Why is health care different?

[Econoline]

This thread is the result of an exchange that took place in another thread here, but I thought it deserved its own topic. Here is the original exchange:

How do the Republicans propose to provide affordable health care to the tens of millions of Americans who are currently uninsured?

I think they are working on affordable cars, affordable luxury satellite TV service, affordable vacations, affordable yachts and all the other things government damn well should be providing as close to free as possible to help voters - sorry, I mean Americans. Just get in line, sickies.

Actually, I think that paragraph pretty much sums up the principal Republican fallacy with regard to health care: the idea that health care is just another commodity like cars, satellite TV service, vacations, yachts, broccoli, beer, laser printers, and all the rest--and that it can and should be treated just like all the others, with no more and no less importance.

Yeah that's why I put it out there. And why isn't it a thing of life that we have to purchase like anything else?

So....

Why ISN'T health care "just another commodity" (or maybe not a "commodity" at all?) or "a thing of life that we have to purchase like anything else"? I've been thinking about that question, and have come up with several answers. In no particular order:

● Actual life-and-death importance. Unlike anything else we pay for, it has a direct effect on whether we live or we die. Not even food--which has more long-term consequences and effects--has this real urgency.

● Need versus want. No one wants health care (unless they need it) but everyone needs health care (eventually). (This point is probably the most important difference: the irrelevance of individual human wants/desires, and the inevitability of human needs.)

● Uncertainty *AND* certainty combined. You never know what you'll need (until you need it), and you never know when you'll need it (until you need it). You can try to plan, but you can only guess.

● Necessary (but uncommon) expertise. Very few people have the education or training to make all their own health care decisions; at some point, everyone has to trust--and pay for--the advice of an expert who knows more than they do. Even a cardiologist sometimes has to trust a neurosurgeon, and vice versa.

● Expense. No one in the world--except, perhaps, for a tiny number of the very richest billionaires--can afford to self-insure for every possible eventuality. We are all, at some point, dependent on some sort of shared-risk scheme (a.k.a. insurance), and thus we are all, to some extent, interdependent.

Anyway, those are a few preliminary random thoughts. (OK, OK, not random...'cuz I know there's a whole 'nother special thread for that!) I'll try to add more later. Anyone else want to argue with those, or offer some thoughts (random or otherwise) of their own?

[Joe Guy]

Why ISN'T health care "just another commodity" (or maybe not a "commodity" at all?) or "a thing of life that we have to purchase like anything else"?

I can't answer that question because health care IS being treated as "a thing of life that we have to purchase like anything else".

Or did the meaning of the question you were asking go right over my head?...

[rubato]

I think he is asking why we cannot require individuals to pay for health care (or it will be withheld).

The moral dimension is obvious; to withhold care from another when it would alleviate suffering or prevent death is morally the same as murder or allowing torture.

But what are the practical arguments?

First of all, there are a lot of benefits of HC which can only be had by ANY (or more than a tiny few*) if they are given to nearly all. We are nearly completely free of Malaria, Diptheria, Measles, Tuberculosis, in the US because of public health programs which benefit all. Vaccination programs work when vaccines are free (or subsidised) and distributed widely. By WWII Diptheria had been eliminated in the US by public vaccination campaigns but US doctors were shocked to see the infection rates unchanged in the UK (this is before the NH). The risk of smallpox was eliminated for everyone, not only those willing to pay. We have clean water which does not cause periodic outbreaks of cholera because we pay for water systems to filter, chlorinate, and then test drinking water.

Without publicly funded programs we would have the same levels of parasitic infection as the rest of the world (billions)

http://www.slideshare.net/InVitroDiagno ... itesslides

The only reason that we can know the effectiveness of drugs is that we all pay for the FDA to test them.

Both billionares and the poor benefit from having fully staffed and stocked Hospitals and emergency rooms ready and waiting for bad luck (or the forseeable outcomes of bad habits) to strike.

A large and often neglected part of HC is the expense of research which provides cures for rich and poor and which is most often paid for by taxes collected from everyone (in one form or another, for-profit pharma companies benefit from the FDA).

