Medicine, part 2, in which I admit my error

I rely you people to correct me when I screw up – and I made something of a howler in that last post. Fortunately, Krugman’s actual column today caught it.

I claimed that the current debate is about how best to reduce the size of the medical industry. That’s wrong. What we’re really arguing about is how to reduce the amount of government spending (taxes) going into that industry.

As Krugman puts it:

Before you start yelling about “rationing” and “death panels,” bear in mind that we’re not talking about limits on what health care you’re allowed to buy with your own (or your insurance company’s) money. We’re talking only about what will be paid for with taxpayers’ money. And the last time I looked at it, the Declaration of Independence didn’t declare that we had the right to life, liberty, and the all-expenses-paid pursuit of happiness.

And the point is that choices must be made; one way or another, government spending on health care must be limited.

Unfortunately, we’re going about it wrong. Both parties are trying, somewhat ham-fistedly, to “starve the beast,” which screws up health care for everyone. Republicans appear to want to return some small fraction of our taxes to some subset of the people as tokens that can only be used for private insurance. That sounds idiotic. It also sounds like their old bugaboo “forced redistribution of wealth.” I would rather keep the money and buy insurance, or not, as I see fit. Of course, because most of us are really bad at life – we probably need to provide some baseline social services for the idiots who don’t (or can’t) buy insurance under those circumstances. Otherwise we’ll have poor people dying of easily preventable diseases. Whether or not you perceive a moral requirement to help the less fortunate – it’s embarrassing and bad for the appetite to have to watch them die.

Democrats have a different problem. In the current system, there are lots of incentives leading to “everyone gets the absolute top of the line.” Litigation (less tests = vulnerability to lawsuits), fee for service (more tests = more money), and lack of cost transparency (my $3k MRI doesn’t cost $3k to anyone involved. That’s just a magic number that allows the insurance company to set profits) are the big three. Democrats appear to want to add another layer of bureaucracy to compensate for that moral hazard / profit seeking. I think that the panel that Obama has proposed would do something like deciding what services are “appropriate” for medicare – but then they would use ham fisted financial methods to pay doctors less for providing these services and hope that the market worked its magic. So we layer a flawed system on top of another flawed system.

Of the two, I prefer the latter. It’s an inelegant solution, but at least it acknowledges the really interesting question: what services are we going to provide for people who cannot pay for them. We can’t buy everything for everyone, and at some point we need to have the real debate about when we let grandma die and move on to caring for the newborn in the next room over.

Neither of them can pay. Who’s it gonna be?

I’ll cut to the chase here. The correct answer – assuming that we want to provide some level of health care to people who cannot afford it – comes in two steps:

1) Decide what’s included and what’s not.
2) Hire care providers to implement those services.

I.e: If we want to provide health care – let’s provide health care rather than insurance or vouchers or whatever. You want to cut out the middleman? Cut out the damn middleman! Hire a doctor!

As above, nobody is talking about limits on what health care you’re allowed to buy with your own (or your insurance company’s) money. Seriously. There’s no death panels here unless you’re too dumb (or unlucky) to save some money or buy insurance. You’re expected to look after your own health. You’re expected to be sensible enough to eat healthy and save some money for end of life care. Social services are what we stand up when we acknowledge that most people are neither sensible nor terribly lucky – and when we also acknowledge that we don’t want those people dying preventably on our front porches.

The question of health care costs for those who can pay is a substantially different rant. There’s a simple solution there as well – but it’ll have to wait.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.