Thursday, June 11, 2009

Health Care: probably solved by the end of this post

Judge Smails continues:
I think we actually agree on most of what is being discussed here. I would quibble with your comments, but I'd rather talk about this:

But health care is not a business, it is a basic human right -- it is promoting the general welfare -- and it is the government's job to take care of everyone in this regard.

I don't know if agree with this or not as a normative statement. But as a positive description of the U.S., it's clearly not true. Health care is a massive business right now, for better and worse. I think it's undeniable that drug innovation in the U.S. is driven in part by the opportunity for capitalistic wealth. And we know lots of people are getting rich in the health care fields right now. It's also true that people are willing to spend hundreds of thousands of dollars (and years of their lives) to become practitioners. Some are purely noble; I think a lot also want to make 300k/year and drive a BMW.

From my seat, however, this is mostly important because it means the politics of health care will be, at least in part, the politics of big business. You seemed aghast earlier today that the AMA would be self-interested and trying to protect it's own. But that seems perfectly natural to me --- I don't seem the AMA as any different than the tobacco lobby or the UAW. To think of people as anything but self-interested (as you seem to think of the bio-tech world) is utterly foreign to me, at least in the world of politics. The doctors are [sic -- aren't?] bad people, they just see their BMW's potentially being traded in for Honda Accords, and they don't like that.

That doesn't make them right. But it does tend to reduce the politics of health care to something like a big version of any kind of politics. However much you (or I) wish we were fighting out the civil rights movement here, we're not. We're fighting over traditional interest-group politics: who gets what and how many zeroes are on the end of the number.

The Judge is right that we do agree quite a bit about this issue. But I think proponents of reform would be unwise to ignore the language of rights and to instead focus entirely on the economics. Surely, the budget picture is how you scare some people into action, but the what-kind-of-society-are-we language is also necessary for building the popular will for reform. And I'm not just saying that as an organizing strategy, but rather because I believe it. By any measure our health care system is bad for all but the most privledged, and I think that's wrong. I'm sure there were economic arguments to be made about various other civil rights issues in the past (as Colbert once joked, segregation was a real boon to the water fountain industry) but the language of dollar signs isn't nearly as powerful -- indeed, I don't think you'll see gays arguing that they should be allowed to be married in state X because there appear to be some economic benefits to states that allow gay marriage.

Relatedly, Ms. McGee furthers by adding more about that New Yorker article I mentioned:
more health testing and more expensive tests, more surgery, does not necessarily equal better health care. In the New Yorker two weeks ago there was an article by a Dr. comparing health care in several different areas of the country, some that have the lowest per capita medicare spending and some that have the highest per capita medicare spending. Guess what, there were no differences in patient outcome or quality of hospital or anything else that functionally matters to people. The thing that was different was in the high cost areas the Drs. are profit-driven, they get trained to do ultrasounds, by an ultrasound machine for their office, and then recommend that their patients get more ultrasounds so they can get billed for it. They also prescribe more home health care visits by home health care aids while telling the home health care agencies that if they pay them 100,000 a year in consulting fees they will send their patients to them.

The low cost areas pool all the $$ earned by all the Drs and then pay all the Drs. a salary. Excess $$ goes to research in comparing and improving treatments, buying equipment, and having a well-trained staff. Another low cost area agreed that all the Drs. would be paid the same fees regardless if the patient was medicare, medicaid, or private insurance. They also had a committee to evaluate patient charts to find out look at poor prevention practices, unnecessary surgery etc.

It seems to me like the biggest innovations are occurring in places where we are trying NOT to let the market/private insurers drive innovations. Its amazing that health costs have sky rocketed over the last decades when people in general have picked up healthier habits, like not smoking. So many of our innovations don't come with rigorous analysis of when to use them and when not to, so if you make a machine that does X, the company that makes that machine is going to find every way that you could possibly use machine X. Then if the Drs. get paid every time they use machine X, GREED will tell them to use it a lot regardless of whether it improves the health of people.
I don't have a problem with people making money -- hell, my former and current advisors have both done very well for themselves in the biotech industry, and I don't begrudge them a cent for it. But they clearly didn't get into biology for the dough, they got into it because they are nerds, and they certainly didn't get into it for the dough while saying they were in it to help people.

I think that's my problem with the AMA -- as an organization representing doctors (rather than, say, pipe fitters) -- is that they'll deny it is about the money and instead spin stories about how it'll harm their patients. Considering the rather exalted station doctors have in our society, and the exalted station they often have in their own minds, I think they should be held to a higher standard (call it the special license plate theory of organized labor or something). Since we'd never tolerate an individual doctor lying to an individual patient (yet we're fine with car dealers just making crap up, in fact, we expect it), I don't see why it is okay for a collection of doctors to lie to a collection of patients.