Strong opinions, weakly held

On health care

Good links on the topic of health care are coming fast and furious this week.

New Yorker writer Atul Gawande has written another piece on health care to follow up on his widely read article on disparities in health care expenditures and the reasons for them. In his new article, he lays out his prescription for health care policy.

The article is really a pep talk on the necessity of health care reform. As he points out, there are many health care systems around the world, and all of them are products of the time and circumstances within which they were instituted. Gawande recommends a mandate for universal coverage as they have in Massachusetts combined with greater measures to control costs, which brings me to my next reading recommendation.

Abraham Verghese writes in the Wall Street Journal about high health care costs, and making the argument that doctors being paid on a per-treatment basis is the fundamental problem with the system. Doctors make more when they order more procedures, and they don’t get paid at all for practices that would save money and increase patient health. Have you ever waited two hours to talk to a doctor for a minute or two about something that could have been handled over the phone? It’s because they can bill the insurance company for the office visit but not the phone call. This is how nationalized systems and single-payer systems save money: doctors are paid a salary and the economic incentives for doctors are completely different. This is, I think, the toughest problem we’re going to have to overcome, because with multiple insurers and doctors in private practice, there’s no easy way to change the incentives built into the system.

Nate Silver explains why the government should theoretically be able to provide health insurance in a more economically efficient way than private insurers. Robert Reich explains why the arguments against a public option are wrong.

I don’t have an ideological dog in the fight over health insurance, but what I do know is that the arc of my adult life would have been different if any American could go out and buy health insurance from a company or the government without regard to previous employment or preexisting conditions. I’ve taken jobs in the past for the sole reason that they offered health insurance. I’d ask everyone to think about how different their life would be if they didn’t have to worry about health insurance.


  1. Not having easy access to insurance at a cost comparable to what I would pay at a mid-sized company is a large disincentive to completely depending on a new business. I’ve had that ER visit with the multi-thousand dollar bill with barely explainable line-items and questionable costs.

    With that experience, I shudder thinking about going through the system without any insurance and being at the mercy of what the hospital, physician and equipment technicians charge. It significantly affects my own entreprenureal calculus.

  2. I would say the biggest problem with health care costs is that the person receiving the care doesn’t care what it costs beyond their copay. Unless patients actually care about the cost of the care they receive no plan, government or otherwise, will be able to control costs outside of rationing.

    Let’s not forget how strictly the government controls the supply of health care in this country. For example, in NC the state controls the number of seats in each medical school, the number of doctors licensed, the number of hospital beds, the number of CAT and MRI scanners, etc. When you limit supply, without changing demand, prices will usually increase.

    I really wish this side of the story were getting discussed at all. I agree something needs to be done, but I don’t understand why we everyone is ignoring the dynamic we have today in which if you have insurance you don’t care about the cost of the care you receive?

  3. Jeff – right, because people are so likely to say “hey, gimme a quadruple bypass and throw in an appendectomy while you’re in there since it’s all the same to me!” Sure, I know people who rush to the doctor for splinters, but I know plenty more people who avoid doctors and hospitals to their detriment and neither has anything to do with cost.

    Come on, now. Healthcare is a service, but it’s hardly the same kind of service as a freakin’ day spa and the same kinds of cost sensitivity simply don’t apply. As it is now, it’s the doctors who are incentivized to offer more or higher-cost options, anyway, as opposed to the best care. Not to mention that preventative options are in nobody’s interest but the patient’s.

    I think the issue that is too often overlooked is the one in Rafe’s last paragraph. We are less free as individuals because of the current structure of the healthcare system. It is a heavy drag on innovation, entrepreneurialism, and mobility for individuals and families, and on the economy as a whole.

  4. Medley,

    Why care that one prescription drugs costs $120 at this pharmacy, while a different drugs costs $80 at a different pharmacy? You pay your $30 tier II copay or whatever and go along your merry way.

    Or how about one of the biggest scams, your primary care copay is $30 regardless of whether you see a NP, PA or MD. Of course, the insurance company gets billed the exact same thing.

    Does it matter if you go to this doctor over here for an outpatient surgery or that one on the other side of town? The costs could be hundreds of dollars in difference. We’ll drive all over the place to save $2 on a gallon of milk, and yet we shouldn’t care what our health care is costing?

    I’m mainly talking about routine care and prescription drugs. Obviously, emergency care and life saving care is fairly price insensitive. Then again, I don’t insure my car against oil changes and new tires, I don’t know why we have health insurance for anything other than emergency care/surgery.

  5. Then again, I don’t insure my car against oil changes and new tires, I don’t know why we have health insurance for anything other than emergency care/surgery.

    replacing your tires regularly can save your life; similarly, getting regular check-ups can prevent major disasters and keep costs at every level contained — when the first time a doctor sees a diabetic is to amputate his feet, nobody wins (not least the system paying for a lifetime of nursing care he wouldn’t have needed with regular oversight of his disease).

    beyond that, penny-pinching can be a disaster in unforeseen ways; we in Pennsylavnia saw a kid of 5 or 6 die a few years back from an infected tooth (which became a full-body sepsis) when his mother had to delay his dental care due to other pressing monetary needs. similarly, the vast majority of prenatal screening does nothing, but for the 5% of mothers with problems, it saves millions in emergency care, high-risk deliveries, and damaged children. there are just lots of ways that regular check-ups are more than a convenience. I wish folks making arguments like yours would look at the actual data.

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