Monday, April 18, 2005

What to do about health care?

First, as we considered last time, the problem is fundamentally insoluble. People want more health care than they can afford. The whole country wants more health care than we can afford, we want to live as long as we can, as healthy as we can, and we want somebody else to pay for it. There's no general solution, either we accept that rich people can afford very expensive treatment while poor people can hardly afford any medical care at all, or we take money from rich people to give poor people some small fraction of what they want, or we do something else along those lines. In every case except the first, somebody has to decide who lives and who dies. Nobody wants to be blamed for that decision.

We don't want a single-payer system for medical care. It would probably be considerably cheaper, but it would mean that citizens had no recourse. As it is, if you need expensive care and your insurance doesn't cover it, you have the consolation that you could have chosen some other insurance carrier. You can ask your employer to switch carriers so the next guy will have a better chance. You have gambled and lost, but at least there's the chance that somebody is winning. With a single-payer system there's no such chance, everybody is subject to the same system.

The best we can do is muddle through to some kind of system that doesn't cost too much and that nobody likes but nobody will rebel against.

Meanwhile, it would be nice if we could cut costs. Every medical test or other procedure that was done cheaper at the same quality would allow us to get more medical care for the same money. One obvious way to encourage that is to arrange for the testing to be cheap for new technology that's designed to do the same jobs as older technology but cheaper. Given a choice between spending a tremendous amount of money to test something new that will fill an unmet need at a high price, versus spending the money to test something that can out compete an existing product on price, which would you choose? There's no profit cap on the new thing.

Here is an alternative that I think is worth following up, that would distract some from the insoluble problem. The federal government could put more money into public health. Public health is a legitimate venue for government. Some of it can't be done without government coercion. Most of it can't be done for profit. To the extent that a strong public health program improved the health of the public, our health insurance money would go further.

Various public health initiatives are currently stalled because people don't like them. We could cut unnecessary health costs by reducing tobacco use. But most tobacco addicts are unable to quit, and many don't want to, and the tobacco lobby is quite strong. Fast foods are generally recognised as rather unhealthy, they provide too-large portions of fats and starches and in some cases carcinogens. The fast food corporations tried providing healthier foods in healthier portions but found that past the first fad they didn't sell well. Etc.

Public health diagonostics are potentially cheaper than ever before. The big cost was record-keeping. Start a trial with 1000 people, in 4 years more than half of them would move and would need to be tracked down. But it's far easier now to track people who don't mind being tracked. And there's more insurance etc information available to qualified researchers.

Imagine that the thing went superbly well. Tobacco use was cut to insignificant amounts, and tobacco-related diseases went way down. Obesity went way down along with obesity-related diseases. Simple sugars got used much less, so fewer diabetic symptoms. Environmental carcinogens were strongly cut and so age-adjusted cancer rates dropped 80%. Health care costs would not drop at all. We would spend the same money to get lots of new medical care, things we couldn't afford and don't even know about today. It would be a good thing even though it would not help the health-care crisis at all. We would be healthier, we would live longer and get more of our expensive health care at older ages than currently.

Sunday, April 10, 2005

The medical care problem.

Here is a statement of the problem as I see it.

First, people occasionally have medical emergencies for which there are treatments available that cost far more than they an afford. Currently this happens at least once per lifetime. At least once per lifetime there's a medical emergency that has treatment the person cannot afford, and the patient dies whether the treatment is done or not. Many people have one or more additional major medical treatment that they do survive.

To deal with the problem of rare emergencies that the person cannot afford, we set up health insurance. Healthy people pay for sick people. Provided a small enough minority gets expensive treatment, the system can pay for itself. This made sense. However, it turns out that far too many people have medical emergencies. And the insurance system got switched around from this sensible beginning.

"Systems expand. And as they expand, they encroach." The insurance industry could do collective bargaining. Each large insurance provider could negotiate cheap rates with hospitals etc to reduce its costs. This was a necessary measure. People want more health care than they can pay for, and at regular rates they would bankrupt the insurance industry -- or the industry would have to raise rates beyond what customers could afford. However, a side effect of insurance industry bargaining was that medical fees were increased for people who don't have insurance. If you want to buy a car and an insurance company wants to buy 10,000 cars, who'll get the better rate? If you want to buy healthcare....

Since the insurance companies could get good rates, they expanded into providing payment for routine care too. They could charge you less than you'd pay yourself for routine things, and still make a profit. When the uninsured rates for routine care rose to make up for the insurance discounts, the uninsured couldn't afford routine care either.

All this was not enough to cover rising healthcare costs, though. So the insurance industry did have to raise rates beyond what most individuals could afford. So employers were called in to pay for health insurance. If you have a great job, you can get great health insurance with it. Businesses that are raking in the money can afford to pay high rates for their employees. If you have a mediocre job then your company can afford mediocre health insurance, but it's better than nothing. If anybody is at fault it's you for not deserving a better job. This approach worked for awhile, for a lot of people.

But the rates kept rising, until increasingly businesses could not afford adequate health coveriage for their employees either. This encouraged them to hire part-time or temp workers who didn't get health insurance.

Meanwhile, costs kept rising and more people were uninsured by employers and could not afford insurance themselves. Many of them were voters. So the government stepped in to provide payment. As the costs continued to rise, it became more than the government could afford.

To reduce costs, both insurance companies and government needed "adjustors". They could cut costs by keeping medical experts from prescribing benefits that weren't necessary. How would an insurance adjustor with a 2-year degree, sitting on the 27th floor of an office building in chicago know whether your doctor's treatment was unnecessary for you? She can compare against common practice, compare against what thousands of other doctors are doing in similar circumstances. And except in a philosophical sense it doesn't matter whether she's right -- she controls the payments. She justifies her salary by the money she saves.

This distorts medical practice in subtle ways -- as well as the unsubtle ways. Say your doctor wants a medical test. He prescribes it, and it gets done by technicians in another windowless lab. It used to be those technicians were highly-trained med techs, but as they get priced out of reach more of the work gets done by trainees under the supervision of med techs, or under the supervision of former trainees. How much should your doctor trust those results? Clearly, as far as he can test them. So when he sends the lab two identical samples under different patient names and IDs, and the results are wildly different, that tells him something. When he sends a sample from a patient who ought to test normal and it doesn't, that tells him something. When he sends a sample from a patient that he already knows should test high and it doesn't, that tells him something. Etc. When he gets unacceptable results he can complain and get the lab straightened out or he can test out another lab. But none of this testing is legitimate as far as the insurance adjustor is concerned. Unnecessary tests are wasteful.

Nobody wants to be responsible for deciding not to give people medical care that they need. So we farm out those decisions to anonymous workers who will do the tasks demanded of them, and if they drink themselves into a stupor after work each day to forget the implications, it's nobody's business but their own and their doctors and their insurance adjustors. It's a natural progression to outsource those jobs overseas.

The whole thing comes because we want more healthcare than we can afford. So we look for somebody else to pay for it. First we tried to get the healthy to pay for the sick, but it cost too much for the healthy people to afford. So we got employers to pay, but it was more than they could afford too. So we went to the biggest money source of all, the federal government, and it's more than the government can afford.

Should we decide that your lifespan should depend on your wealth?
"If life was a thing that money could buuuuyyyyy"
"The rich would live, and the poor would diiiieeeee...."

So now what? It isn't like people are being unreasonable. They don't want to die.