Wednesday, November 26, 2008

Health care and personal responsibility: a few semi-random considerations

I want to highlight two comments by Pandora in our ongoing discussion about health care. The first comes from her own post at Delawareliberal about health insurance [please read the entire post to insure this is not out of context]:

After “Am I going to die?”, and sometimes even before, “Is this procedure covered?” has to be one of the most asked question of Doctors. And, frankly, I resent it. I resent the fact that Insurance companies have forced their way into my Doctor/Patient relationship. I resent that they have the ultimate veto power over my health.

But, most importantly, I resent that I even have to think about Healthcare insurance.

[Truth in advertising: the major point Pandora is making is that insurance companies deny claims to boost the bottom line. I am not challenging that. I have a different focus at the moment.]

Then, in response to my original post about health care that advocated making people responsible for their own routine care, which would allow market prices to drive those costs down, Pandora responded,

The only concern I have is the number of people who would put off seeing a doctor on a regular basis because it wasn't paid for, thus allowing small illness to turn into big ones.

Okay, okay, I know that that's irresponsible, but people are irresponsible. And if they skipped the wellness visits could that raise the 20% mark? Couldn't this possibly lead to a "sicker" population?

Okay, there are two very important points here.

1. People don't want to worry about whether a procedure is covered, but somebody has to. Even in either a single-payer or government-run universal healthcare system based on the European model, there are not infinite resources available, either in terms of capital or capacity. Somebody, somewhere has to worry about what it all costs--especially if you don't. And when people think a service is free, they inevitably use more of it. There is also the problem of capacity. Capacity--especially capacity for technology-intensive treatments--has physical limits. There are only so many kidney dialysis machines in the country, and each can only service so many patients within a certain geographic radius. At some point, somewhere, somebody has got to make decisions about who receives treatment and who doesn't.

Think these dilemmas don't occur in Europe? Then you haven't been reading carefully.

2. There is the question of whether policy decisions about health care should be based on preventing the consequences of individual irresponsible behavior. Pandora worries that, if they have to pay for routine care, some people will avoid it until the problem becomes bigger, and that this will result in a "sicker" population. I have to first admit that I do not have a lot of sympathy for the idea that government should step in when people make dumb decisions about their own care [and here I am assuming she is not talking specifically about people too poor to afford any price), so I do have a bias.

However, there is another point to be made. When that routine care is free or subsidized below a reasonable market price, physicians become inundated with people who probably should not be there in the first place. Not every case of a cold, or influenza, or sprained ankle actually needs to be seen by a doctor. But in today's society (just ask a lot of general practitioners) our family physicians spend a lot of time weeding out what we used to call "ash and trash" complaints in the military. That time is not available to spend with patients who really need the care, or whose cases would profit from the extra five minutes of diagnostic time.

In either case--Pandora's or mine--there is an associated risk factor to public policy. My approach places the people who do not act responsibly at greater individual risk; her approach transfers that risk to people who have acted responsibly.

And this is the oft-unspoken nub of the problem. The devil resides in the details of the implementing philosophy of any health care system, free-market, government-run, or mixed.

Do we allow people to suffer the consequences of their own responsible or irresponsible actions, or do we argue that the greater societal costs of not forcing/subsidizing them to do what they ought to do for themselves in the first place is a good reason to have a system that forces them to act responsibly. And, in so doing, takes more freedom and resources away from those who would have acted responsibly on their own.

A forestaller for nemski: none of this conversation is (at least not yet) aimed toward the poor or the working poor. I am primarily (and I think Pandora is, too) talking right now about the middle-class folks who already have access to some form of health insurance. We'll get to poor people in a little while.


Anonymous said...

I see both our points. I think we're both talking about opposite ends of the spectrum when it comes to being responsible. On your end there are those that should, but do/don't, and on mine there are those that would, but do/don't.

Shoot, gotta help with the turkey! Hold that thought!

Anonymous said...

Okay, let me try this again.

First, there are no simple answers. Both of our solutions will create problems since there will always be people who abuse ANY system. I tend to be uncomfortable with any law/system designed towards the fringe of the population. It's like the woman who uses abortion as her only method of birth control. I don't like that approach, but I don't want to focus on this extreme example when tackling the problem.

Will some people abuse a new healthcare system? Yes. Do some people abuse our current system? You betcha. Some people will always take advantage of any situation. Is it possible to take this group off the table for this discussion?

My biggest problem with healthcare is the insurance industry - talk about abuse - and their complete power over life and death. Even Doctors have been cut out of the decisions, instead Insurance Co. rely on their charts and tables to justify care... or lack of care.

It is this abuse that worries me most. In some ways I find parallels between the health insurance industry and the auto industry. Both of these groups have ignored the writing on the wall for quite some time, both knew they were offering a product that people were unhappy with, and both made no significant changes to ensure their own survival. (Perhaps, not the best comparison, but hopefully you can see my point.)

Healthcare has been building as an issue since the early 1990s. How has the Insurance Industry dealt with the possibility of its own extinction? By raising rates and cutting services. Have they made any consumer friendly changes? Have they tried to address the healthcare problem/cost facing individuals and business? Nope.

In fact, they've added big business to their enemy list. Really stupid. Twenty years ago people who worked for big companies didn't give health insurance a second thought - neither did their employer. Now the cost of health benefits is one of the main reasons companies cite for shipping jobs overseas - true or not, big business has tossed health insurers under the bus, and I'm not shedding a tear.

I don't have a perfect answer to this problem - I doubt there is a perfect answer. I just know something must be done.

Anonymous said...

Steve, I'm starting to get a complex. Do you consider my response so off the mark that answering me is pointless? ;-)

Steven H. Newton said...

Naw, pandora--I just finished a full week of inlaws in my house and such writing as I did here was almost purely responsive rather than original. I'm afraid this discussion will get quite attenuated over time, because health care is one of those issues where you actually have to take your time and do your research.

Bear with me.

Anonymous said...

Fair enough. It's just that I'm starting to think we might be onto something with our posts/solutions. I don't claim to have all the answers. In fact, I believe some of the best solutions are achieved when opposing viewpoints hash the problems out.

Oh my... did you say a WEEK of in-laws?