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September 07, 2007

The Smartest Thing I've Read Today. By Far.

Megan (Not McArdle...calm down) writes:

My policy professor taught me that policy beliefs originate from a model of the individual. The rational economic actor is one model of the individual. The policies that you trust are aggregations of your model of the individual:

For health care, my model of the individual:

People live in denial, do not do good risk analysis (as evidenced by my erratic use of bike helmets.) They do not conscientiously save against medical emergencies, even though they could. They do not have the capacity to compare fancy-dancy medical treatments (I should figure out what chemo regimen is best for me? I DO NOT WANT TO, because that is outside my expertise and BORING. I want to trust an expert, if it comes to that.), especially if the pain has already started. They do not have any interest in comparing not-fancy treatments. (When I broke my arm, I realized I had no information whatsoever on which of the four local emergency rooms had good reputations. None. I had never cared until it was too late.) I derive zero utility from comparison shopping for health care; I want someone else to handle it.

I figure people are roughly like me, non-savers, bad risk assessment, more than willing to delegate their health care. (I am not willing to delegate my fitness or nutrition, but that is different from disease or injury.) You know what makes good sense for that model of the individual? Government based health care that does a decent job by me. You know what doesn't make sense? For profit insurance agencies who do not have my best interests at heart.

For what it's worth, this is exactly my model of how individuals relate to health care too. When I bring this up with conservatives, they often protest that individuals simply haven't been properly trained to be mega-rational health care consumers. This sometimes makes me think they've never met any individuals. When i ask what will happen to all those individuals who falter between now and when we've trained people to be perfectly rational, they sort of shrug and say that people have to take responsibility for their own actions.

September 7, 2007 in Health Care | Permalink

Comments

Its a stereotype that's gone stale.

People are increasingly more involved in their own health care-- I've seen it with my own experience as well as data looking at internet use for health conditions, for example, show a dramatic increase over the past decade.

Megan's model is exactly what the parents of the baby boomer generation thought/think. This is much less true for the baby boomer generation (as above) and will be even less so for Gen X/Y when they start having medical conditions in mass.

The so-called "experts" are increasingly less so in a medical world that grows more complex by the day. Its a fiction that may make people feel better about their doctor, but its not true.

I've said this before-- put the health care reform element aside for a moment. If you're solely relying on the health system to provide you care as Megan describes above, you are getting worse care. Period.

Posted by: wisewon | Sep 7, 2007 3:07:44 PM

Unhealthy or dead consumers do not buy products.
It's helpful to remind corporate conservatives of this.

Posted by: Garuda | Sep 7, 2007 3:25:08 PM

Maybe the better question for conservatives is are they personally mega-rational health care consumers? And if they are not, are they training to be such?

Posted by: George Tenet Fangirl | Sep 7, 2007 3:32:25 PM

"The so-called "experts" are increasingly less so in a medical world that grows more complex by the day. Its a fiction that may make people feel better about their doctor, but its not true."

What a ridiculous argument. So, we the common laypeople are supposed to keep up with the latest in health care rather than trust people who deal with health care as a career?

"looking at internet use for health conditions"

Looking up what a rash is on webmd is much different than trying to cost-compare ER services for a broken leg (and what happens when you break your leg on a ski vacation, cost-compare when you book your flight to Colorado?)

Megan's model described me to a tee, including the part about not wearing a bike helmet often enough. And I am in the thick of the Gen-X age bracket.

Posted by: verplanck colvin | Sep 7, 2007 3:36:10 PM

I can't say Megan is wrong, since I have no idea who she as a person nor do I have any knowledge of her experiences. I can say that her model for the individual does not fit with my family. We're not this way, and we've had a lot of interaction with the healthcare system in the past 5 years. Our neighbors across the street, who have 2 great, yet unhealthy children, aren't this way either. Yes, this is anecdotal, but it goes to show that Megan's picture of the world fits a portion of it, but far from all of it.

With all this being said, who says a healthcare system can't handle both realities? Any new system needs to change a lot of incentives, and I don't think single-payer changes Dr.'s incentives in a way that helps both types; Dr's will continue to employ more expensive, low probability of success remedies (such as a last ditch angioplasty for my dying father, who knew it wasn’t going to help but went along with it because a) he wasn’t paying for it and b) his Dr. suggested it) because their customer, the patient, has no incentive to care.

