Shortly before I gave up entirely on the world, the flesh, and even the devil, I spent two years as an intern in the Department of Clinical Bioethics at the National Institutes of Health, where my immediate boss was Dr. Zeke Emanuel - one of the architects of Obamacare (and also, as it happens, a great guy - even if he does happen to have a brother named Rahm). So I've been around all this health-care policy stuff for more years than I care to remember. In fact, I've been around it for so long that I can hardly stand to think or talk or write or read about it anymore.
Which, I guess, is why I missed this absolutely terrific article by David Goldhill, published in last September's issue of The Atlantic. Big, big tip o' the hat to Stephen Spruiell, at The Corner, for bringing this to my attention. He quotes Goldhill:
"'I'm a Democrat, and have long been concerned about America's lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system - largely problems of incentives - our reforms won't do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand the role of insurance; focus the government's role exclusively on things that only government can do...overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices and sensible trade-offs between health-care spending and spending on all the other good things money can buy." [Emphasis added.]
Spruiell comments: "If you want one single statement summing up what conservatives' guiding principles on health care should be, that is it. And if you want to know why most conservatives that I know hated this bill, let me explain: It expands, rather than reduces, the role of insurance; widens the government's role to include things that the government shouldn't be doing...deepens our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and reduces the role of the consumer as guarantor of good service, reasonable prices, and sensible trade-offs."
Consider the point about insurance. Many conservatives, I think, have a reflexive tendency to defend the health insurance business against criticism - simply because it's a business, I guess. But, in its present form, it's a totally crazy, misbegotten horror of a business. Goldhill again:
"...health insurance is different from every other type of insurance. Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We've become so used to health insurance that we don't realize how absurd that is. We can't imagine paying for gas wih our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance. Most pregnancies are planned, and delieveries are predictable many months in advance, yet they're financed the same way we finance fixing a car after a wreck - through an insurance claim...
"Insurance is probably the most complex, costly, and distortional method of financing any activity; that's why it is otherwise used to fund only rare, unexpected, and large costs. Imagine sending your weekly grocery bill to an insurance clerk for review, and having the grocer reimbursed by the insurer to whom you've paid your share. An expensive and wasteful absurdity, no?"
Well, indeed. And Obamacare doubles down on such expensive and wasteful absurdity. Instead of reducing our dependence on insurance coverage for day-to-day expenses, with all the perverse incentives and moral hazard that entails, it forces millions more into the system.
Lunacy. Utter, hopeless lunacy.
It's hard to choose a favorite insight from Goldhill's article, but I particularly liked his damning discussion of hospitals and their malign political influence, including this refreshingly skeptical passage about "the oft-quoted 'statistic' that emergency-room care is the most expensive form of treatment." He writes:
"Has anyone who believes this ever actually been to an emergency room? My sister is an emergency-medicine physician; unlike most other specialists, ER docs usually work on scheduled shifts and are paid fixed salaries that place them in the lower ranks of physician compensation. The doctors and other workers are hardly underemployed: typically, ERs are unbelievably crowded. They have access to the facilities and equipment of the entire hospital, but require very few dedicated resources of their own. They benefit from the group buying power of the entire institution. No expensive art decorates the walls, and the waiting rooms resemble train-station waiting areas. So what exactly makes an ER more expensive than other forms of treatment?
"Perhaps its accounting. Since charity care, which is often performed in the ER, is one justification for hospitals' protected place in law and regulation, it's in hospitals' interest to shift costs from overhead and other parts of the hospital to the ER, so that the costs of charity care - the public service that hospitals are providing - will appear to be high. Hospitals certainly lose money on their ERs; after all, many of their customers pay nothing. But to argue that ERs are costly compared with other treatment options, hospitals need to claim expenses well beyond the marginal (or incremental) cost of serving ER patients."
I mean, whoah. Did I say damning? Or did I say damning?
Goldhill concludes his article with some eminently sensible practical suggestions, which he summarizes as follows:
"A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care - with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance."
I'm not in love with all of the details of his plan (which includes individual mandates.) But there's just no doubt that his general approach would be infinitely preferable to the monstrosity that we all just got stuck with.
So RTWT, already.
It's a beginning.