Testing, and you should read it anyway.
I’m testing my Digg hookup to the blog, and luckily one of the dugg stories today links to a short story that is perhaps just as much my favorite as it was Asimov’s. I couldn’t tell you when I first read it, it seems like ages ago, but as a boy or young man I remember that in the span of a few pages it changed the way I approached thinking about the Universe.
I have two girls, the oldest being 3 1/2, and I fervently hope that as they get older that each at least reads a little bit in the genres of science fiction and fantasy. I hope that it would help them be able to think creatively, or at least that then we would have something to share.
Testing . . . testing.
How sick am I, exactly?
First and most importantly, is anyone but me having trouble with Cato Unbound’s trackback system? My last post should have connected via trackback to the Lead Essay, but I got nothing. It’s happened before, and I’ve rectified it in the past by reposting–the trackback feature has in the past worked fine the second time, but it didn’t this time.
So anyway if you’re really into this kind of topic and you’ve got way too much time on your hands, feel free to go back and peruse my last entry.
I don’t know what type of contribution this entry is going to make to Matthew Holt’s Reaction Essay, but one part in particular jumped out at me–whether it is possible for consumers, if paying for health care services at an individual level, to make informed decisions. If you follow Kling’s model and go with insurance rather than insulation, the consumer still has threshold decisions to make regarding care. We can’t all be like Uncle Mort and not go to the doctor ever until you die of old age at 102.
The field of medical care is science, but it’s a science I believe is quite beyond the grasp of even intelligent people outside of the field. The typical libertarian response to something like that would be to call me patronizing, or to say that I have a dim view of humanity if I poo-poo the average Joe’s ability to grasp some concept or set of concepts. But really, once you get outside of such things as the common cold or a broken bone, how many ailments can you say with any confidence you could self-diagnose?
In other words, in Kling’s system one of the first calls you have to make is whether to go to the doctor. You would have a high-deductible plan which means you’re going to be paying to have something checked out, and the deductible would be high enough that you would be paying out of pocket for common minor ailments or injuries for which you seek medical care. There is a built-in disincentive to seek medical care unless you think you’re really sick and/or injured. Because when you get cancer, or you are in a serious car accident, that’s what Kling’s insurance is designed to capture.
Some of that is more of an obvious call than not. None of us are the Black Night, apparently impervious to amputation. But what about the plethora of other serious conditions that may have simple, even innocuous beginnings–when catching something early means the difference between either life or death, or even between an early treatment regimen with moderate cost vs. a critical late-stage medical intervention costing substantially more?
And perhaps in isolation most individual cases are easy to figure out. Well, stupid, if you were having X symptom you should have gone to see the doctor. Now you’re dying. But a perusal of web sites relating to, say, early cancer symptoms shows lists of potential symptoms that you might not go to the doctor for under a high deductible policy. By the time you go see a doctor they could very well say–well, crap, if you had been here 6 months ago maybe we could have done something . . .
And it’s not just cancer. You could have symptoms related to serious and worsening heart disease that start out relatively innocuous. If you have kids you might be tempted just to stay home when sickness gets passed around (as it often does, particularly around the holidays), only to find out later you were exposing them to something more serious than the flu or a cold.
Point is, from a cost perspective and from a medical perspective catching a serious condition early is almost always significantly preferable to diagnosing something when the symptoms become blatantly obvious. But this ties into my first point–most of this stuff we’re never going to realize. We are not trained professionals and no matter how much time I spend at WebMD I’m hardly ever going to be able to tell whether a symptom I am having really needs to be checked out or not.
That is one of the nice things about insulation–if I can go in often, a doctor is more likely to catch a big one when it comes. When I go in for small things, a good doctor may ask questions that help build a solid medical history that can be very valuable in a pinch.
I haven’t translated this into a specific policy philosophy regarding health insurance–I’m a libertarian at heart, but the ability to obtain, assess and apply good information is the core to good market function and at the end of the day I just don’t know that I’m convinced that is possible in the medical “market”. I know that there is a market itself for good, consumer-level medical information, but even then assessing and applying that information to put together an informed risk assessment? Tall order for any of us given the stakes.
