Is Health Care Different?
What should determine who gets what in health care?
With respect to other basic needs (food, clothing, shelter, physical safety, etc.) all developed countries have safety net institutions that — often very imperfectly — ensure that the least well-off have some minimal provision. Beyond that, whether people get more or better depends on their income, wealth and personal preferences. No one seriously argues that we should all eat the same kind of food, wear the same kind of clothes or live in identical housing.
But with respect to health care, attitudes are often very different. Here is what the founders of the British National Health Service (NHS) had to say:
Aneurin Bevan, father of the NHS, declared that “everyone should be treated alike in the matter of medical care.” The Beveridge Report, the blueprint for the NHS, promised “a health service providing full preventive and curative treatment of every kind for every citizen without exceptions.” The British Medical Journal predicted in 1942 that the NHS would be “a 100 percent service for 100 percent of the population.” The goal of NHS founders was to eliminate inequalities in health care based on age, sex, occupation, geographical location and—most importantly—income and social class. As Bevan put it, “the essence of a satisfactory health service is that rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged.”
In the modern era, here is Uwe Reinhardt saying much the same thing. Yet as I have written previously, Britain has not only fallen short of this goal, its own internal studies suggest that inequality of access to care in Britain is greater today than when the NHS was started after the end of World War II. So here are three questions to help us think about this problem:
- Is it possible even in principle to make access to health care independent of income, wealth, social status and other patient characteristics?
- Even if it were possible, is it always desirable?
- If it’s neither possible nor always desirable, why do so many people insist on talking about it?
Think of this as being introduced to a socialist high, followed by the real downer of coming back to earth.
Sunday Morning Coming Down
Consider the class of patients who need bypass heart surgery. We know there is a lot of variation in the quality of this surgery among hospitals around the country. So let’s say that we rank them from best to worst — the worst being not so bad that they get closed down, but still well below the best. Depending on who goes where, clearly, some patients will get better care than others.
Is there a way, even in theory, to create equal access to high-quality heart surgery? We could imagine assigning patients to hospitals randomly. Then, no particular patient characteristic (income, education, etc.) would correlate with better outcomes.
In practice, however, many obstacles would arise. Suppose the Cleveland Clinic announced an opening for surgery tomorrow morning at 8:00 a.m. (prepping begins at 6:00 a.m.). I have a better chance of getting there if I own a private plane. Even if commercial air travel allows, I must be able to pay for airfare, a hotel room the night before, and a hotel room for the period of recovery. The higher my income, the more affordable these options are. More generally, travel requirements and the need to be flexible on time favor the affluent.
This may be one reason why there is a major racial gap (and one presumes a socio-economic status gap) with respect to organ transplants in the U.S. — even when the federal government is footing the bill (as in the case of kidneys) and even when there is a legal prohibition against buying organs.
With respect to more mundane medical services, I have no idea how you would even begin to randomize access. Whatever procedure you erect, it will be just one more barrier to care. I have previously argued that whatever rationing system is in place, people with higher socio-economic status will have an advantage in overcoming it.
Public education may help everyone think about health care more clearly. Within a 5-mile radius of downtown Dallas there are probably 160 campuses for the average parent to choose from — all providing free education services. But to be able to choose from the entire gamut you need to be able to afford a house in any neighborhood and perhaps be willing to drive a considerable distance to work. If you can’t afford to buy a home and if you don’t even own an automobile, your children are likely to end up at one of the very worst campuses of the lot.
Even if we could make access equal, would that be desirable? Suppose you were an emergency room physician on triage duty and chance forced you to choose between saving one of these two patients:
(a) A 90-year-old or a 20-year-old
(b) A scientist or a derelict
(c) A brain-damaged child or an otherwise healthy child
(d) A successful entrepreneur or a day laborer
(e) A concert pianist mother or a welfare mother
I’m not going to ask you to reveal what choice you would make. I’m also not going to suggest that the decision would be easy. Triage decisions in which life and death hang in the balance must surely be agonizing. I for one am glad I have never been forced to make one.
The questions I am asking are: Would you make these choices by flipping a coin (thereby giving each patient equal opportunity)? If you could dictate a decision rule to all emergency room doctors, would you insist that others decide by coin flipping? If you were standing behind a Rawlsian veil of ignorance — realizing that you have an equal chance to be born as either of the two opposing patients in each set — would you impose a coin-flipping rule on the world you are about to enter?
While you are pondering all that, let me assure you that almost nowhere in the world are decisions such as these made by a coin toss. And you would be hard-pressed to find an emergency room doctor anywhere who thinks they should be. Not only that, when doctors are forced to make such decisions they tend to make similar decisions — and those decisions are not independent of patient characteristics.