Posted by: DM | Sep 7, 2007 3:36:50 PM

The problem isn't really the unplanned $5,000 medical expense. If you don't have savings to handle that, a credit card will do the trick. It's not the preferred method of handling the problem, but it works.

The real problem is the $50,000 medical expense, which is utterly beyond the means and/or savings of the vast majority of Americans.

Posted by: fiat lux | Sep 7, 2007 3:38:18 PM

Those who have a chronic condition or a condition that requires some kind of extensive treatment do typically compare their options, evaluate doctors, and make different decisions about treatments and providers.

Unless any of those situations apply to us, odds are that our mindsets are similar to Megan's.

Ironically, the ability to make all of these comparisons and do all of this research and consultations is a privilege of having insurance, because you know you can make a good decision with the benefit a choice of providers and without worrying that it will bankrupt you. Without insurance, you show up to the emergency room and take what you can get.

Posted by: Tyro | Sep 7, 2007 3:45:19 PM

I can say that her model for the individual does not fit with my family. We're not this way, and we've had a lot of interaction with the healthcare system in the past 5 years. Our neighbors across the street, who have 2 great, yet unhealthy children, aren't this way either. Yes, this is anecdotal, but it goes to show that Megan's picture of the world fits a portion of it, but far from all of it.

See, I completely love this. Because now we are talking about things that can be verified. Someone with a grant could figure out which approach is more common and which one our health care system should address or how much to address both or whatever.

We also know why we disagree on a big picture; our little pictures are different. That is useful and
informative and can still be a respectful discussion. Yay!

Posted by: Megan | Sep 7, 2007 3:47:22 PM

The notion that people nosing around the Internet is the same as relying on trained experts to read peer reviewed journals and studies to recommend a care plan is absurd on its face. WebMd is not the New England Journal of Medicine. Even if it was, you would not understand it without training and experience. People rely on their Doctors for a reason and it's not their bedside manner. It's their expertise.

Posted by: hebisner | Sep 7, 2007 3:47:29 PM

The notion that people nosing around the Internet is the same as relying on trained experts to read peer reviewed journals and studies to recommend a care plan is absurd on its face. WebMd is not the New England Journal of Medicine. Even if it was, you would not understand it without training and experience. People rely on their Doctors for a reason and it's not their bedside manner. It's their expertise.

Posted by: hebisner | Sep 7, 2007 3:49:46 PM

What Megan's post says to me is that she has a good handle on who she really is, and therefore supports policies that meet the needs of people as they really are.

Those who expect everyone to either be perfectly informed, always-rational actors, on the other hand, either have an inflated sense of their own abilities or unrealistic expectations for themselves.

It's funny to listen to people with health insurance and the financial means to address health problems preventively or at their early stages talk about how the real reason they've gotten good care out of the American healthcare system is the knowledge and involvement that they bring to the table.

I'm quite sure that people who go to an understaffed, underfunded county hospital will get exactly the same care as they would anywhere else, as long as they look up their symptoms on WebMD beforehand. Oh, but maybe they don't have internet access or a computer at all. Well, they can just think really hard about what's wrong with them and make a strong resolution to be a rational consumer of healthcare services when they go to the ER.

I'll put my involvement in my own healthcare up against anyone's. But I still support UHC because I've got this totally weird ability to recognize that not everyone in the world is me, and not everyone in the world has the exact same set of advantages I do. Further, I'm able to recognize that what they do or don't do and what happens to them actually can affect me.

Posted by: Stephen | Sep 7, 2007 3:59:52 PM

” I'll put my involvement in my own healthcare up against anyone's. But I still support UHC because I've got this totally weird ability to recognize that not everyone in the world is me, and not everyone in the world has the exact same set of advantages I do.”

But UHC, without more consumer involvement, doesn’t encourage better care. Sure, it mitigates the financial risk to the patient, but relying total on a Dr., whose incentives are different than your, has its risks.

You are spot on: not all people are like my wife and I and they may not take care to educate themselves on their particular malady. But UHC, or single payer isn’t going to solve for this either.

