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Posted by Rick Denney on May 15, 2003 at 14:45:25:

In Reply to: Re: Re: Re: Re: Re: Re: Re: Re: Re: Bad News List posted by Mary Ann on May 15, 2003 at 10:05:40:

The notion of health insurance and HMO's operated like credit unions and owned by the customers makes perfect sense to me. But, just as with credit unions, stock-based commercial health care enterprises should be allowed to compete with them. Then customers could choose.

But it won't solve the problem of the insurance company bargaining with providers for lower costs, which is what causes the prices to be higher for the uninsured.

We have a shortage of health-care professionals--both doctors and nurses--in most places. Why is that? I think there are lots of reasons, but pay isn't one of them. Most doctors I know do quite well. There are other reasons for the limited supply, and these are artificial manipulations of the market. One is that the AMA accredits medical schools and make it terribly difficult to get into them. Then, medical schools themselves torture their students in ways that have nothing to do with making them better doctors (e.g. residents having to work 90-hour weeks, and so on). All of these are designed to weed out prospective doctors. Do these methods weed out those who would be poor doctors and leave those who would be good doctors? Not at all. I have met very few really good doctors who can provide more than conjunctive care for only common illnesses. No, I think these practices are common because doctors control who will become doctors, and they have an incentive to minimize fresh competition.

This is a manipulation of market forces. Anybody with sufficient aptitude and resources should be able to attend medical school, and medical schools should provide stringent academic and clinical standards, not physical endurance tests. Were there enough doctors, those 90-hour weeks would not be necessary.

Another part of the problem is that doctors are frequently targeted by people who believe that if anything bad happens to them, it must be somebody's fault and it must therefore be compensated. Thus, you can't get a doctor to actually tell you anything anymore. I have much recent experience resulting from observing a terminal illness in my family.

The enormous accountability of doctors discourages them from straying even a bit outside what is considered common practice, and this surely inhibits treatment in many cases. It also adds tremendously to the costs. 20 years ago, doctors in private practice typically paid nearly half their income for professional liability insurance.

Of course, we also live in a hypochondriacal society that runs to the doctor for every small complaint, and that expects a chemical solution to every symptom. But I'd rather suffer the consequences of that than let anyone else determine for me when I should and should not go.

I also agree with you that all human systems work better if the participants carry in some sense of morals. But I fear that we are reaping the harvest of decades of attack on the very idea of morals. If you want to accuse someone of being immoral, and you call them immoral, they won't even know what you are talking about. You have to say, "It isn't fair". Of course, fairness as morality is a myth--fairness results from morality. The corollary is that any system, no matter how good, can be corrupted if enough people abuse it unethically. But I would not be too quick to assume that it is the money-grubbing corporations are the only ones at fault here. Certainly those folks who run to the doctor for every complaint must share some blame. And those who sue doctors as a result of risks known to them share some blame. Doctors themselves contribute to the problem when they blather on about how their work has life-and-death consequences (as if many other professions could not make the same claim), which they use as justification for limiting their future competition.

Individuals are also to blame when they demand that their insurance cover every possible aspect of their health care, portraying their providers as scoundrels when every expense isn't reimbursed. The point of insurance was to provide a safety net, not to render null and void any possible negative outcome from the dangers of life. Those expectations are false, but everyone has bought into them, even the hype of the insurance companies.

Joe suggests that we return to the old days of health care provided at direct cost to the consumer, and there is a lot of merit in that argument. That is certainly the most free market model. But the main reason people can no longer afford health care is that health care does so much more than it used to. Now, you don't get an X-ray, you get scanned by a million-dollar MRI or CT scanner, which has to be amortized. We like these improvements, but we have to be willing to pay for them. But I think I'm the only person who wants the doctor to explain the reason for every test, so that I can decide if I want that test or not. One big reason for ballooning health-care costs is that people no longer look in their wallet before making those decisions even if they are given the opportunity--they just do what the doctor suggests and often never even see the price tag.

Rick "who can't find that much capitalism in health care and who is therefore unwilling to blame it" Denney


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