20 September 2011

Let them die!

And other assorted useless phrases

I noted especially the last paragraph. Which refers back to the same bugaboo I had. "Saving lives" is a meaningless term, particularly in the medical context. Or at least, whatever meaning it has has not a drop of relevance to public policy debates and medical spending vis a vis the state of health care in this country.

Other notes: the bystander problem is a serious framing problem. That is: we let all kinds of people die for various reasons. They weren't born here. They went skiing or swimming somewhere they shouldn't have. They couldn't afford persistent and effective legal representation in a death penalty case and its subsequent sentencing appeals. We tend not to let people die if they don't have health insurance. One basic reason, is that it is entirely possible for people to act in that circumstance. The money part then has to work itself out later. The reason there are problems at that stage, and not before, as I said before, is largely a story about governments.

1) Health insurers don't standardize rules in such a way that most any ordinary hospital or clinic people go to will take it. That's a relative dumb regulation that could be easy enough. What we have instead is a system where if you go to someone they don't cover, you're on your own. Sometimes that seems like a sensible precaution. But not most times because there is so rarely much substantive difference between medical providers at the quality and price levels.

2) Or where there is much disparity at the price level, then another dumb regulation would be requiring price transparency (listing prices for basic services, showing people who have the option the bill/estimate beforehand, etc). This would probably help get rid of a lot of that price indifference problem and insurers wouldn't be so concerned if people went out of network. I prefer dumb regulations if we must have them. They are harder to game.I suspect one reason we don't have regulations like this in effect (the price transparency one is actually in ARRA, and is about the only thing I liked in it) is that people don't actually want money to be associated morally with health care. Unfortunately for them, there's no way to apply it, research it, distribute it, and so on, without associating some amount of cost into the system. It has to be paid by someone somewhere. Most other developed countries get around this "unpleasant feeling" by passing some variety of universal health care delivery or universal insurance and making it seem like health care is thus "free", or at least mostly free and that there is no money involved. This just transfers the problem however. Passing the buck as it were. It should properly be OUR responsibility to decide how much health care we wish and how much we can afford. At a wider level, there is a societal responsibility to care for the sick, and to attend to their sufferings, and this certainly entails some measure of response where people are too poor to attend to their sufferings themselves. But we are abdicating a major responsibility by not learning about and making "informed" decisions on this topic and by refusing to acknowledge that there are monetary and governmental fiscal costs (most people do not associate Medicare with government health care for example, even though it is).

3) The use of health insurance itself is backwards because of government interference. There are rules preventing actual insurance in some states (New York for example). Or much more commonly, conflating pre-paid health care plans with minimal max limits of coverage with actual insurance and then distributing that through employers as a tax write-off. Or also commonly, requiring coverage of all sorts of medical cases. This could be better standardized into the purchase of insurance in a more transparent way (again, for basic medical care that most people would need, things like delivery of child, birth control, screenings for certain cancers after certain ages, etc).

4) The actual price of medical care is distorted by governments yet again by restricting access to the delivery of health care to certain licensed professionals. Dentists don't have to do all the things they do, they can have lesser agents do some of it. Same with doctors. Merely having this expensively trained person in the room shoots up the price considerably, even if they don't do very much more than their nurse or staff could have done. Having access to this expensively trained person if there's a real problem that shows up or is caused by inadequate care, that's eminently reasonable. But paying for doctors and dentists to do things that their secretary could probably do merely from being around and certainly assistants hired on staff to do precisely those things, not so much.

All this means the debate over "let them die" has serious problems. These stories however are far more important to the actual problem and imply very different solutions than simply passing some sort of universal government delivery of health care, or even some sort of universal government delivery of health "insurance" (disclaimer, I do actually favor some use of forced medical savings mandated by governments as in Singapore as well as some public provision of medical assistance, again, as in Singapore. But not for the purchase of largely useless prepaid health care disguised as "insurance" as under current laws and not for the vast majority of Americans. And I really don't favor getting these useless plans through one's employer, or using them as tax write-offs so that generally very wealthy people can effectively get health care for free). It would be useful if we talked instead about these things rather than letting a few wackos get to shout out "let them die!" and make libertarians look more and more like assholes. Because thanks dickhead.

It would also be useful if we dropped the "saving lives" context. The cost of health care is most properly discussed in a cost-benefit framework where its actual utility in terms of improving quality of life and occasionally extending life by healing injury and curing disease all matters a great deal. The question we haven't asked ourselves is how much this is actually worth. I guarantee insurers ask themselves this question, hell even the government asks this question (it ducks giving an answer by not passing a docfix amendment every year for medicare providers). The public does not ask it.

One wonders why the public thinks they're being fucked on this issue. I'd guess they're too busy worrying about "saving lives" and pretending doctors are some sort of wizards.
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