The Surreality-Based Community on Health Care

I have read a couple of debates on health care recently, by crowing members of the “reality-based community” who, in those posts, say that anyone who disagrees with them is “dumb” or “delusional” (those are direct quotes). Somehow they view themselves as different from Republicans. Behaviorally, I see little distinction.

There’s an amazing amount of simple dismissing of economists, because the conclusions they come to do not square with ideology. This is a perfect mirror for conservative attitudes toward evolutionary biologists–and yet the opposition to biology was brought up as somehow having to do with the value of markets in regard to health care.

Several times I saw these points brought up in the discussion as “refutations of right-wing canards that have been disproven time and and time again.”

  1. Markets do not work in regard to health care, so market-based arguments are irrelevant. “First off, markets don’t work in health care.”
  2. Price information is impossible to achieve in health care, so a market-based solution cannot function, even if markets applied to health care, which they don’t. “The provider community has resisted, and will continue to resist, price transparency. Lotsa luck getting them to agree to post their prices in a way the consumer can use.”
  3. Health care is not substitutable, so there is no competition in health care markets. You must have all services immediately upon falling ill, and there are no choices in treatment. “Every ecomonic law I am familiar with has, at it’s heart, a rational actor. Well, I can’t think of a less rational economic actor than a mother with a sick child, can you?” “the heart attack victim who is brought in, unconscious, on a stretcher, is in no position to ask questions about the army of practitioners and laboratory full of machines that is brought to bear in saving his life. Rational decisionmaking is gone.”
  4. Implicit in these critiques is the idea that our current system is an unfettered market system.

The first three can be partially refuted by looking at eye surgery to improve vision. It’s substitutable–you can get contacts or eyeglasses. Price information is frequently touted on the radio. And, as it is regulated only to the extent of quality and not for provision (it is not covered by any insurance or government program), prices have declined over the same period that prices have risen for healthcare generally. It also helps refute the fourth: if you compare the procedure to get LASIK versus insurance-covered medicine, there’s not a great market at work in insurance-covered medicine.

Of course, it is optional, and therefore fails to meet the time-dependency test of the third objection. To respond to this, I want to take two tacks: first, such conditions are not unique to health care, and second, most healthcare is not provided in that severe a crisis.

If you are a homeowner, and a pipe breaks, and you do not know where the shutoff valve is, do you shop around for quotes from a plumber? Or do you call the first number you can find to have someone come out and deal with it, and pay them whatever they ask? Of course it’s the latter. Does this mean there’s no market for plumbing? Should we have National Pipe Care? And do you call the most expensive plumber, or do you first call the plumber you’ve felt has a good price and only not go with them if they’re not available?

Of course, most plumbing calls are for leaky faucets and repair work after an emergency has been dealt with. Similarly, non-life-threatening diseases form the bulk of primary care. Most mothers with good insurance bring their little tyke in for every sniffle, even though the vast majority are viruses that will pass in a week, with or without treatment. They demand antibiotics anyway–otherwise, there would be no antibiotic crisis in the First World. So clearly, incentives matter to mothers with sick children. When they don’t have such insurance, they don’t bring them in as often, because they have to trade off the money for a useless antibiotic versus just letting a cold run its course–and since it’s non-life-threatening, a child who doesn’t get better can come back for further treatment if the cold doesn’t go away. Even when the disease is life threatening, moving into the more expensive areas of medicine, the progressions are rarely fast enough to prevent a day’s worth of price versus quality comparison shopping.

Of course, with employer-provided insurance, you never see the price or make the decision of where or whether to get treatment, or whether a less expensive treatment will do you well enough. So doctors have no incentive to post prices. That gets us back to whether what we have is a true market. Why do we tie insurance to your job? Because a long time ago, the government put in place wage controls. So to compete for workers, employers would offer insurance. The government allowed it by making such “contributions” tax-exempt. That basically distorted the market in favor of third party payment for health.

So that brings us to the final Surreality-based objection: any criticism of single-payer or government-provided health service equates to a defense of the current system. Not even close. I want lots of changes to our current system, and I’m far from sanguine about it. One reason national health systems are cheaper than hours is that they don’t attempt to be heros all the time: they ration care. Canadians have far fewer MRIs per capita than Americans. Not all headaches require MRIs, folks. Of course, if Americans payed directly for their MRIs, they’d probably opt for more cost-effective treatments. The biggest problem in any market system is getting people to go to preventative care, when it’s most affordable. I think allowing catastrophic care insurance (which is what really should be covered by insurance) to require the insured to get regular physical exams (and gym memberships?) and charge discriminatory prices based on controllable risks, such as weight or smoking, would go a long way to addressing that problem.

But the blinkered gainsaying, straw-manning, and ad hominems that are practiced in the Reality-based community while simultaneously posturing themselves as the “smart ones” who are “sane” (and they say libertarians are elitist…) pretty much earns them a spot right next to Tammy Faye Baker on the next Surreal Life.

I’d love to see some more progressives who admit that the market does things well and who explicitly accept and identify the tradeoffs of efficiency versus other values they’d like to make–including an acknowledgment of the pain they will cause people, especially poor people, before their justification of why that pain is necessary for their other value. That’s a conversation I could have much more readily than trying to dissuade somebody who believes that nobody involved in health care responds to incentives.

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