So if equal access to care is not possible and maybe not even desirable, why do people talk about it so much? Here are some theories:
The Collectivism in Disguise Theory. Very few people are egalitarians. But lots of people are collectivists. In a previous Alert, I argued that collectivism is very probably in our genes (though more in some people’s genes than in others). At least one can see how the collectivist gene could have had evolutionary survival value among warring clans thousands of years ago.
Yet there appears to be no appealing case to be made for collectivism as such. When people are asked to sacrifice for the group, the appeal is almost always couched in terms of religious or patriotic sentiment (i.e., church and state). On the other hand, fairness also appears to be in our genes. And if a case can be made that equal access to health care is fair and that equal access implies collective decision-making, then “equal access” can be seen as an appealing way to promote collectivism.
Theory One, then, says that “equal access” rhetoric is a ruse to get people to buy into collectivizing the health care system. Many people have remarked that the debate over ObamaCare does not seem to be a debate about health care at all. (The people engaged in the debate don’t even seem to know anything about health care!) Instead, the real issue appears to be government control. Theory One is consistent with that observation.
The Slippery Slope Theory. It’s possible that the advocates of nationalized health care really don’t think that health care is different. Maybe they would also like to collectivize the meeting of other basic needs as well. After all, the same British government that erected the NHS also arranged for a large percent of the population to live in public housing. Theory Two says that health care is just a convenient and appealing port of entry — from which to slip slide into collective control over other aspects of life.
The Conscience Cleansing Theory. On my many trips to Britain over the years, I have often had this experience: I would find business people or people with an upper-class background who, without any hesitation at all, would express their support of the NHS. But as the conversation wore on it would invariably emerge that the NHS supporter had private health insurance! This is like finding in the United States a vocal advocate of public education who sends his own children to private schools. (That, I understand, also happens a lot.)
Is this hypocrisy? Of course. But the Brit with private insurance may find that kind of hypocrisy easier to live with than being an opponent of the NHS. Theory Three says that people advocate equal access to care in order to assuage the guilt they feel over the fact that their own access is not equal.
The Political Expediency Theory. There is something fundamentally unattractive about the unconstrained pursuit of self-interest in politics. If I say “Vote for me and I’ll rob Peter and pay you $1,000,” chances are you won’t feel great about that. You might even feel guilty. But suppose I instead say, “Vote for me and we will be able to do many great and wonderful things and an unavoidable consequence of all that is that Peter will be worse off and you will be better off by $1,000.” At a minimum, you’re likely to feel better about robbing Peter.
Theory Four says that nobody really believes in equal access to care and nobody expects it to happen but talking about it makes us feel better about the theft we are about to engage in for no other reason than the fact that it is politically expedient and we can get away with it.
Those are my four candidates. Maybe you can think of better ones. Put them in the comments section below.
Excellent post. They type of thing I have come to expect at this blog. Arguments and points of view you don’t find anywhere else.
I agree with Tom. Where else are you going to find a rational discussion of what is happpening and what should happen with respect to access to health care?
Certainly not at any of the other health care blogs that I am aware of.
I have never seen this point made before. But I think you are right. Genuine equality of access to health care — independent of such personal characteristics as wealth, education, social status, etc. — would require a coin flip in triage situations.
John, you struck another bulls eye. When I was an MD in government service, (drafted) we were told RHIP, Rank Has Its Privileges. Can you imagine a public figure or “important person” waiting for an unimportant person? Other systems developed within the politically equal system, a covert barter system. The underclass found chips to bargain with at government expense.
I imagine the government programs would be much more punitive against physicians and hospitals that do not comply. If this health bill is not reversed, then we will have deep penetration into Socialism. I suggest the reader look at the Chapter on “Socialism and History”, which is in Will Durant’s book, “Lessons of History”.
It’s all in there. Those looking for free lunch at the expense of the masses will learn the lessons of history.
Thanks for keeping us alert to developments in illness care. You will never know what “insurance” you have until you make a claim or in the case of health, get sick, really sick.
An excellent post. I would amplify the item about the variety of public schools in Dallas by noting that the only reason that you’d have to sell your house and move to a new neighborhood (thereby generating significant friction costs) in order to send your kids to a better school is that the government enforces small-area geographic monopolies over K-12 education in the name of “equality.” (A superior explanation is that this makes life easier for the educational bureaucrats and unions.)
