Priceless: Chapter (2 cont.)


by Aaron Carroll

Source: The Incidental Economist

I just finished reading Chapter 2 of John Goodman’s book Priceless. I have a few thoughts. I look forward to hearing more of yours:

1) Right off the bat, John leaps into an argument that those who don’t understand systems shouldn’t tinker with them. I couldn’t agree more. Of course, I assume he doesn’t demand perfect understanding of something, because we shouldn’t let the perfect become the enemy of the good. But what confused me is that he admits health care is a complex system only as an argument to avoid “experts” making decisions. I would make this same argument (and have) to say that often it’s a reason why we shouldn’t always put things on individuals. People don’t discriminate well between necessary and unnecessary care. That’s proven. It’s why I often have a problem with consumer directed health care. So I feel like he’s making an argument against what he likely supports.

2) I agree with John that regulations are an issue. Malpractice, on the other hand, isn’t in the same class. Tort reform will not fix the cost of health care. And while we’re on regulations, I have to admit I’m a little tired of people on the right claiming that those on the left don’t think the doc shortage is a problem. Come on, do you read this blog? It’s a problem regardless of the ACA, and I FULLY ADMIT THAT BRINGING MORE PATIENTS INTO THE SYSTEM WILL REQUIRE MORE DOCTORS. Happy? The “government” isn’t the stumbling block here.

3) I get that John doesn’t like “shifting” in the sense that one group is better off and one is worse off. But if we spend less on health care, then providers will make less money. Someone has to. People arguing for more consumer directed care want the same end result that those who like the ACA do. They want less spent on health care. The results of that are the same: people in the health care system will make less money. They just differ on the means by which we achieve those goals. Pretending that they differ on the end result is misleading.

4) I agree with Austin that John’s arguments about the price of waiting are good. But wait times are often created by the lack of physician availability. Why is that entirely government’s fault? There are plenty of groups fighting that.

5) If John wants to give everyone on Medicaid private insurance (ie the exchanges), he’d find a lot of support for that from Democrats. But it will cost money.

6) John and I have gone around and around with respect to the fact that a few people spend a lot of the money. I see that as a reason HSAs won’t work. He sees that as a reason they will.

And now we get to me. Yes, me. Surprisingly, I make a real appearance in Chapter 2, for this post:

If my child’s life were at stake, I would fight tooth and nail to get anything – and I mean anything – to save him or her. I’d do it even it it cost a fortune and might not work. That’s why I don’t think you should leave these kind of decisions up to the individual. Every single person feels the way I do about every single person they love, and no one will ever be able to say no. That’s human.

Similarly, I don’t think that it’s necessarily fair to make it a physician’s responsibility. I also want my child’s doctor to fight tooth and nail to get anything that might save my child. Many times, physicians have long-standing relationships with patients. Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.

So whose job is it? Well, mine for instance. That’s what I do as a health services researcher. That’s what policy makers should also do…

I’ll note that I have continued to evolve my thinking on this issue, as happens with a blog. Citing one blog post isn’t the best way to lock in my thinking on an issue in perpetuity. But I do see how that post served as a good foil for John’s arguments.

But he misrepresents my intent a little. I wasn’t arguing that government should set what people can and can’t do. I was arguing that – in certain cases – dispassionate third parties may need to. Insurance companies do this all the time! Here’s what came after the ellipses:

That’s what we, as society should do. There are people who should have the responsibility of debating and deciding what is and is not cost-effective. They should have to make decisions that may be unpopular, and they should have to face the wrath of those whom the decisions impact. But there’s no good way to make it an individual’s responsibility to determine what is cost-effective for their child. That hardly seems “ethical”. I’m not sure asking doctors to do it is such a good idea either.

But ethics is something we can and should debate. I hope we can have a robust discussion about this.

John makes a lot of hay by claiming that my desire to spend any amount of money even for no benefit is not a rational or usual way to spend money. He’s right. I was talking about a specific instance, one in which my own child was dying.

I’m acknowledging that while I’m entirely rational and even “parsimonious” in many activities, as a human being and a parent those abilities may be lost in this specific case. I’m also acknowledging that in this specific case, doctors who are involved with patients may lose that ability as well. In those cases, we may need others not emotionally lost to help us decide how to spend other people’s money. At least, I think we can debate that point without imagining it’s the ravings of a government-loving-Soviet-style-planner.