In many ways the rich are getting the greatest benefit from things they don't pay much for and the poor, though their taxes and their labor are providing them and then being deprived because they can't pay yet again (or at that moment). A 55-year old who lost his job and spent his retirement because of the economic collapse can die from a treatable illness whose cure he helped to pay for.*

So the starting point is that for the most part HC is a benefit which can only be effective to any substantial degree if provided to all. Imagine Warren Buffet being translated back to Venice in 1500 with his proportionate wealth intact. No matter how much he pays he can't be treated for infectious disease, coronary artery disease, most parasites, a broken bone, uncontrolled blood sugars or any of the myriad things we take for granted. He can't hire a competent doctor because they don't exist; the training, education, and medical research which provides competent doctors today has only been possible by sharing the costs over all.

yrs,
rubato

*
They do today in Texas:
http://www.texasobserver.org/a-galvesto ... afety-net/

[Econoline]

Why ISN'T health care "just another commodity" (or maybe not a "commodity" at all?) or "a thing of life that we have to purchase like anything else"?

I can't answer that question because health care IS being treated as "a thing of life that we have to purchase like anything else".

Or did the meaning of the question you were asking go right over my head?...

Well, just because it's being treated (by some) as if it's just another commodity, doesn't mean it *IS* just another commodity. You might get another car or another computer if you want it, and can afford it. Dialysis or a coronary bypass (for example) would, I think, be something fundamentally different: no one gets either of those simply because he or she wants one, and you get one of those things regardless of whether you feel you can afford it--or you die. And for an economist or a politician to theorize that the former two "commodities" are fundamentally the same as the latter two and for "consumers" (i.e., actual human beings) to accept this theory as truth strikes me (and many others) as just plain wrong.

I was trying to put into words exactly why this is wrong; if you disagree, fine, but I'd be interested in hearing your reasons.

[Long Run]

You make a good point, Econo, that this difference of opinion does drive some of the difference in how to deal with policy. Your examples are of life-saving medical care. As we all know, everyone has coverage for these things, either earlier (with health insurance or a government program) or later (walk up at the ER). One of the goals of the ACA was to increase the number of people in the former and decrease the number in the latter category. However, the vast majority of healthcare, which is the day to day checkups, office visits for minor ailments, etc., is a commodity like any other. In fact, as you note, there is no difference between eating a healthy diet and exercising and such early diagnostic care -- it is meant to reduce the chance that you will need life-saving medical care. (One quibble -- everyone does have access to dialysis since everyone, no matter their age, who has renal failure is covered by Medicare).

[Scooter]

Your examples are of life-saving medical care. As we all know, everyone has coverage for these things, either earlier (with health insurance or a government program) or later (walk up at the ER).

Simply not true. Going to the ER does not confer any sort of "coverage". No one can be denied emergency care for inability to pay, but the expectation is that you will pay whatever they can squeeze out of you But more to the point, we are talking only about emergency care. So yes, an ER will treat someone who is bleeding or who has broken bones or who is having a heart attack even if they can't hand over an insurance or credit card, but if you have cancer or need a bypass or an organ transplant, being unable to pay the bill means you die.

Which leads to your next gem:

the vast majority of healthcare, which is the day to day checkups, office visits for minor ailments, etc...

What universe do you inhabit? Over 75% of health care costs go to treating chronic disease (link.

... is a commodity like any other. In fact, as you note, there is no difference between eating a healthy diet and exercising and such early diagnostic care -- it is meant to reduce the chance that you will need life-saving medical care.

First, could you please point out where Econoline has said anything remotely resembling the words you are trying to put in his mouth, because it wasn't in this thread.

Second, the fact that both a healthier lifestyle and early prevention and treatment reduce the risk of more serious disease does not make them substitutes for one another as you are trying to portray them. Nor should the increased risk of disease and premature death from inadequate preventive care be seen as any sort of rational "trade off" that any person should have to make.

Third, a lot of what goes on in those "day-to-day" checkups dealing with "minor"ailments could not be achieved any other way. Many conditions are largely asymptomatic until they have done enough damage, and aren't going to be detected except by a medical visit. And even infections that are "minor" in nature will need to be treated with antibiotics to effect a cure. The lack of realistic alternatives means no real choice, which means greatly diminished bargaining power for consumers, all of which are antithetical to being a commodity.

Fourth, I understand that the private insurance interests that you shill for incessantly here do not like the mandates for preventive care, because they liked being able to insure only healthy people and gouge them wilth a deductible high enough discourage them from accessing preventive care. Well sorry, but their interests are not the only ones to consider, and the financial consequences of their shortsightedness will fall largely on Medicare and higher out-of-pocket costs. To say nothing of the non-medical costs of disease that will fall primarily on the patient and his/her family, employer, etc.

Don't get me wrong, preventive care should not be immune from cost effectiveness considerations. But neither should the true cost of disease, and who is paying it, be ignored.

