Sunday, June 18, 2006


Yes, I'm still reading Crisis of Abundance, Arnold Kling's smart little book on health care economics. I should be posting more, and I apologize to the (almost certainly hypothetical) readers that have been eagerly awaiting my next post. Today - chapters 3 and 4


Health care economics are all about deciding how best to spend the limited pool of dollars available. This may seem obvious when you think about it, but many people probably don't. It's easy if you look at in extreme terms. For example, lets assume we have a billion dollars to spend. What if we could use it to save one life through an incredibly expensive but 100% effective medical treatment? What if that person was already 80 years old? What if we could instead spend the money ensuring sanitary drinking water for an entire developing country, saving thousands of lives that would otherwise be lost through cholera or dysentery? From this viewpoint, you'd almost certainly decide to let the one guy die and save the thousands.

In real life the decisions are a lot closer, and sometimes the answers aren't at all clear. These are the problems Dr. Kling engages in chapter 3 of Crisis of Abundance. He makes five "key points" at the start of this brief chapter and fills them in.

What I get out of the chapter:

  • A lot of health care spending isn't clearly necessary or unnecessary; it instead falls into a gray area.
  • In a perfect world, we could look at a given medical procedure and measure the probability it will help, and value of the benefit if it does work, against the cost of the treatment. In the real world, we can only know the costs for sure; few treatments are 100% effective, and the value of the benefit of the treatment, even if it were 100% effective, is often at best a rough guess.
All of this is complicated by the availability of different diagnostic procedures and treatments with different possibilities of success. The "best" diagnostic tool might be only 10% more effective than the next best, but it may cost 3 times as much. It's not so important if it's a difference between a $10 procedure and a $30 procedure, especially for a serious ailment, but it can make a big difference when you have a $5000 procedure.

Given these difficulties, it's not surprising that different doctors and patients come to different conclusions. Even for Medicare, which is fully paid for out of taxes, the results vary widely by regions. One statistic jumps out of chapter 3"

The proportion of patients seeing 10 or more physicians in the last six months of life ranges from a low of 17 percent to a high of 58 percent."
I don't think it means we have widespread random malpractice in the treatment of dying patients. It does mean that a lot of capable doctors and concerned patients are groping in the dark for answers.


What, then, should a health care system look like? Chapter four begins to look at this. No system can be perfect. He starts the chapter as follows (highlights are mine):

Any health care system must reflect a compromise of preferences. We cannot have a health care that is both accessible and affordable while insulating consumers from the cost.
It's a point that should be obvious to grown ups, but is often lost in the health care debates. You can can't have whatever you want whenever you want it for free. So we have to sacrifice some combination of accessibility, affordability, or cost. Which go over the side?

accessibility. In a world where we ditch accessibility, says Dr. Kling,

The solution would be to have government set a budget that limits the supply of health care services. Bureaucrats would set health care priorities. Inevitably, some consumers would be denied treatments that they seek.
Affordability. Maybe we could decide we want the best heath care possible, screw the cost. Is that a good idea? At some point it seems you run out of money.

Insulation. Here Dr. Kling hits an area that is one of my pet ideas: if "somebody else" is buying, you'll spend more. The lottery winner just walked in and is buying drinks for the house? You put down your bar scotch and order the Glenlivet.

The conclusion? Dr. Kling puts says that "insulation" goes over the side:

For an economist, it makes sense to sacrifice the principle of insulation to promote unfettered access and affordability. The principle of access unfettered by bureaucratic intrusion is consistent with consumer choice, free trade, and other concepts that economists hold dear. The principle of affordability also has an obvious economic appeal. However, the principle of insulation has little or no economic justification. In fact, I think that the task for economists, and for Chapter 5 of this book, is to explain the high cost and dubious benefits of catering to the principle of insulation.

So on to chapter 5 in the next post.

Previous Crisis of Abundance posts (6!):

Expat comments on Crisis of Abundance Posts.
Premium medicine in action
C of A: "Three Health Care Narratives"
Crisis of Abundance: "Premium Medicine"
May 20, 2006
May 16, 2006

1 comment:

hgstern said...

Great post!

I absolutely agree with "(w)e cannot have a health care that is both accessible and affordable while insulating consumers from the cost."

I'm reminded of a truism:

You can have it cheap, you can have it fast, you can have it good.

Pick 2.

And of course the "insulation" issue impacts directly on CDHC.

Dang! Now I have to go buy another book!

(or, I could just keep reading here...)