Dedicated to the Game

The healthcare reform law is still alive and the squabbling surrounding it, too stupid to live yet too overwrought to die, is reanimated. Here I go, unable to resist the smell of brains, shambling back into the scrum with the rest. In my own defense, I work in the non-systematic system this law purports to reform. I also have something more constructive to mumble than “Brains, brains!”.

Just look at the objective of the law. Its primary aim is to finalize the conversion of the health insurance industry to a healthcare financing industry. In other words, to convert it from Lloyd’s of London to GMAC. This objective is very modest, as the industry is already two-thirds of the way there. Kaiser, with its souped-up HMO model, is almost all the way there. By finalizing this transformation for the whole insurance industry, the authors of the law hope to provide universal access to healthcare and control costs. These goals are not so lofty as they first appear. In fact, the second one may not be possible by legislative means at all.

We already have universal access, just not rational universal access. Call 911, and someone will come to help you without checking your credit rating or insurance status. Go to the clinic because you have symptoms of diabetes, and you will not get the same courtesy. You must wait for the ensuing heart attack or coma.

Objections to universal access must start with what we already have, and I think these objections, since they have life and death implications, require some earnest gesture before they get serious consideration. I’d propose an opt out. If you think our polity should not concern itself with the physical well-being of its constituent individuals, please tattoo a Gadsden flag across your forehead. Then we can demand payment up front if we find you bleeding by the roadside or keeled over on the sidewalk, or we can simply choose to pass you by. Until you bear that mark, you won’t be taken seriously.

The legitimate objection regarding universal access relates to efficacy. Giving people financing, and thus access, doesn’t mean they will automatically access healthcare rationally. They will probably do a little better than they do now, but the cost control envisioned in the law depends on people doing a lot better at seeking care rationally. People probably won’t live up to that expectation.

Market forces are the problem. Efficient choices in healthcare are difficult. Even clear-cut problems often require some technical knowledge to allow for good decisions. For ill-defined problems, not even the experts can tell the consumer what he or she is buying. So, the consumer must make purchases based on emotional facts rather than physical facts.

From the perspective of emotional facts, healthcare choices break down into two broad categories: care we care about and care we don’t care about. Care we care about is reassuring care and impressive care. Reassuring care is any care that addresses illness we fear, like cancer. Impressive care is care with visible, immediate, dramatic results, like open heart surgery. Care we don’t care about is public health and chronic care, especially if it is merely preventative.

Among these two sets of choices are tests and treatments that are expensive and effective, cheap and ineffective, expensive and ineffective, and cheap and effective. The market favors care we care about, without regard to those sub-categories. Allowing people to participate in the market alone won’t help control cost, for this reason.

Agency is necessary to sort care rationally, in the light of physical facts. Physicians have been the de facto agents up to this point, but they really haven’t wanted the job and therefore serve the role poorly. A financing company might be able to act as an agent, but would be limited to guiding choices among preexisting options.

The Affordable Care Act contains some elements that gesture in the right direction, like ‘death panels’, ( guidance on end of life care). People don’t like those elements because they seek to rationalize, and thus ration care, which entails a loss of autonomy. People are loath to cede autonomy to any agent, especially a visible yet impersonal one like a panel, real or imagined. Until doctors choose to willingly alter their practice and fully embrace the role of agent, everyone will continue to get expensive and ineffective care we care about, and do without cheap and effective care we don’t care about.

To that end, the recent fights over USPSTF recommendations for cancer screening are the sort of fights we need to be having. We’ll see if the political process will allow those fights to go on and spread. As for the ACA, whatever, it’s a start. At least it doesn’t propose to expand market distortions until care is rationed by price alone or beg for a forehead tat.