[Econoline]

Thanks, Scoot, for pointing out what I most certainly didn't say, here in this thread or anywhere else--and again for debunking what is actually a pretty common misconception about emergency medical "coverage".

And I stand (somewhat) corrected, LR, re dialysis; I didn't know that. But I just looked it up, and while renal failure qualifies anyone for Medicare regardless of age, the benefits don't kick in until the 4th month of treatment, meaning the patient is responsible for 3 months either out-of-pocket or through some other insurance. (So guess what happens if you're uninsured and can't afford 3 months of dialysis?)

As for the distinction between life-saving medical care and regular/preventive medical care, I get your point...but it's a continuum, not a dichotomy, and in many cases (cheaper) preventive care is a substitute for (more expensive) life-saving care, so it's absurd for anyone to say that the latter should be considered a "public good" while the former should not.

[Long Run]

Thanks, Scoot, for pointing out what I most certainly didn't say,

In fact, as you note, there is no difference between eating a healthy diet and exercising and such early diagnostic care -- it is meant to reduce the chance that you will need life-saving medical care.

First, could you please point out where Econoline has said anything remotely resembling the words you are trying to put in his mouth, because it wasn't in this thread.

Unlike anything else we pay for, it [health care] has a direct effect on whether we live or we die. Not even food--which has more long-term consequences and effects--has this real urgency.

Sorry, if I misinterpreted what you said, but it seemed like you were saying that the nutrition from food plays a vital part in someone's health, with long-term consequences and effects either positive or negative for good or poor food choices. If I was wrong, my apologies. fwiw, I agree that it is a continuum, as to whether a treatment or an activity is preventative or ameliorative, but drawing the line on a continuum is a common public policy choice (and so deciding something is truly needed medical care versus preventative will be somewhat arbitrary, as it already is).

The real challenge, and the one that the ACA did not address, is making health care more affordable by reducing the rate of increase in medical care in this country. That is a complicated problem with many components. But, if the cost of medical care can successfully be addressed it becomes much easier to solve the problem of people not having coverage (i.e., people can either get coverage for themselves or it becomes more affordable to provide it for them). It seems since that is the root cause of health care being unaffordable, it makes the most sense to spend the time and effort solving that problem. Adding more demand for the limited supply of medical services (the ACA approach), will only make this problem worse. In the end, the policy has to be to add coverage in affordable ways while also implementing mechanisms to reduce costs. A hard task, but truly the only way to address the problem.

[dgs49]

Very basic stuff:

You cannot have a RIGHT to services that must be provided by another human. Because, unquestionably, they have a RIGHT to decline to perform those services. Or to require payment as a precondition therefor. Therefore, there is no generalized RIGHT to "healthcare" in the U.S.

Once GOVERNMENT decides to provide something for "free," GOVERNMENT must make that "free" benefit available as equitably as possible. If healthcare were provided directly by Government, then maybe we could have a legal "right" to it, provided it were available (money is always a constraint).

Many countries made the choice long ago that GOVERNMENT was going to be the country's primary service provider when it came to health care. They assumed the obligation of providing the training, staffing, hospitals, labs, clinics, meds, and so forth. Government employs the doctors, nurses, and other practitioners, and spreads out their benefit as equitably as possible. And in those countries, they are rightly trying to make healthcare available to all, given the limits of what CAN BE made available (funding is not infinite). In THOSE countries, one could say that healthcare is a right.

The U.S. government NEVER MADE THAT CHOICE. Indeed, such a decision would require a constitutional amendment.

Large elements of the U.S. healthcare system have been conceived, grew, and are driven by the profit motive. Doctors are largely compensated on a per-procedure basis; they work like crazy, and make a lot of money. I suspect that the average working week of a typical U.S. physician is at least 60 hours. (My PCP is older than me and works 70 hours/wk). If they all worked as employees of the Government at a fixed salary, and were prohibited from "moonlighting" for high-paying private clients (a key provision of "HillaryCare"), how many of them would continue working those 60-70 hour weeks?

Today's American "Progressives" want to pretend that the Federal Government can somehow create a mandate in the U.S. that effectively guarantees "healthcare" to all, without going through the painful process of changing our basic healthcare platform and figuring out how to pay for it. The word that comes to mind is, "Unreal."

Even "single payer" would render the entire U.S. health insurance industry obsolete. What politician would take up that crusade?

In short, to the extent that "healthcare" represents individuals paying for services, it is not much different than paying for a massage or a BJ.