I had thought that the reason government was able to exert significant control over medical resources was that most people are seldom in need of medical care, so are not well-informed enough to resist the government’s blandishments. This was obvious in the recent health-care debate. Of all the politicians, including President Obama, Secretary Sebelius, Speaker Pelosi, etc., I can probably count on the fingers of one hand the number who had the slightest understanding of health policy. (The above-named politicians are not amongst them.) Of course, there is no reason for a politician to master health policy (or anything else except campaigning and fundraising) because the people would not reward him for doing so.
According to this theory, the reason that Social Security is effectively “voucherized” and Medicare is not is that seniors spend their whole lives paying rent or mortgages, shopping for groceries and other consumer goods, buying cars, etc. So, if the government said that it would cancel Social Security and give seniors the goods and services they need “in kind”, seniors would immediately understand that having the government decide what groceries, for example, they could have, at what price, and having the supermarket send the bill to the Department of Agriculture, would be ridiculous.
Unfortunately, my theory falls down when faced with K-12 education, a process which everyone experienced as a child and most experience as parents, day in and day out, for many years. And nevertheless, we allow the government to monopolize access to it, despite blindingly obvious harmful consequences.
I suppose the answer is that people have a core element of collectivism in them, and they want the government to ensure that nobody gets away with not contributing “fairly.” That is why most people resist allowing voluntary actions to achieve collective results.
Because people value this “social solidarity” the government is able to extract huge economic rents through the exercise of collectivisation (borne as deadweight costs to society) and transfer them to its favorites, e.g. public-sector unions.
In both health care and education, the providers exhibit enormous control over what is done. Afterall, they get the money — not the parent or the child or the patient.
How about Wishful Thinking and Blissful Ignorance?
When they are surveyed, people typically respond that everyone should have equal access to health care. Most experts agree this is partly because respondents are rarely told the cost; or even asked to consider the cost. Even if respondents do consider the cost, it’s not the same as a revealed preference.
Also, under a collectivist system (of which our Medicare, Medicaid and employer markets are pretty good examples), each individual perceives their share of the cost as low because they believe they are not paying the bill (they also under-estimate the cost of their own employer plan).
If consumers knew how much they are actually paying for health care; and if they really understood how medicine would work in a free market, I suspect they would be less collectivist in their view of health care.
Excellent post. I was making notes of points I wanted to make while reading your introduction and you made most of them. One additional point I would make is that health care equality has one additional aspect that food and housing do not have.
That is there is the perception of potential death as a consequence of the lack of health care. That I think plays on many people’s perspectives of what needs to be done. You can follow my posts on health care delivery at http://www.hcbn1.com
Uwe Reinhardt’s table lists levels of disposable income, starting at $20K. Unless his definition of disposable is different from mine, I would have made the same entry at each line: “Up to 100%, as needed.”
The whole debate seems to be based on the false premise that there is only a fixed amount of a commodity called health care which must be rationed among all consumers. In fact the only real scarcity is revenue with which to purchase care. Individuals have limited resources to spend on their own health needs, and society can only afford to spend a limited portion of its GDP on care for the destitute. Spending from affluent individuals doesn’t take resources away from the poor; in fact it’s often the reverse. I hope I don’t need to list the obvious examples.
I like the political expediency theory. It most closely fits the facts.
Excellent post, as others have so readily stated. I will be picky about one analogy you made, however. The comparison between the about 11% of Brits who have “private medical insurance” (PMI) but support the NHS is not really similar to the supporter of public education in the states sending their children to private school, but I am sure the point is getting across. PMI is not a “total replacement” concept, as private school is. PMI is essentially a queue (such a lovely word) jumping device, and while much of the services thus rendered are in fact done “outside the NHS,” all GP services, preliminary diagnostics, follow up care, most chronic care, and even lots of acute care services themselves are still performed by the NHS on persons who happen to have PMI. Ironically, in recent decades, the GPs have grown accustomed to actually asking the patient if they happen to have PMI when a condition of some seriousness arises, something that was never done in the “old days.” Now, the GPs encourage its use in order to take pressure off the NHS resources, as well as get speedier treatment (if necessary) for their primary care patient. At any rate, it isn’t an “all or nothing” replacement as with the school situation. By the way, many of that 11% who have some form of PMI in England get it through their employer, and might very well not buy it as individuals. It has been a pretty steady percentage over the years, though.
You hit the heart of the ethical dilemma many Docs face in the ER.
Having been an emergency physician and having friends that have chosen ER as a career, rarely do you see patients treated differently in a true emergency (except in the rare occasion where patients who have shot a policeman, raped an adolescent, etc. which elicits many of the feelings you may have)…
It’s a place where decisions have to be made clearly and fast.
For non-emergent situations, the case may be different.
Regardless, physician, take your own pulse first.
