By Pascal-Emmanuel Gobry
Wednesday, October 25, 2017
Note: Pascal-Emmanuel Gobry, a conservative writer
and fellow at the Ethics and Public Policy Center, is writing a series of
columns on uncomfortable truths about health care in America. Some will make
conservatives more uncomfortable, others will make progressives more
uncomfortable, but most should make everyone uncomfortable.
Gather ’round, children, if you want to hear a scary
story. Last time around, I pointed out that while everyone “knows” that there
is a lot of waste in American health-care spending, we engage in widespread
self-deception about the true magnitude of the problem. That half,
approximately, of all U.S. health spending is wasted, is simultaneously
scientifically uncontroversial, ignored by health-policy experts, and totally
absent from public debate.
But that’s not the worst part. In fact, it could be good
news in a way: The magnitude of the problem suggests that there’s a lot of room
for improvement; more important, if we can only educate more people about the
fact, then positive change might be on the horizon.
Fat chance.
Because it’s not just that we waste so much money, it’s
that the most wasteful spending is also the most popular.
Some of this is already broadly understood, at least
among those with an interest in health-care policy. America’s two major
health-care entitlements are gobbling up ever-bigger amounts of cash for less
and less value. The two major health-care entitlements I am referring to, of
course, are Medicare and employer-sponsored health insurance, which is
subsidized by the biggest loophole in the tax code. (You thought I was going to
say Medicaid? True, Medicaid is terrible, but for
different reasons.)
Yes, the latter is very much an entitlement. Some
conservatives resist that sort of language in the interest of a philosophical
defense of private-property rights, the idea being that to call a tax break
government spending presupposes that our money belongs to the government. I
applaud and share the philosophical attachment to private-property rights, but
we shouldn’t let it obscure the fact that macroeconomically, tax expenditures
have many of the same effects as government spending, since they represent
spending directed by the government rather than private individuals.
While Medicare’s dysfunction is mostly only on the radar
for right-leaning health-policy wonks, there is broad unanimity that the tax
break for employer-sponsored health insurance, passed during World War II to
get around wage controls and having since ballooned into a monster, is one of
our major sources of waste. It is a huge giveaway to insurers and virtually
ensures that third-party payments — the “original sin” of the American
health-care system, that which prevents consumer dynamics from operating — remain
the center of the system.
It is also the most popular part of the American
health-care system. There’s a reason why Barack Obama, no dummy, made a refrain
of “if you like your plan, you can keep your plan.” And there’s a reason why
breaking that promise made Obamacare so unpopular, and there’s a reason why the
GOP suddenly became the party of keeping your plan — that is, the party of
entitlements.
One of the few good parts of Obamacare was the so-called
“Cadillac Tax,” an attempt, albeit a ham-fisted one, to get this monster a
little bit under control by taxing the most expensive plans. It’s also no
coincidence that it’s the part whose implementation keeps getting delayed and
the part that Republicans are united in wanting to repeal.
This, at least, is fairly well understood among
health-policy experts, even as the political impossibility of doing something
about it looms so large. But wait, there’s more! There’s something that’s just
as bad, if not worse, and even more popular — and that isn’t even on most
health-policy experts’ radar: doctors.
Doctors are the biggest villains in American health care.
They are also, of course, its most popular actors.
As with public-school teachers, we should be able to
recognize that a profession as a whole can be pathological even as many
individual members are perfectly good actors, and even if many of them are
heroes. And just like public-school teachers, the medical profession as a whole
puts its own interests ahead of those of the citizens it claims to be dedicated
to serve.
One of the most celebrated pieces of health-care
journalism in recent years has been Atul Gawande’s New Yorker exposé on the Herculean efforts by a handful of
scientists to get intensive-care physicians to implement basic hygiene measures
so as to stop hospital-borne diseases, which kill about 100,000 people per year
according to the CDC. The “checklist” was of no cost to the doctors, and its
scientific rationale was unquestionable. Doctors still resisted it with all
their might because they found it mildly inconvenient; perhaps they found it
even less acceptable that anybody might tell them how to do their jobs.
Somehow, “sociopathic” seems a mild descriptor.
It goes on, of course. The evidence that artificial
intelligence is better at diagnosis than most general practitioners is pretty
robust at this point, and the profession resists it tooth and nail. In a
few years, we’ll be able to know how many unnecessary deaths this led to, but
the number will have lots of zeroes. It’s hard to think of a measure or policy
in the interests of patients that doctors haven’t ferociously resisted as a
group.
Much like public-school teachers, the medical profession
has used its positive image to create a legal structure that fills its pockets
and prevents accountability. Medical-licensure rules make the health-care
system a gravy train run for their benefit. Countless procedures that doctors
have a legal monopoly on could just as well be performed by less skilled
experts. This is hugely wasteful, but it only scratches the surface.
The legal regime’s reification of medicine prevents new
and successful forms of medicine from appearing. Milton Friedman liked to point
out that the Mayo Clinic, by all accounts one of the world’s top hospitals,
whose success is credited to its group practice and tertiary-care model, would
have been illegal under the medical-licensure rules that were passed later on.
In other words, the biggest problem with medical licensure isn’t that we’re
paying too much for the services we’re currently getting (although its effects
include that too); it’s that it is preventing new and much better services from
being born.
It’s hard to say if general practitioners, as a
professional category, should even exist. We treat the breakdown of medical practitioners
into “doctors” and “nurses” as a self-evident law of the Universe or the
product of some sort of scientific imperative. In reality, it is a mandatory
reification of the way the medical profession worked a century ago, and there
is no reason to believe that it is the way health care should be run. In
Africa, which suffers from a dire doctor shortage, there are examples of
professionally run clinics that deliver a first-world standard of care to
hundreds of patients without a single doctor. It’s highly probable that in a
deregulated system you would have a broad spectrum of medical professions going
from less skilled to more highly skilled, perhaps even without the concept of
“doctor” except in the same vague sense that an “engineer” can be both a
low-skilled technician and a cutting-edge researcher and everything in between.
This is a good analogy: When computers were first
invented, (largely male) skilled engineers worked on arcane computer code while
(largely female) lower-paid and lower-skilled assistants turned the code into
punch cards and the punch cards back into code. As the technology evolved, that
division of labor became obsolete, and even as the word “engineer” remained, it
covered a completely different reality. Imagine that at some point circa 1964,
engineers had successfully lobbied so that only those with a Ph.D. could
program computers (and that their association would control the accreditation
of computer-science schools and how many people graduate each year). You can be
sure that in that parallel universe, in 2017 a computer is something that looks
like something from our 1980s and costs $20,000. We would have none of the
economic and cultural transformations that the software revolution wrought —
and even worse, we wouldn’t even know what we were missing.
But to circle back to this column’s original point, we
have Stockholm’s Syndrome. Except for the more reckless libertarians, nobody
dares to touch the doctors, because economic literacy is so low and because our
emotional investment in the idea of their expertise and professional dedication
is so high.
It’s not just that we’re wasting half the money. It’s
that the most wasteful half is the most popular.
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