Sunday, November 1, 2009

Healthcare pragmatics

The debate on healthcare reform is practically over and the important points haven't even broken the surface of the public debate. Have we dumbed ourselves down to the point where we can no longer publicly talk through an issue? So it seems. Well, here's an attempt to state the obvious, which will put me ahead of most news media and way ahead of both political parties.

  • Healthcare costs money. Someone has to pay. Different schemes distribute the cost and benefits slightly differently at the margin. But, under any plan from government run single-payer to pure pay-as-you-go, roughly the same people are going to pay. For all the ideological histrionics, you and I, middle-class america, are going to pay no matter what. We'll get middle-class healthcare for ourselves and subsidize healthcare for the poor. This arrangement won't change much whatever reform happens or doesn't happen. The amount of subsidy coming from the executive class healthcare of the rich varies a bit from one scheme to another. Different segments of the poor or working poor are better off under some plans. But, for the most part the poor have no money and the rich have accountants and lawyers, so the middle class has to pay.
  • Healthcare is a public good. For several reasons, I have an interest in your health. For example, if you could refrain from coughing any H1N1 on my lunch, I'd appreciate it. I depend on my coworkers, local businesses, and my community. If those people are out sick, or worse yet, out in public spreading viruses, I suffer. So, am I willing to contribute to your healthcare? A rational person should say, "yes".
  • The benefit of insurance comes from pooling risk. Middle-men cost money. In the case of insurance, we accept the cost of the middle-men because they help us by redistributing risk. If we let insurance companies choose to insure only the healthy, we lose this benefit. Likewise, if we let people wait until they're sick to buy insurance. The employer-based insurance system is stable, despite making the work-force less efficient, because it effectively limits how much either side can game the system. Any system that replaces employer-based groups needs to have the same property. In the current setup, insurance also plays a redistributive role in monetary (rather than risk) terms. For example, if I have a baby, the cost of the birth is subsidized by the non-parents in my company. I subsidize the cost of insuring those with less healthy diets than mine. The young subsidize the old. Overall, it's reasonable for us, as the buyers of insurance, to ask how much this service is costing us and what kind of value we're getting.
  • People respond to incentives. Distorted incentives are all over healthcare. We're well on our way to making primary care medicine like teaching - a profession that you would do only for love because it pays so little. Already many rural areas have shortages of primary care. Also, if you threaten doctors with law suits, you get expensive (uncomfortable, potentially risky) tests. It's called CYA medicine. And, of course, those spending someone else's money tend to spend too much.
  • We're all going to die. Saudi princes with personal physicians, plebeian patients of HMOs, and tin-shack squatters with nothing all share the same fate, in the blink of an eye that is our short lives. Medicine has awesome powers and will gain much more awesome powers in the coming decades. But, the final outcome is not going to change any time soon.
  • Healthcare is not a right. Human rights, in general, mean you have the right to do for yourself unmolested by others. You do not have the right to force others to do for you. Your right to life means that nobody has the right to kill you. It does not mean you have the right to force doctors, nurses and drug companies to take care of you. Healthcare is a limited resource and it should be treated that way.
  • The current American system is very inefficient. Countries pay for healthcare in different ways. All countries struggle with healthcare, but several countries get better outcomes for a lot less than we spend. ...think we could learn something?

A Scotch Drinker on Debt

When historians look back on the current time period, they will notice many things but I think the main thing they will find interesting and worthy of study is our penchant for debt.

A political economy

A recent piece in the Economist ( A new anthology of essays reconsiders Thomas Piketty’s “Capital” , May 20, 2107) ends with these words: &q...