Priceless: Chapter 6-7


by Austin Frakt and Aaron Carroll

Source: The Incidental Economist

Reading chapters 3, 4, and 5 of John Goodman’s book Priceless left me exhausted and disappointed. As I’ve already expressed in my reviews of them (all under the Priceless tag), the book’s style doesn’t suit me, I’m finding a lot of selective reading of the literature, and seeing arguments that strike me as wrong, sometimes strangely so since they seem unnecessary to John’s focus. After writing my Chapter 5 review, I told Aaron I wasn’t sure I should continue, especially if doing so caused me to feel the need to respond at length to every chapter. By now, you know I kept going.

Fortunately, Chapter 6, about how price competition could also improve quality didn’t upset me. I have no major problems with it. I concur with John that, all other things being equal, more price competition is a good thing for the health care market. What I want to see more of is consideration of the consequences beyond price and consumer satisfaction. Here’s a key question: would providers sell and would people buy more or less care that is beneficial vs. harmful or useless?

With that, I moved on to Chapter 7. It begins with a typical Goodmanian assertion, the form of which is: Conventional health policy wisdom is X. Everyone (but me) is wrong. In truth it’s not X, it’s Y. In Chapter 7, X is that price is a barrier to health care access to the poor. John says that’s not right, that non-price barriers, in particular waiting times, are the main culprit.

Even if John is right, this set-up still bothers me. What’s wrong with acknowledging that both price and non-price barriers exist? Why does it have to be John against the world? Beats me. But boy is it tiresome.

By the way, here’s a study that shows that financial and non-financial barriers to care are nearly on the same footing, even for the poor. According to this study, waiting times are not the major issue, even among non-financial barriers. But, yes, non-financial barriers deserve more consideration than they are afforded in policy debates. In light of this, can we really say, as John does, that “everything we have been doing in health policy to make healthcare accessible for low-income patients for the past 60 years is completely misguided”? That’s a little extreme, don’t you think? Extreme views are typically wrong. To accept one, demand the most thorough consideration of the evidence. John didn’t provide that. (Nor, by the way, have I. But I’m not taking an extreme view. I’m not suggesting that nearly everyone else on the planet is wrong. Nor do I need to.)

Anyway, I reiterate, what I’d like to know is whether the marginal person able to access care — whether due to decreased financial or non-financial barriers or both — is getting beneficial or non-beneficial care. Isn’t that relevant? I would love to know if I’m spending an unpleasant hour in my doctor’s waiting room for something that is worth my time, if not my money.

John raises the issue of whether health insurance affects mortality, winding up with a citation of Richard Kronick’s study. Stan Dorn, for one, is not as impressed with that study as John is. You can read a lot more about insurance and mortality by Michael McWilliams and Harold Pollack. Citing Michael Cannon, John suggests that the health care additional insurance might facilitate wouldn’t have a large impact on health. I think we need to keep in mind the fact that half of longevity gains in the last half-century or so are due to health care. John sets up the straw-man of decreased mortality being the sole goal of health care. Is that why you usually see the doctor? To prevent imminent death? Me neither.

There are many studies that show health insurance matters for health, even Medicaid. Does John disbelieve the results of the Oregon Health Study? For all that, you will get no argument from me that Medicaid could be improved.

John lauds the systems of the Parkland Memorial Hospital in Dallas.

Clearly the Parkland system should be continued and its replication encouraged in other cities [...] with nurses following computerized protocols.

But, remember, John also doesn’t believe replication of what works is possible. John doesn’t believe that adhering to protocols is a good idea.* His book is very confusing.

I read the rest of the chapter less carefully. I noticed it returned to a topic I’ve already addressed: waiting times in Massachusetts. I’ll leave whatever John wrote about Canada and the NHS to those of you who wish to discuss it in the comments.

On Monday I will post about Chapters 8 and 9.

* I’m being flip. I think it is likely John could articulate when protocols are good and when they’re not. But, as far as I can tell, he hasn’t, or not in a way that I can understand.