A health care solution that would work but will never happen

[snousle]

The current health care reform flap has got me really down. It seems clear that enough of the American public is so paranoid, stupid, and/or easily led that an even vaguely rational solution is just not going to happen. This irrationality, of course, is promoted by the great mass of parasites that leech off the health care dollar. Do you really think that armies of bureaucrats who shuffle incomprehensibly complicated insurance paperwork around are going to let that paperwork go? No, they are not - the obstruction of useful work is their cash cow.

Any sensible person would recognize that under a rational system that optimizes overall health and maximizes quality-of-life-years, they aren't going to get all the health care they might want, or even all the care they might benefit from. Unfortunately, Americans seem unable to accept this - if there's a million dollar procedure that might save Grandpa, somehow it's an automatic entitlement, and the deniers of that care become "government death panels".

It has occurred to me that what Americans want is not actually health care. They want individual attention and validation of their suffering. They don't want MRIs, they want Marcus Welby holding their hand when they die. Health care reform is ostensibly about health, but its opposition is driven by self-importance and magical thinking.

And you know what? Maybe that's just fine. The solution to giving everyone what they want is really very simple: the deregulation of medicine. The majority of Americans already disbelieve the foundations of biology and have no clue about statistics. They are completely unable to evaluate or appreciate the idea of public health. And more importantly, they are actively hostile to scientific medicine and its implications. So why not abandon science entirely, at least as far as national policy is concerned, and let Americans go to any practitioner they like? There is little reason for human medicine to cost substantially more than veterinary care, which is less than 1/10th the price. The cost problem is the result of regulation and monopoly power. Open up the practice to anyone, give doctors strong limits on their personal liability, and let the free market - a truly free market - do its thing.

Of course, doctors would still want to seek accreditation, and there is no reason the AMA couldn't continue to accredit doctors. I would seek out an AMA physician myself. But if barbers want to go back to doing general surgery, or new-age crystal therapists want to branch out into radiology, I say let them. A new generation of Dr. Feelgoods could dispense opiates at will. And the whole system would be caveat emptor - which is what people seem to want anyway. Lots of people will die for lack of appropriate treatment, or from incompetent treatment, but that will at least be their own choice. Far more people will have access to reasonably effective but vastly less expensive care once the floodgates are opened to real competition. It's not a 100% solution, but the current situation is so awful that it's hard to imagine anything worse.

This will never happen. But it's the solution the US - and only the US - actually needs, this being the only first-world country that lacks the baseline rationality required to implement a more sensible one. Or, perhaps, this is the solution the Americans deserve. It might not improve care, but it would go a very long way towards ending the systematic injustice and intractable conflict over who will pay for it.

Comments

[muckefuck.livejournal.com]

There is little reason for human medicine to cost substantially more than veterinary care, which is less than 1/10th the price. The cost problem is the result of regulation and monopoly power.

I thought one of the major factors driving the differential here was malpractice insurance. No matter how bad a butcher a vet is, juries just aren't likely to approve a multimillion-dollar payout for one dead puss.

[bigredpaul.livejournal.com]

malpractice insurance is barely a dent in the cost of health care.

http://makethemaccountable.com/myth/RisingCostOfMedicalMalpracticeInsurance.htm

[snousle.livejournal.com]

Thanks, I knew that but was lacking a source!

[jawnbc]

That report doesn't say that malpractice insurance isn't becoming incredibly expensive: it's saying that claims aren't driving it: insurance company greed is.

Liability insurance at the institutional/organizational level has skyrocketed. And every medical clinic and hospital has liability insurance...

[snousle.livejournal.com]

This is a factor, but one that is greatly exaggerated by physicians. Malpractice settlements are (I believe) only a few percent of overall health costs. Hence my comment about the need for limits on malpractice cases; disbarring from an accrediting agency is probably a more appropriate punishment than cash rewards for the patient except in the most egregious cases.

I have grave doubts about American notions of liability across the board, but medical liability is a particular problem because medical care is inherently risky and uncertain. For example, exposure to liability may lead physicians to simply refuse to treat high risk patients. I think there are much better ways of dealing with incompetent physicians, though it's never easy; the best method may be through confidential case reviews and physician counselling, which is not punitive but has the advantage of real transparency. Otherwise, truth goes out the window and you never know who the butchers really are.

[fingertrouble.livejournal.com]

Although I love the NHS, some deregulation on access to pharmacies wouldn't go amiss.

It drove me mad that as a long-term asthma sufferer with no known cure (although it's going away) I had to fuck around going to the doctor each time, expensively due to prescription charges (although nothing like the US). I couldn't see why, as someone with a chronic disease (I suspect a lot of the swine flu deaths are those with asthma, although have nothing to back that up as privacy laws means no-one is saying what the 'serious health issues' are in those cases!) I couldn't just go to Pharmacies R Us on the web.

Well I can but it's illegal here. And very dodgy...sigh.

