8/04/2009

08-04-09 - Health Care

Okay, I've been resisting writing about health care, because it's just so depressing and pointless. As usual, the Dems are proposing some very modest reforms that really don't get at the root of the problem at all. And as usual the Reps are going into insane reactionary mode for no reason and attacking them in ways that are just nonsense. The Dem plan does almost nothing to change the way current health plans work, or the way Medicare works, both of which are fucked. The Reps are using this bizarre bullshit that the Dems are going to let old people die - the ironic thing is that if that were actually true I would be way more excited about reform.

We desperately need to do two things that we aren't going to do :

1. Remove doctors from the position of hallowed unquestionable saints. We need more transparency and consumer power. The consumers need to be able to make more of an informed capitalist decision about their own care, and furthermore the health insurance companies need more real tracking of doctor's performance so they can decide who should get paid. There's this false idea floating around that in the ideal system, doctors have unlimited freedom to provide care and the health insurance company gets out of the way. That's retarded. The health insurance company should be your agent to ensure that the insurance pool you're paying into is used well - it should only be spent on people who have real serious health problems, and it should only be used by doctors in ways that are really necessary and cost effective.

I often think about health insurance by comparing it to car insurance. What if your car was wrecked and you took it to a shop and the mechanic just said "trust me; I'm not going to tell you how much I'll charge, and no you can't find out how well I've done in the past" and the insurance company couldn't check to make sure the damage was real and the repairs necessary and fairly priced. Of course that would be a disaster of extortion. The service provider needs to be kept in check by both the client and the insurance company, that's what motivates them to provide good services cheaply.

2. Ration care. Rationing is crucial to controlling costs, and also crucial just for being rational sane policy makers. Of course we all implicitly put prices on lives every day. When you choose to buy a cheaper car that's not as safe, you are putting a price on your life. When the city chooses not to spend the money for separate bike lanes, they are putting a price on life. When you have limited funds, you should allocate them to the place that provides maximum benefit. The correct policy is a kind of rate-distortion analysis slope chasing thing. You set a certain slope - a [Life Value]/[Cost] slope - and any time that slope is better than some threshold, you spend the money, if it's worse than that threshold, you don't. To do otherwise is just retarded.

"Estimates show that about 27% of Medicare's annual $327 billion budget goes to care for patients in their final year of life." - this is a little tricky because it's hard to tell when exactly it is an old person's last year of life. In that final year, 40% of their cost is spent in the last month of their life, presumably because they become in-patients and undergo various emergency life extension attempts. There are tons more statistics like this. The crucial thing is that we're obviously wasting massive amounts of money on these things.

It's important to frame the rationing question the right way; what we're really doing is "health care optimization"; the point is that with cost held constant, we are trying to save more lives. By letting one geezer die, you would have enough money to help ten black people avoid diabetes. And in fact, when you optimize money allocation for the public health, you'd see that actually we'd be better off if a lot of this money we're wasting on health care was spent on more general societal things like safer roads, better standards for bumpers on large trucks, more public parks, more food inspections, etc.

Anyway, my point is not to convince you that optimization is necessary - it's inherently obvious that we should do optimization, and anyone who says otherwise is just a hopeless tard that you can't even debate with. The sad thing is that in our political system it has zero hope of happening. Politicians will say "are you suggesting we should choose to let someone die because they are too old and too sick?" ; of course I'm saying that, it's the only reasonable position to take, and of course hospitals already do it, they just draw the line way too far out; if we seriously want to limit costs we need to draw that line in a bit, and more importantly perhaps just change the entire attitude that the point of the health care system is to spend arbitrarily large amounts of money to make arbitrarily small incremental improvements in life span.

Furthermore, because of the power of doctors and the AMA, #1 is not going to happen either. Doctors don't want patients to know their success rates or their costs, or to see their real alternative treatment options. When you go into a doctor, you should get information like : you could do this or this, for each option it will cost X, and the success rate is Y - but doctors don't want you to have that, they want you to be ignorant, because it lets them charge you too much and treat you poorly without you knowing about it. When you go in with a sprained ankle, right now they send you for an x-ray and maybe an MRI right away. Instead someone needs to say "you could get an MRI, but it costs $10,000 ; or you could just go home and ice it and see if it gets better in a few days".

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old rants