Of course, then I go back to questioning–what alternatives to market-based health care are sustainable? And if you read my last post you’ll see markets are still my preference, but damn, even in talking about medical markets–much less medicine, there is a whole hell of a lot of information to wade through to try to come to a semi-competent philosophy (see, e.g,. Cato Unbound’s recent topic on the pros and cons of democracy itself).
Tough one. Are there markets where the challenges to informed decision-marking are so significant that the market itself is too ineffecient to operate properly? Is this one of them? Is it too much for a libertarian to admit, even if true?
You mean I should have read the end first?
Once again I return to Cato Unbound to comment in areas I have no business commenting on regarding fields beyond my depth. But hell, it’s better than working, right?
This month’s Lead Essay by Arnold Kling goes through all the mechanics of what he believes market-based health insurance would look like (which he refers to, surprisingly, as “insurance”) and what is wrong with the current system of going to your doctor any time you get a hangnail (described as “insulation”).
I did chew through the whole thing, in which there was a variety of interesting statistics, examples, anecdotes and arguments. I have done this so that you do not have to, a service of substantial value were it not that you would not be here but for reading Kling’s essay first. I recommend reading only and exactly two parts–the introductory section describing the premise of the Lead Essay, and the last paragraph.
Why do I say that? Because of the following items: (1) The public has proven and continues to prove to be amazingly resolute in ignoring logic backed by evidence in favor of temporary benefit and/or relief for discomfort (such as fear); (2) Kling spends what I consider to be an inordinate amount of time telling us what market-based insurance would look like, an exercise I consider to be a waste of time; and (3) the last paragraph contains the only useful information about what is going to motivate the public to seek reform.
With regards to the first point, I don’t see any other way to interpret the political data we have accumulated over the history of this country. We have gradually shifted from a relatively free (if generally dysfunctional) society to a relatively quite regulated (and still dysfunctional) society. Libertarians have as much ammunition as anyone should need for various evidence-based arguments, yet even under a historically limited-government political party we continue to slip further and further towards whatever end of the political spectrum guarantees us less freedom–sometimes moving both left and right at the same time on different issues, see, e.g., prescription drug benefit and civil liberties in the past couple of years. There is perhaps some small amount of evidence that libertarians are making inroads in specialized areas–local and state movements regarding marijuana, for example, but talk about sticking your thumb in a dike full of holes!
The point is that the public has become so mistrustful of and cynical regarding ”data” itself that I don’t know whether the dissemination of what libertarians consider to be fair and impartial data means much of anything except to those already predisposed to believe it. I believe Kling’s last paragraph provides the only real evidence people will believe.
With regards to my second point, Kling seems fairly comfortable describing what he believes the market would provide absent government incentives for the status quo. While I don’t have any outright objection to his doing so, I generally tread in these areas very carefully. Even given contemporary and/or historical examples, should anyone really feel comfortable claiming reliable speculation in advance as to what a market solution will look like? Perhaps Americans value insulation to such a degree that markets will adjust in a sustainable way to provide affordable levels of reasonable insulation. After all, if this millenium has shown us anything it is that fear is still the great motivator. What if Kling’s MRI results had shown a more serious injury? Or if his nephrologist has actually turned up something important to his health?
Perhaps he would not have been here to write his well-argued lead essay, but it would have been the optimal market result! At least it would be under his framework (and don’t get me wrong, I’m on his side). And perhaps that is the right answer, but I don’t know that I would foreclose the idea that people will spend a lot on their own health and the health of their loved ones. If you have trouble convincing people of the logic in arguments on a logic-heavy topics, wait until you try to convince them of something relating directly to the health and well-being of their children. That’s getting off-point a little bit (but is certainly worth noting in any discussion involving changes to our health care system), so I’ll just go back to saying that even someone as well-researched as Kling I believe will struggle to be accurate in predictions about how the market would react without the presence of government interference other than to say that market forces would impact the status quo very quickly and that the general direction would be towards more overall efficiency.
My final point of the three, and quite frankly if you’ve read from the beginning I’ll say that you almost certainly could have skipped directly to this paragraph, is that I believe the last paragraph carries as much persuasive power as you are ever going to get out of this subject, and no one is going to believe it until it happens. See point 1, re: data cynicism.
Good luck, Mr. Kling, you’re going to need it.