[fingertrouble.livejournal.com]

Yes the weird situation in the US has at least one upside - you get what you pay for, and if you can get that million dollar treatment paid for you can have it.

Here things are better for the poor, but the medical advancement and money to pay for it is less...new treatments tend to come from the US, because the guinea pig pool is larger.

But for those without insurance, and even those with (the amount of LJ posts I read from people in steady jobs saying 'My insurance was declined' etc is surprising - it really doesn't seem to work even for those who can pay!) it's hell, obviously.

[snousle.livejournal.com]

Third-party insurance really is hell. This is why we fought so hard to remain with Kaiser - there is no squabbling over bills, because the plan doesn't involve a separate insurance carrier.

Go read Andrew Sullivan's recent blog entries for hair-raising tales of billing. Hospitals routinely inflate charges by more than 10x for individuals (who have no negotiating power) compared to those for insurers (who have lots). The conflict of interest is totally unsustainable.

[furr-a-bruin.livejournal.com]

As an aside, that really does illustrate the difference between the implementations of Kaiser in your area as opposed to down here. Frankly - I almost think I'd rather go uninsured than have Kaiser down here.

[snousle.livejournal.com]

I've heard that the quality of Kaiser care varies dramatically by location, but are there actually implementation differences?

Both John and I have unfortunately spent time in the Santa Clara location, both the old one and the new one, and found the quality of care to be completely excellent.

[furr-a-bruin.livejournal.com]

I can't honestly say - I've never had any personal contact with the Northern California Kaiser system. My only contact with them here was seeing how they handled a friend of mine some years ago who developed an HIV-related brain tumor, and I was absolutely horrified at what I saw. (And yes, he wound up dying of the tumor with nothing substantive being done about it.)

[muckefuck.livejournal.com]

At the million-dollar level, it hardly matters what kind of system your country of residence has, since you can always fly elsewhere for treatment. Even American millionaires do this when the experimental treatments they want aren't available in the USA.

[bitterlawngnome.livejournal.com]

I dunno, I don't think it's hopeless at all. Remember it was a struggle and a battle to get it implemented here, too. And there was considerable resistance in Britain, iirc. The fact that it's a fight doesn't mean it's pointless.

[snousle.livejournal.com]

I hope you're right, but the current situation has left me feeling very pessimistic. The US is now going through this for, what, the fourth time? With luck, Obama may succeed where Clinton did not, if only because the situation has become so much worse.

[jawnbc]

I would agree with Bill. It really requires a leader with the cojones to take on the insurance industry and the AMA and the cojones to remind most of the newly elected members of his caucus that they wont their seats because of him.

This week's Economist has a nice analysis on why Obama might have blown it by letting Pelosi and others drive this through Congress.

[beastbriskett.livejournal.com]

I initially had hope for substantial reform, but the equivocation of the Blue Dog Dems, and the no price negotiation deal with big pharma has left me with little hope. The best we can hope for now is getting a tepid law passed, and work on strengthening it later.
What scares me is the effectiveness of the Astroturf mobs disrupting town halls. It's impossible to have a discussion of the real issues when that kind of noise is drowning out actual facts.

[jawnbc]

Stop having the town halls? They're not serving their original purpose anyways. In 3 years, who'll care?

[gloeden.livejournal.com]

I believe most Americans do want some sort of systemic insurance.
But, since there is no clear plan in the offing, there is plenty of room for doubt and suspicion.
But I don't fall into the trap that the mainstream media has provided of thinking that because a few people in the pocket of Big Health Insurance are starting shit that most Americans fall for their line.
Next up: Obama wants mandatory abortions for pregnant teens!

[fogbear.livejournal.com]

I like your solution. Give the people the Hobbesian option they want!

[jawnbc]

Because, you know, it's not Americans sue each other entirely too much already or anything. For every knucklehead who wants to disavow themself of any personal culpability, there's 12 who will award him $1M for his troubles.

"government death panels"

[ursine1.livejournal.com]

"if there's a million dollar procedure that might save Grandpa, somehow it's an automatic entitlement, and the deniers of that care become "government death panels"."

As compared to the current system where some insurance clerk denies coverage and gets rewarded for doing so. As others have stated, the rich always have their options.

Spain is like the other countries with public health care, there's both public and private options. As a resident I qualify for public health care, but I carry private insurance (which even covers me in the US when visiting.) But the fact that there is public health care brings down the cost of private insurance because of the competition.

And the government negotiates prices with big pharma.

Chuck, you don't see much criticism of the current dual-system

[hudson-phoenix9.livejournal.com]

I couldn't agree with you more.

[mellowtigger]

I wholeheartedly support the complete deregulation of health care. I got into a lengthy debate on a Friends-locked forum months ago about the wrongness of "right way" medicine (legally performed only by authorized providers).

We won't get an open marketplace of medical solutions. Everyone much prefers using lawyers to blame other people for their problems, instead of taking responsibility for their own decisions and outcomes.