Tuesday, May 12, 2009


Here, in my opinion are the immutable facts that must be addressed in any healthcare reform discussion. These are not the breezy idealistic musings, populist rhetoric, or doctrinal appeals that make for good politics but bad policy. These are the realities.

1.) Healthcare is not a right. Those that assert that it is are indulging in an unhelpful abstraction, because there is no practical way to provide healthcare services in a manner that is consistent with the notion of rights. Asserting that healthcare is a right is nothing more than a political gambit that is divorced from reality.

2.) The huge marginal costs of healthcare expenditures goes to providing a relatively small amount of high-performance services. The Pareto principle suggests that 80% of healthcare services result from 20% of the expenditures, and consequently, 20% of the high-end services consume 80% of the costs. The ratios are obviously somewhat arbitrary, but do serve to illustrate the fact that a disproprtionate amount of healthcare resources are consumed in intensive care units, tertiary care facilities in the last weeks of life, and in interventions with low likelihoods of clinical success. "Basic" halthcare is realtively cheap, but Americans have come to expect (and apparently are willing to pay for) much more than the basics.

3.) Healthcare is a limited resource. Resources require stewards. Stewards should know more than book-learning about what it is they are responsible for. The most appropriate stewards of healthcare resources are physicians, but physicians have a multitude of conflicts and perverse incentives imposed upon them that impair their ability to realize the most efficient use of healthcare resources. Government bureaucrats are not good stewards. Just as there is no bureaucreat who knows better than a parent what is best for an individual child, there is no bureaucrat who knows what the best healthcare recommendations are for a particular patient.

4.) There is no consensus as to what the definition of healthcare is. This creates the conditions that will allow healthcare expenditures to grow exponentially as politically connected causes are able to claim more and more services by arguing that they are part of healthcare. These typically begin with appeals to hard cases, with the underlying assumption that, despite attempts to ration or craft clinical practice guidelines, exceptions will be made for photgenic and sympathetic people disadvantaged by bureaucratic medicine, thus opening the floodgates to healthcare policy being made not only by unqualified bureaucrats and politicians, but by Oprah and Geraldo as well.

5.) The assumption underlying most of the good-sounding calls for healthcare reform, particularly the single-payer utopians, is that healthcae is really relatively straightforward: a patient has a complaint, a doctor orders a test to figure out what is wrong and orders a cure. This is not even remotely similar to the reality. Physicians do not have the same luxury that a car mechanic or washing machine repairman have. A physician can not take a patient apart, swap out parts and see if that fixes the problem. Not every disease has a consistent presentation or definitive test. Not every symptom complex is indicative of disease. A good many patients have good clinical outcomes solely because of the gifts and expertise of experienced practitioners, and these cannot be replaced or even approximated by clinical practice guidelines, critical pathways, or other cookbook approaches to healthcare. Making practice standards more uniform benefits public health statisticians and self-perpetuating bureaucracies. They do little to replace the insight, experience and intuition of skilled practitioners.

6.) Claims about healthcare reform being an element of social justice really suggest the foundation of market-based reform. It is simply common sense to recognize that if a person chooses to forego an intervention and opt not to pay for it as part of his personal healthcare, he should not be compelled to pay for it for someone else. And likewise, if if he opts not to pay for such intervention for his own health, he should not expect others to provide it for him at someone else's expense.

7.) Healthcare coverage, in the sense of insurance, does not provide access to healthcare services. The insurance aspect of health insurance insures the assets of the person against financial ruin precipitated by medical expenses. Access does not result from insurance, or compassion or government mandates. Access results mostly from industriousness of people who benefit from providing such access, and from policies that recognize the mutually beneficial relationship between motivated providers and the society that is beneficiary of their efforts.

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