ObamaCare – damning with faint praise all one can do

Two weeks ago President Obama signed what is being called an “historic” health care bill, and belated the United States is to have a sort-of-almost-maybe national health care system. Except that much like the Holy Roman Empire, which was neither Roman, holy nor an empire, US health care will not be universal (some fifteen million people are still left out in the cold), national (people still have to buy health insurance) or particularly historic, since everybody else in the western world got health care 40+ years ago. So, er, hurray.

comme-ci, comme-ca health care*

Of course everybody hates it.

The left because they maintain, not unreasonably, that Obama gave up the public option (early on he seemed to be harbouring the vain hope that it would lead to some bipartisan support) and as such Medicare, the existing system for seniors, was not expanded – which would have at least provided a kind of national health care without starting from scratch. Pity. That would have been the logical route. But nooo. Not in America. So, the basic, dysfunctional structure of American health care remains – and insurance continues to stand firmly between the patient and the health care provider.

The right hates it more and for a lot more reasons – although there’s some serious irony here since the genesis of this bill was the Republican proposal to counter what was dubbed HillaryCare back in the 90’s.

First and foremost, the right is cranky because a lot of them listen to Glenn Beck and Fox News and hang out at those tea parties where there aren’t any sandwiches, and they simply hate anything Obama does. More rationally, however, they object to the form of the bill, which forces individuals to purchase health insurance (which, if they can’t afford, the government will subsidize). Here they have a point, since you have to admit it does seem a touch undemocratic to make people buy something whether they want to or not.

Republicans add that the the bill makes no attempt to cut costs or deal with the ludicrous consequences of  litigation; this argument is true albeit disingenuous since if they had actually got involved, as Obama had asked, they could have added that in.

Business is not too keen on this bill either, probably because health insurance is currently provided, for the people who have it, through their employer, and business has no idea what this bill implies for them, and they loathe uncertainty.

(The bill would tie health insurance to the person, so even if they lose their job they keep their insurance. There is also talk of creating some kind of risk ‘pooling’ for people who are not employees but self employed or what-have-you. Plus, in theory at least, insurance companies will no longer be allowed to turn away people with pre-existing conditions – though I’m sure some clever lawyers are already figuring out other ways to reject people they think will cost too much. Too tall, perhaps or too freckled.)

My problem with this bill is its fundamental premise, namely that health care has to be administered by insurance companies. It’s a nincompoop idea and only one that a country besotted with business could endorse.

Insurance companies, boys and girls, are what are known as bu-si-nesses. This means that they exist to  make money: their raison d’etre is profit. If it were otherwise we’d call them, oh, NGO’s. Not-for-profits. (That’s what we used to call charities before we opted for the more unwieldy name.) Except that health care, medicine, is not and cannot be (ever!) a business. Economists long ago realized that it simply does not fit the market model.

Health care is not a commodity. You cannot make money on health care. Never mind that you shouldn’t. Why? Well, for those of you who missed Econ 101, I’ll explain. Please pay attention, there’ll be a quiz later.

The free market is at heart transactional: I make hand-embroidered doilies; you, for reasons that elude everyone else, like and want hand-embroidered doilies. So, I make them and you buy them from me. And we’re all happy. I, in turn, use the money I make to buy things I want/need, like food and shelter and some really cool stilettos. Supply and demand.

But (and here’s where it gets tricky), if a villager in China can make aforesaid doilies that are just as nice for a lot less, then you will get them from her so I will be out of business, unless I move my manufacturing to an even cheaper place, Bangladesh, say. This, in a nutshell, is the free market, which, in Adam Smith’s immortal baker metaphor, does not rely on the goodness of anyone’s heart but is inherently rational. As are consumers.

Now you and I both know that this is patent nonsense. Not only are most people not rational consumers, most of the time they  are crazy. Or, as a psychiatrist would say, stark raving bonkers. Why else would tens of thousands of people line up on Boxing Day to get a gizmo they don’t need? Or pay good money to buy a piece of bacon wrapped in a pancake with a list of ingredients too long to read? (I could go on but you get the picture.)

