There’s little doubt that one of the most persistent of the crises that we face is in health care. A Rand Corporation study recently concluded that 60% of the care delivered was substandard and that about 25% of the cost goes to administration. This problem is about to become even worse as people lose their jobs and the bennies that come with them.
The argument over health care usually revolves around whether it’s better to have market forces or the government determine how it’s delivered. The market champions emphasize how costs can get out of control if we don’t watch them, and the proponents of government care stress the importance of universal coverage to maintaining a healthy society. Both are right, but the current system is so far from being remotely adequate in either way that the current debate makes no sense at all.
About 44 million Americans are uninsured, and those with inadequate insurance which doesn’t cover much are probably another 60 million or so. This is certainly far from universal coverage, but covering those without insurance now will be more difficult, especially if much needed mental health coverage is included. Many have pre-existing conditions, which is why they were denied coverage. Their use of emergency rooms and other crisis services certainly runs up the cost of health care, and those costs are shared by the rest of the system. In terms of the current debate, we have the worst of both worlds.
If we did take the current system and manage to find the money to insure those currently without it, we run into other cost problems. Employers currently fund most health insurance, meaning that people do not trade off cost and benefit because they don’t bear the costs. While there has been as shift in costs to co-pays and other user fees, there is still little discussion about what things cost to the consumer.
If you fall and damage your shoulder, your doctor will order an MRI without asking what it costs; ask about the tab and you’ll probably get a blank stare. No one knows what things cost in the current “system”, but more importantly the doctors are obliged by medical ethics to insist on the “standard of care”. Making a somewhat less sure diagnosis without the MRI is generally considered “unethical”. It’s even harder to make a good diagnosis outseid of the “standard of care” in most mental health issues.
Without information about cost and the relative benefits, the basic tenants of a free market stop making sense in a hurry. A lot will have to change in our accepted standards of care before this is even relevant. Yet making this current system universal without any attention to cost is equally dangerous. The result is almost certain to be a spending spree that may soon appear unaffordable and politically unpalatable.
Many things go into being healthy. We have doctors and hospitals and so many nurses that do a wonderful job, yet it’s still not enough. In many cases, the world around us is what makes us sick. People have to want to be healthy, which is to say that they have to follow the advice of their doctors and physical therapists. They also have to eat well, get regular exercise, and not smoke or drink to excess. If we did manage to craft universal coverage in a system that wasn’t horribly expensive, we would still have all of these critical external issues. Would we deny care to people that openly defy doctor’s orders, or do we allow them to clog the system constantly seeking help? What about people that eat poorly or those who smoke?
Some of these issues, difficult as they are, will have to be dealt with later. We need to correct the problems with our system as soon as possible. The crisis is only going to become worse, and soon. What matters is that the current debate about health care makes little sense and needs to be replaced with a more relevant debate.
Universal coverage will reduce many costs, especially in administration and at emergency rooms. Critical market forces will be essential to keeping the tab from getting horribly out of control even in this system. There are far, far more important things to argue about as we move forward – and if we don’t move forward soon, we’ll be in terrible trouble.