By way of Jubilee, I came across this list of healthcare principles by Tyler Cowen. It brings to mind one of the things I considered writing about for the Inequality Symposium (but ended up cutting from my piece, as otherwise it would have gone in too many directions) — to what degree are we willing to accept that poor people will have access to lower quality healthcare?
Elias highlights this paragraph from Tyler’s piece:
2. A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor. Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence. We need to accept the principle that sometimes poor people will die just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree. We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes. [emphasis added]
I suppose it is admirable, in its way, to be so blunt. But I question whether it is indeed something we need to accept, that poor people will die because they have less access to quality healthcare.
As I wrote in my Inequality Symposium piece, almost everyone will need access to healthcare at some point in their lives. Live long enough and you’ll get injured or sick sooner or later. By those lights, I would call access to healthcare a need. How much of the healthcare administered in the United States is truly necessary is an open question, but I’m going to take as a given that it’s better to get medical attention when you’re sick than to go without.
Now Cowen is obviously right that the rich enjoy nicer stuff. But there is a difference between the need for healthcare and our other needs. The same ingredients, prepared in roughly the same way, will nourish you just as well if they are served to you at Per Se or the local soup kitchen. Four walls and a roof will protect you from the elements, whether they are in a housing project or a suite at the St. Regis. And a coat from the local thrift shop will keep you as warm as whatever monstrosity Comme des Garçons is sending down the runway. (Probably more.) The added luxury of the higher quality items or services does not necessarily make them more sustaining.
Not so with healthcare. A bad doctor can actually make you worse. Not just keep you less healthy in the long run, but actually make you sicker.
I see this in my own practice all the time. We direct all patients to Boston Children’s Hospital for emergency or subspecialty care, even though it is much farther away than many more convenient local hospitals. Most comply with this recommendation. Unfortunately, some do not. And the ones who go to the local hospitals almost always get substandard care, be it cursory or outmoded or simply incompetent. While Boston Children’s is not without its flaws (and not everyone reports a wonderful experience after going there), the care delivered is unquestionably better in my estimation.
It is also more expensive. For patients who are covered under a tiered insurance plan, Children’s is almost always in the most costly tier. (I have no idea where my own practice falls for any given plan, and have no good way of finding out. But that’s a different post for a different day.) Which means that parents may have to choose between taking their chances somewhere cheaper, or paying more than they can afford. And I gather that Cowen thinks that’s meet and proper. I am not so sure.
Now, quality and cost of healthcare do not correlate perfectly. Some of the richest (and most expensive) pediatricians I’ve ever known were also some of the very worst, and when patients are treated too much like customers problems can arise. Conversely, I know many dedicated, excellent medical providers who work in clinics that serve the poor. But to the degree that higher quality care tracks with higher cost, to what degree are we willing to say that the poor should take what they get and be glad of it? If their kid ends up with a worthless prescription for albuterol syrup, is that just the brakes for being poor?
I fear that some of Cowen’s other suggestions would only compound this problem. He suggests:
4. Price transparency (mandated if need be) and real competition in the health care sector, including freer immigration for doctors, nurses, and other caregivers, and relaxation of medical licensing and encouragement of retail medical clinics, a’la WalMart style. This helps keep the cost of the mandate to reasonable levels.
I’m all for price transparency. The opacity of healthcare pricing is a significant problem. But I’m not at all sure that relaxing the rules for licensure and allowing freer immigration for healthcare providers per se is the right answer. (I favor looser immigration rules writ large, not just as pertains to healthcare workers.) Not to be terribly chauvinist about medical education in the United States, but we at least know what the requirements are for accreditation for medical schools in this country. If Cowen is referring to medical providers trained in developed nations, then I don’t have many worries. But I’m not at all sure that a doctor trained in Germany or Japan is going to be any cheaper once imported. If he’s referring to providers trained in the developing world, where standards are less clear and who we might thus expect would charge less for their services, isn’t that just another way of saying that poorer people will be getting less reliable care? Isn’t it reasonable to presume that providers who would have a hard time meeting current licensure requirements would also be less apt to deliver good care?
I’ve already expressed my concerns about retail clinics, and shudder to think of Wal-Mart doing to medical care what it’s done for other retail products, though I will admit that they may be a good alternative for urgent medical needs provided there is good follow-up communication with primary care providers. But I’m skeptical that the price differential between private providers and urgent care clinics will be a significant source of healthcare savings.
Finally, I’ll raise a question that occurs to me whenever cost controls are mentioned (as Cowen does in his point 5). Should providers at a place like Children’s be allowed to charge more? Should I, who have gone to the trouble of getting and maintaining privileges there, be allowed to have higher fees than someone on staff at Our Lady of the Worthless Miracle? (Since pediatric care contributes a relatively small amount to overall healthcare expenses in this country, perhaps [as with Robin Hanson] my specialty will be spared the knife.) Which costs are to be controlled and how is a remarkably fraught question.
As far as publicly provided professional services are concerned, medical care isn’t unique in its difficulties. The plight of students in certain failing public schools is well-known, as are numerous examples when public defenders have neglected to give their clients effective counsel. I am not suggesting that all disparities in healthcare be eradicated, any more than I am suggesting that all children are entitled to attend Phillips Exeter or all defendants are entitled to retain someone from Debevoise & Plimpton. I’ve said before that people who are willing to pay for extra tests or referrals should be allowed to get them, even if I think they’re superfluous. (This may or may not equate with “better” care.”)
But just as we would (hopefully) recoil from bland acceptance of an innocent man being executed because of incompetent counsel or of students graduating from high school functionally illiterate, so I would hope we would recoil from blithely accepting that some people will die because they can’t afford to go to a decent medical provider. As in my response to the Hanson piece above, I have more questions than answers. But I cannot believe that the best answer to the questions that persist, intractable as they may seem, is to shrug and say “that’s just the way it is.”