.
I’ll have to think about government setting prices. It simply doesn’t sit right. And having owned a couple defense suppliers, I can tell you for a fact that won’t work out well.
The federal government already sets prices. That’s been the case for more than a half century. Now that’s so ingrained it can’t be changed without rebuilding the system from the ground up.
The shortest distance between the points is in limiting how the subsidies can be spent.
“not only are patients unaware of prices, there’s no practical way to determine prices”
Not so true now. Many insurers are making prices available and many states are putting prices online. Individual hospitals are advertising prices. My hospital does (and they are about the same as the Oklahoma place conservatives like to cite, and this is a surgicenter which should cost less) and others are also. However, what we are seeing is that the availability of prices is not changing behavior very much. And, yes, the lower prices would actually result in people saving money if they used the information. People are not as price sensitive, for many reasons, when it comes to health care.
As to your general topic, I see it more as an obligation that we ought to try to fulfill.
Steve
“I’ll have to think about government setting prices.”
Works pretty well everywhere else.
Afore we get all misty eyed about Single Payer, take a look at the systems we do have and how well they can controlled prices, e.g. Indian Health Service, VA, Medicaid, Tricare, Military medicine, USPHS. Even when the profit motive is elided, costs keep rising and its difficult to find folks who will work for the pay provided.
If Americans want quality health care as a right then they should move to Germany. We aren’t capable of administering such a system in our own country.
The young should leave for better things and leave their elders to face the consequences of the mess we’ve made.
“Indian Health Service, VA, Medicaid, Tricare, Military medicine, USPHS.”
Medicaid is much cheaper than Medicare, which is much cheaper than private insurance.
Steve
As I’ve noted before we too frequently dismiss the enormous breadth of our experience with health care. We administer the world’s largest single-payer system (Medicare) and the world’s largest fully socialized national health service (the VA system).