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Health care priorities

Health care resources, as we all know, are scarce. How has our country chosen to distribute these resources?

In Michigan, family medicine is "dying" as medical students are lured away from primary care.

More than a quarter of Michigan's 12,700 primary care physicians are at retirement age, according to a recent report from the Michigan State Medical Society. At the same time, today's medical students are being lured to specialty fields that promise better pay, more manageable hours and the chance to work with flashy new technologies and treatments. (Via Kevin, M.D.)

At the same time in California, EM physicians are finding it harder and harder to find specialists who will care for their patients:

Hospitals are paying $600 million a year to ensure that on-call physicians are available - and still some communities are having problems finding specialists," Emerson said.

Kivela said that if a patient shows up at the emergency room with a broken jaw and has no insurance, the emergency room physician has a dreadful task of finding an oral surgeon willing to come in and take the case.

"I'll have to call eight or 10 different doctors," he said. "I'll spend two hours making these calls while a bed is taken up in the emergency room while sick patients wait." (Via Symtym.)

This may be absurd, but it's not chaotic. We have a system that draws money and talent away from the most cost-effective fields of primary care and into the less cost-effective specialties, while this same system also makes it more and more difficult for a patient to gain access to those specialists. It's no wonder that our country performs so poorly on virtually all measures of public health like life expectancy and infant mortality.

Of course, we haven't gotten here by accident. We've chosen to endure these piss-poor public health results because we don't want to disturb our unquestioned ability to provide the world's best high-tech medical care to those patients who can afford to pay for it themselves.

We've chosen to lower medicaid and medicare payments to primary care physicians because we're both unwilling to bear the tax burdens of these redistributive public health programs, and we prefer to spend what tax revenue we do collect on the development of high-tech medical treatments. These high-tech solutions are favored by the private sector because they're a lot more lucrative than low-tech primary care. We've chosen to funnel our finite amount of health care resources into the pockets of pharmaceutical companies, medical device manufacturers, hospitals, and specialist physicians who primarily treat the wealthy self-insured. This has been at the expense of cost-effective primary care and low-income chronically ill patients.

Is this a good thing? Some of us think not. More of us -- at least to the extent that our policies reflect our democratic preferences -- think it is.


But our policies don't reflect our democratic preferences; they reflect our market preferences. And when many people in the market either (a) can't afford health insurance or (b) don't choose the sort of health coverage we get, the situation ends up somewhat absurd.

I agree that our policies don't reflect democratic preferences. I think if you ask most people what is wrong with healthcare, one of the first things that will pop into their mind is malpractice. It is definitely a buzzword that is an easily packaged concept (evil lawyers hurt good doctors), while the real problems/challenges, although they include malpractice to a degree, are largely ignored/unknown/misunderstood by the public.

What you're saying is that government interference has distorted the market, right? I don't know enough right now to be categorically for or against government-provided health insurance. But it sure seems to me that, if it's going to provide insurance, the government should try its very hardest not to distort the market by (in this case) making arbitrary decisions about what price is fair. Am I missing something or do we agree on this, Carey?

L: Actually, I'm saying the exact opposite. We've made the political decision that our scarce health care resources shall be allocated in a way that doesn't deviate too far from the market allocation.

I'm also saying that this is a mistake. Basic healthcare should not be treated as a commodity and allocated by market mechanisms. Certain cosmetic procedures and elective tests might certainly be treated as commodities, but not basic healthcare.

It's no argument against this position that it would be difficult to decide what "basic healthcare" should consist of. We already make tough decisions about what to regulate and what to leave to the market all the time.

I'm saying that I think we've made the wrong decision about healthcare.

Laundry soap? A commodity whose price should be set by the market. Dialysis for kidney failure? Not a commodity. Make sure that everyone who needs it, gets it.

I'm not arguing against your position that everybody who need Dialysis should get it. I agree with that. But how should it be provided?

Let's assume for the moment that it is the government's responsibility to provide health care to those who can't afford it for themselves. What you say is that medicare/medicaid decided to reduce payments to primary care physicians and this caused a shift in the market which makes people less likely to become primary care physicians. That makes sense: lower the salary, and you'll see less people interested in the job. That is a political decision that our scarce health care resources should be allocated in a way that deviates from the market allocation.

I don't really have a problem with government-sponsored health care. It is when government no longer just pays for health care but determines its value that I start questioning. How do you decide how much a doctor's time is worth? If the program starts to become too expensive, what's going to be more expedient, raising taxes or cutting payments? Once doctors start bringing home less bacon, aren't you going to have fewer and fewer people interested in becoming doctors? Maybe there's an answer to these questions, but I'm not convinced that the government can provide it. If I could be sure that a national health program could resist the temptation to manipulate prices through its coercive power I might be able to support it. Otherwise, I don't know.

I still think we mostly agree on this issue. I agree that we can decide what basic healthcare is, and we can pay for it for those who can't afford it themselves. Maybe where I differ from you is that I think we shouldn't be deciding how much it is worth. Is that a fair summary?


I'm a little confused as to how the government can pay for health care without paying attention to how much they're willing to pay for it. What definition of "market" are you working with, where one party pays without questioning?

Of course, that wasn't me. Although shockingly, I am not an H-Dogg either.

Not an H-Dogg,

I think there are lots of ways to envision that. Just to pick one out of the air, there could be a progressive scheme of co-payments for various medical things, perhaps with an income cutoff below which there would be no co-payments at all. Something like taxes. Obviously I haven't really thought this through. There are probably better ways, that's just the one that occured to me first.

I'm just saying that I don't trust the government to set prices in general, and in fact that is exactly what Carey is complaining about. Enlarging the system is not the answer, because it just gives more power to those who set the prices.


I agree that one source of the health insurance problem is that the people getting the health care don't really have choices because it comes from their workplace. Why is that the case? Why does it seem that affordable health insurance is only available through larger entities such as employers and universities? I really don't know, but I would like to.

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