Monday, June 8, 2009

Change we can believe in

Look, this blog isn't supposed to be about healthcare politics. It's supposed to be about healthcare IT. But the intersection between the two is enough that I feel justified in commenting about this blog entry that one of my spies alerted me to.

The Kennedy-Dodd bill would create an individual mandate requiring you to buy a “qualified” health insurance plan, as defined by the government.  If you don’t have “qualified” health insurance for a given month, you will pay a new Federal tax.

And then it continues with a whole lot of analysis, which my spy aptly summarized as:

Take all the things that are off about US healthcare, ignore them, and heave a corporate subsidy into place as a solution.

Well, I think that's a pretty good summary. But that's what they did with the wunch of bankers, so why would you expect anything different in healthcare?

As I said, I had hoped that “Change we can believe in” didn’t mean that kind of change the Health IT Nerd believes in, the kind that I usually see in the healthcare system – namely, just a different kind of stupid. But it looks like that's what we're getting, and what we're going to continue to get. 

I say that because just like every 'reform' proposal is stupid, every criticism has its own built in time bombs. Take, for example, this:

Those who keep themselves healthy would be subsidizing premiums for those with risky or unhealthy behaviors

Just think that one through. Who's going to say, 'well, you know, someone else is going to pay my healthcare costs, so I'll drink myself into the ground'? Look, I know plenty of people who are drinking themselves into the ground, but for most of them, the availability of healthcare sure doesn't factor into that choice (and for the few that it is, it's the fact that they can't get the healthcare they need that means they have no reason not to drink).

And just how do you think any form of healthcare coverage works, from pay-for-yourself-as-you-go through to a fully collectivized economy? The healthy pay for the sick, either by saving up for when they're sick, or entering into some cost sharing scheme known as "insurance" or "tax" whereby their sickness risks are shared to the mutual benefit of all. 

So, the real question here is, do people indulge in risky or unhealthy behaviors because their consequential healthcare is subsidized? Economists believe this sort of stuff as a matter of religion, but real people don't make health decisions like that based on financial considerations. They're far more... emotional. Anyway, it's not as if private insurance schemes are really successful at preventing those with risky or unhealthy behaviors from getting coverage. No, what they're good at is preventing those with risky or unhealthy heritages or histories from getting coverage, which is a whole different kettle of fish (usually called discrimination).

Another typical claim of the opponents of national healthcare services is this:

force patients to accept what a bureaucrat deems “proper” healthcare regardless of what the patient deems proper care

Yes, I can see why people are skeptical about accepting what a government bureaucrat thinks is best. I sure can. After all, the government bureaucrats have no stake in the outcomes either way, what would they care?

So I've got a heaps better idea: instead, we'll let some company decide what proper healthcare you should get, and you can pay them for that instead of relying on the government. After all, they have a stake in the game, which is that the less healthcare you get, the more profit they make. Yep, definitely an all-round better idea! I can see why everyone wants to go for that. (at least, that is, it's a better deal for the people who own the insurance companies, who seem to be the only ones at the table)

Ahh, but wait, the economists will be saying right now, you've missed the key point, which is that it's all about choice. If the consumer has choice, then the insurers will be forced to compete to give us the best deal, and that'll be much better than if the government takes that choice away. 

Well, my response to that is three-fold. 
  1. if you are economist, have you actually heard about transaction costs? (and see also this about free market efficiency)
  2. for the rest of us who live in the real world, does the word "cartel" sound familiar? At least you vote for the government (and round the rest of the world, governments routinely get voted out over the state of their health systems)
  3. yep, choice itself is a good thing, but the mere fact that the government is going to provide healthcare doesn't mean choice goes away. 
Just to reinforce that last point, to my knowledge only Canada prohibits a private healthcare system. Because only Canada has USA as a realistic option for providing the second-tier healthcare system- because everyone needs a two-tier system (everyone important anyway). 

Not that any of this matters anyway - as long as the government is paying, then nothing will change. The costs will keep climbing like a rocket. In addition to the reasons I explained earlier, also because as long as the government is just paying, people (I guess we have to call those beasts running the health insurers that) will be just ripping the government off, and we've just been shown how to do that on a grand scale in a real expert fashion. That's why in other countries, the government is not only payer, it's also provider. 

Anyhow, as long as morons are running around making these kinds of claims, and voters are listening, then there won't be any real progress on healthcare in USA. But it seems to me that these kinds of concerns are built into the very fabric of USA, part of the basic social contract enshrined in the constitution: what's good for me is what's good for everybody. And, therefore, vice versa: what's good for everyone can be judged by whether it's good for me. USA is a country founded on a very different set of principles than other countries. Accordingly, it can't have the kind of healthcare system other countries can have, and comparisons with other countries (such as seen here on The Big Picture) are pointless and misleading. Because USA isn't ever going to achieve the outcomes other countries can - and neither can the other countries achieve what USA does. 

See, if you choose individual wealth over shared wellness, then that's what you're going to get.