Even if consumers aren’t nuts their actions are often dictated by a lot of things other than reason, price and need. Otherwise nobody would ever buy a Kelly bag or have eighteen pairs of virtually identical black trousers. But for the sake of argument, let’s stick to the model – this is 101, remember, and we don’t have time to veer into behaviorial economics and all that complicated stuff like status and advertising and whatnot.

So homo economicus operates on simple efficiency and if he or she can afford it, they will get the best darn doily or car or house they can get. So, people with money get the nice stuff, the cashmere sweaters and the Prada belts, while everybody else makes do with Joe Fresh and H&M. That’s life according to economics.

Health care doesn’t work that way. Nobody gives up a trip to the Bahamas to check themselves into the hospital for a quadruple bypass for fun. That’s because, in economics-speak, health care is not a direct “purchase” but is subject to agency issues. In other words, there is a person or a group between the person and whatever is being bought, whether it’s a bypass or a prescription. When I feel sick, no matter how many internet sites I surf or friends I text, I really don’t know the reason; I need a doctor. Or a nurse. Or a faith healer if that’s what I happen to believe in. Even if I did figure it out the diagnosis, I can’t write myself a prescription or do surgery on myself. I need someone else, an “agent”, to confirm my choice. (In terms of that quadruple bypass I should really go back to the internet and do some serious research because there’s no evidence it is in any way preventive if I’m feeling all right, but that’s another post.)

Medicine, unlike cars and refrigerators and new tiles for the bathroom, is about a patient, a person who is sick and vulnerable and scared and in no position to make rational choices about anything. This is also why there are medical ethics and professional organizations and the Hippocratic Oath (though that’s just a metaphor, the actual Oath hasn’t been used for nearly a century no matter what TV shows would have you think.)

“Enough”, when it comes to cars and refrigerators and trips to sunny Spain is only limited by your budget and, presumably, greed and appetite: if you really want thirty six SUV’s, or feel the need to stuff your kitchen with 97 Sub-Zero fridges full of chocolate ice cream and would like to give Imelda Marcos a run for her money when it comes to shoes – well, if you can afford it, it’s your choice. Medicine is not like that.

Too much medicine – too many medical interventions – can kill you.

It’s called iatrogenesis. A term from the Greek, meaning harm caused by medical treatment. One aspirin can take away your headache; popping the whole bottle is a suicide attempt. One operation could save your life (if it goes well) but if you have an appendectomy and for whatever reason things screw up and you end up in ICU with sepsis and need four more operations, well, you could easily end up maimed or dead. In fact the more you get done medically, the lower your chances.

As Peter Davis writes in the Canadian Medical Association Journal (“Health Care as a Risk Factor”, http://www.cmaj.ca/cgi/content/full/170/11/1688), close to 70,000 preventable adverse effects occur each year, some 20% of which result in the person’s death. This, writes Davis, is not because hospitals are inherently dangerous places but because the “unchallenged therapeutic imperative” tends to move people to ever-higher (and more complex) levels of care, levels that they are unable to sustain.

When people proudly proclaim that American health is “the best in the world” therefore, as they are wont to do, what they mean is that they have access to more MRI’s and operating theatres and doctors than anyone else. The model they’re using is that of the market. Except they’re dead wrong (so to speak). By any objective measure American health care is the worst in the developed world. Life expectancy is lower, infant mortality is higher and your odds of surviving healthily after a heart attack are considerably lower than they are anywhere else in the west. Why? Iatrogenesis. Americans do too much. Too many tests, too many surgeries; too many drugs. In short, overtreatment. Because medicine in the US is treated like a commodity, like cars and refrigerators and Prada bags, which it is not.

That’s what Obama’s bill didn’t even begin to address. True, some of the currently uninsured might, if  all goes well, not end up bankrupt if they get sick. More people will have access to health care. The notion that health care might be a basic mark of a civilized society has at least come up and might even be discussed further. It will continue to cost too much (16% of GDP at last count versus an average of 10% in Canada and France and everywhere else); doctors will continue to practice “defensive” medicine and Americans will continue to get sub-standard care. But at least it is a start.

Too bad it was so fitful.

* photo c/o creative commons and newsrealblog.com