Today’s Health alert is an excellent example of economic anthropology! One of the best I’ve seen.
An excellent post! I agree with John Baden and Tom.
I also agree with Devon. “Equal access” sounds great. And because health care includes the risk of immediate death, it’s easy to rationalize a single payer system.
I’ve been doing my own reading about collectivism, and I think it is partly genetic. It’s partly learned behavior. It’s also in style right now. Back in prehistoric times, we had to cooperate or else we starved. But society has evolved, and we now have the possibility of being self-sufficient (via earning our own wages through a capitalistic system and trading them for goods/services that satisfy our needs).
This is, of course, horrifying to some people, both because they fear being unable to take care of their own needs and they feel beholden to others who might not make it in the free market.
I think collectivism is, at heart, fear. Fear of the unknown, fear of independence, and fear of being without a “community” to bail you out.
And there’s nothing more frightening than being sick and not knowing what to do. It’s in those times that “equal access” seems so appealing to so many people who fear the unknown and lack the tools to invent better solutions than stealing someone else’s property.
That’s my theory, anyway.
I would pick the 20 year old and the Scientist and the healthy child over the brain damaged but I would pick the welfare mother over the concert pianist because one is raising children and the other has a talent very few people enjoy. These decisions are real and require a strong mind but health insurance requires that we design a system that is rationale. With progressives running the show you get the process of building a national health insurance system. Our Constitution and our individual rights mean very little.
John,
It is interesting that no English conservative or Tory can say the NHS is bad institution. Some people have the attitude that slavery was not such a bad thing. So attitudes are the evolution of thinks and make a difference , like justice or human rights.
To equate the color of shoes with health care seems like you may be lost in your philosophy text book.
Is the NHS getting better or worse over the years. I would imagine it is better by most benchmarks.
Remember NHS was done in 1947 ..when UK was very economically depressed and in some ways to save money and yet cover the entire population– even foreigners. UK asked for loans and we declined to help after WWII.
Regardless of all the critiques, it was a very progress step forward in human history. I am not an expert on this NHS but I did spent time studying GP services and the geriatric service. The geriatric system in UK set standards for geriatric care in USA and around the world for 40 years or so.
They invented it. ! We are still trying to recreate the geriatric models from UK now amd we have not been very successful to create such a quality system in USA. Primary care was weak in some ways, but it has been improved. It must be remembered that their system .. by choice . is cheap.!! 8-10% vs our 17% of GNP.
Stan, it is not my study that said inequality in Britain has gotten worse over time. It is the British government’s own studies that conclude that.
That is the problem with the “Equal Access” argument, it is a lie. Everyone does have Equal Access to medical care. The argument as I read today is a lot of people ,as the Democrats intended, read it as “Free Insurance”. Insurance agencies have been bombarded with calls of people asking how they can get their free insurance.
I just read Richters “Picture of a Socialistic Future”. It really gets John’s point across. Satire at its best by taking an agrument to its logical conclusion. To bad Americans are not taught to do that starting in middle school.
The best line I have read is a bumper sticker my CEO has on his car “If you think medical care is expensive now, wait until it’s free”
Your post is a thought-provoking exploration of the reasons any of us might support, or at least appear to support, some sort of system that equalizes access to health care. The last of your theories seems to come closest to the reason I believe to be most accurate but does not quite go far enough.
I believe your theory should explicitly include political correctness. As you and others have noted, few Americans would reject the proposition that “All Americans should have equal access to health care.” I believe an equally small percentage of the population would affirm publicly the proposition that “Wealth should determine access to health care quality and innovation.” Yet, I am quite confident that all of us would affirm the proposition that “If I or my family needs health care not accessible through public or private insurance and I can afford to pay for it, I should be able to purchase it.”
Personally, I would not affirm the first two of these propositions to make myself feel better. My conscience is not so easily assuaged. I might affirm these propositions because I support them at least in the abstract, or perhaps because I do not want to invite the wrath or scorn of friends or colleagues who would attack me for being realistic (as I discuss further below) and honest with myself (i.e., to be politically correct). All of us would affirm the last of my three propositions because, in truth, we are motivated fundamentally by self-interest (in this case more particularly self-preservation).
There is another reason that I and others might affirm the first two of these propositions that I think bears a bit of elaboration. Many of us, especially those of us who have thought about the issue of health care more deeply than is typical for mass media, might affirm these propositions because we know them to be futile. In other words, we may believe that a legal declaration of the right to equality in health care would be limited by practical constraints such as economics, capitalism, selfishness or limitations on the resources of healt care collectivism enforcement officials.
