Medical Care: State of the Confusion Address

President Bush’s State of the Nation address tonight will focus on certain health care reforms. Pre-address critics abound. A more informative address would be to highlight our State of Confusion about medical care.

The confusion centers around two central points: First, many of the ailments of present arrangements that are focused upon are exaggerated; Second, many of the proposals are insufficiently understood in their side-effects or actual intended results.

Such an Address would also be politically unpopular in some circles, or even impractical if one believes politics is more about gulling the public, or more charitably about incremental resolutions that through trial-and-error and more discrete measurability and manageability lead toward larger ends.

Polls that measure specific measures are usually judged practically, even though generalized questions often yield desires for a chicken in every pot. On the other hand, whenever large-scale “master plans” are put before the voters, they are defeated. So, there’s probably more practical understanding among most Americans than they’re given credit for having.

Simply put, the overwhelming majority of Americans are satisfied with their health care, although many are anxious about their future access or affordability. Both the number and severity of the uninsured’s situation is overblown, yet is driving takedowns of health care for the rest of us. The increasing demands for health care services – primary driver of increased costs -- are functions of both advancing technology and drugs able to help more people, and the aging of our population. The former is a good thing, and the latter is unavoidable. Politicians might shuffle those costs somewhat from one group to another, but they aren’t going away.

Again, simply put, we usually fail to sufficiently disaggregate the components of and publics for healthcare, which leads to master plans that aggravate virtually everyone, frequently misallocate resources, or leave many problems unattended, as common with master plans. There are, generally, two master plans proposed by advocates: government-run single-payer health care and free-market health care. Both ignore flies – or elephants – in the ointment, in pursuit of a salve for their larger ideological objectives: statism, in the case of the former, or laissez-faire individualism, in the case of the other.

Depending on the particular reform, either ideologic path may have as many side-effects as intended results, or even be more disease than cure. But, both deal with the same three unavoidable components of health care: access, cost, and quality. The statist path puts faith in bureaucrats to make close to one-size-fits-all decisions for all, concentrating information – though imperfect – among a few with attendant funds and power. The free market path puts faith in each individual to make appropriate personal choices even with highly imperfect information or lesser resources or individual power.

Both sides of the debates are heading in similar directions, rationing, cost controls, quality leveling, in different ways, and with different side-effects and ends intended.

Putting more cost-responsibility upon individuals leads to some more self-rationing, which can also lead to some less self-care than needed. Government-run HMO-like care controls also leads to rationing, but less specific to each’s needs, and has been heavily opposed by most Americans during the ‘90’s. More personal cost-responsibility for care incents more self-informed choices, and increases demand for worthwhile information, although many are too lazy or inadequate to taking advantage of it, and in the case of most care and the most costly portions of care does not materially decrease overall demand. Increased taxes and charges upon those not poor to increase care for the poorer may also make those less poor more reflective on what care is necessary, but doesn’t do that so much for the poorer, and doesn’t so much impact overall cost-driving demand. Putting more cost-responsibility upon anyone, increased self or imposed rationing, both reduce the incentives for entrepreneurs to devise or invent remunerative therapies, which require huge risky investments. The freer market approach still leaves many with the means to and freedom to pay for cutting-edge care. In the more statist approach, as evidenced in Canada and Western Europe, there’s less freedom among patients to seek or financial incentive for entrepreneurs to meet the demand or needs for cutting-edge care.

Just as President Reagan dramatized the runaway federal budget and process by plunking on the podium the giant budget resolutions during his State of the Nation address, President Bush would do much to focus attention on the runaway demagoguery about health care by paraphrasing Helen Hunt’s line from “As Good As It Gets,” by saying “No to a giant government-run HMO.”