In considering this possibility, we can refer to past battles in this country over “equality.” The meaning and justification for equality, in the U.S. at least, has evolved and undoubtedly will continue to evolve. Before various amendments to the Constitution and Supreme Court decisions, equality was limited to white men of certain religions. Thankfully, we have evolved our law well beyond this limitation, but limitations remain and some of those limitations (such as the geographic and economic limitations discussed in some comments with regard to education) undermine the potential of the constitutional rights granted or affirmed in those amendments and Supreme Court cases.
Health care is no different in my view. Whether or not we individually believe truly in equal access to health care, equal access to health care is no more achievable than has been equal access to education, housing, or anything else, if by equal access we mean that everyone is entitled to the best or to no more than a governmentally defined level of quality or quantity. No successful nation has achieved such perfect equality (except perhaps the idyllic Federation of Planets from Star Trek), and no nation of limited resources ever can. Those who have more resources always will find ways to acquire better health care more quickly, conveniently, and comfortably.
One final point on your post. Collectivizing health care not only is impractical it is counter-productive. The quality of health care in our country, and probably world-wide, is a result in substantial part of innovation in technology, technique, education, pharmacology, and many other fields. Innovation occurs for many reasons but one of the dominant reasons is economic gain — wealth for the individuals and companies who conceive, refine, test, and reduce to working form innovations. Suppressing the power of our country’s wealthier citizens to purchase better health care services and technology inevitably would suppress innovation in health care and, therefore, retard the pace of improvements that ultimately the wealthy and not so wealthy will enjoy.
Political expediency and correctness should be recognized for the obstacles they are to improving the lives of everyone. If reality and practicality prevailed, or even had modest influence, we could establish workable systems of health care and education and many other essential services that would deliver better quality, more quickly, and more efficiently. Regrettably, reality and practicality do not win political elections.
“It’s all in there. Those looking for free lunch at the expense of the masses will learn the lessons of history”.
Laurence B., I couldn’t agree with you more. Do you realize that the phrase, “There’s no such thing as a free lunch,” is much more broad in meaning than the strictly monetary connotation that is placed upon it? Time, health and dignity are just a few of the external, opportunity costs involved in making American life so convenient. Consumer reluctance (including employers as labor consumers) to pay a dime more for the entire cost of production simply transfer those costs to others.
“Find a better job” is akin to asking a physician to “treat more patients” when uninsured patients are unable or unwilling to pay for medical procedures. The cost is simply pushed onto someone else. Whether someone has chosen or was chosen for a particular job, someone else receives a benefit from that labor along with the worker. Supply and demand has created a great deal of low paying jobs with many benefits to consumers. Relevance of labor is irrelevant when discussing supply and demand. We demand cheap products, and then bitch when asked to pay for the healthcare of the many that help make our demands possible?
What do you do when you have to choose between saving a pedophile doctor, and a fat pizza boy? I wish life were so simple as you all have made it. According to the American legal system, you better have a damn good reason for not saving either of them.
Asking someone to pay for your healthcare really isn’t that different than asking someone to provide for your consumer wants for a wage that doesn’t sustain their life. Government , taxation, and regulation imposed through the democratic process is probably the most civilized way to solve this particular problem. You may not feel that everyone deserves healthcare, but can you understand why everyone wants it? We aren’t that different.
Where is the free market incentive for insurers to reduce healthcare costs for anyone? Affordable healthcare makes insurance unmarketable.
Not all docotrs are motivated by greed. In fact, the majority are not. Doctors leaving medical school today will earn only a fraction of what docotrs earned a decade or more ago. Doctor salaries are going down, yet medical costs continue to go up. Med students today pay significantly higher tuitions (even adjusting for inflation) than in the past, have to take more tests, go through longer residencies, and pay more fees than in the past, and have to expect lower salaries. Yes, they still get a good salary when compared to national averages of the general population, but for what they go through, docotrs earn it. BTW, residents do pretty much the same work as a full attending physician but get paid less than 50K a year. Given how many hours they work, that’s barely above minimum wage per hour.I do agree that we need more primary care physicians. GP’s and pediatricians are woefully underpaid compared to other specialties. The highest paid specialties: opthalmology and dermatology. Not what most would expect. Those fields deliberately manipulate that by only accepting a few residents a year.One point not mentioned: liability/malpractice insurance. Some specialties such as Ob/gyn have such high liability insurance in some states that it’s hard to recruit docotrs to do the job. Reform is needed to control the costs of lawsuits and what cases really are legit. Now, I’m not saying that if your doctor is negligent that you shouldn’t have some recourse. But, you must understand that your doctor is human and not an omnipotent miracle worker. Some things are out of their control, and/or are simply unknown factors.