Posted by: DM | Sep 7, 2007 4:07:17 PM

For what it's worth, this is exactly my model of how individuals relate to health care too. When I bring this up with conservatives, they often protest that individuals simply haven't been properly trained to be mega-rational health care consumers.

The problem with this theory is that medical treatments are REALLY REALLY complicated and hard to understand. Almost as importantly, it's impossible for the average person to keep up with the medical research and studies even if they wanted to. If doctor's who have spent nearly a decade recieving training struggle to keep up with new medical findings what's the chance that a parent working 40 hrs a week while raising their kids is going to be able to keep up with the near infinite number of possibie medical procedures.

Posted by: Phil | Sep 7, 2007 4:18:24 PM

"i dont want to, because that is outside my expertise and boring."

i have a difficult time understanding people not taking responsibility for their health care and their finances.
...what can be of greater practical concern than maintaining health and financial safety?
boredom in those matters is a luxury that no educated person can afford.

Posted by: jacqueline | Sep 7, 2007 4:19:29 PM

To respond to all of the WebMD comments:

My comment about the internet was not about whether its effective (I wholeheartedly agree that its not-- today), but rather as evidence of people's intent-- to be more involved in their health care-- which is a different model of the individual.

Megan and others clearly feel differently about themselves (as an aside, I didn't realize she was actually speaking about herself, I'm not out to invalidate her feelings)-- there is diversity of mindset which is a great thing. We should have a health-care system that can cater to people's different needs. (As an aside, that doesn't sound single-payer, does it?)

My point is that the trends are moving in a certain direction: people wanting to know more and physicians (relative to the growth of medical knowledge) are knowing less and less. Greater consumer involvement is where our system is trending-- even without great tools or incentives to do so.

Rather than refuting the efforts of those searching on WebMD, we should be discussing the dearth of validated information that exists, what could and should be developed, what role there is for government to help get that information on-line, etc.

Posted by: wisewon | Sep 7, 2007 4:36:51 PM

Fiat lux, what percentage of Americans have a credit card they can put $5,000 on? Certainly the $50,000 expense is worse, but I think there are plenty of people for whom $5,000 is a real hardship.

Posted by: KCinDC | Sep 7, 2007 4:37:32 PM

I fail to understand how employing a trained expert or experts to perform cost-benefit analyses of various complex medical procedures is considered "not taking responsibility" for your medical care. I consider it extremely responsible to recognize one's own limitations.

Posted by: space | Sep 7, 2007 4:46:12 PM

I'd also add that there is nothing to my knowledge that would prevent people from accessing WebMD were we to implement a single-payer system.

Posted by: space | Sep 7, 2007 4:50:35 PM

Rather than refuting the efforts of those searching on WebMD, we should be discussing the dearth of validated information that exists, what could and should be developed, what role there is for government to help get that information on-line, etc.

I actually use WebMD and other online resources, though of course I take everything with a huge grain of salt. And I agree that as time goes on the amount of information available to certain segments of American society will only increase.

But there will always be people who don't have access to the information, and there will always be people who might have access to it but are simply incapable of understanding what they read.

I'm not trying to be elitist or arrogant. But I imagine that my ability to get an advanced degree - in a highly specialized and almost completely unmarketable field, mind you - helps me to understand things when I read the prescribing information on various drugs or even when I look up things on WebMD.

The progressive ideal when it comes to this type of thing is that society shouldn't put specious barriers between people and their ability to get decent healthcare. In our current system, and certainly in any system where all of one's medical costs are born by the individual, there are millions of people who are unable to go to a doctor at all because they can't afford it. They can't afford it when it's obvious they need it, and they certainly can't afford the cost of going to the doctor when they think they might be sick.

And when you can't pay for that, all the information in the world about choosing the right doctor, understanding the way different drugs work, identifying what tests and procedures have a low success rate and all the rest isn't going to do a damn thing.

In any system, even some government-run system, if you take the time to learn about healthcare for yourself you'll see benefits. It's not like a UHC system is going to make it illegal to look stuff up online or in a library.

Let's make healthcare available to everybody, and then we can actually see how many people take charge of their own healthcare instead of just using biased assumptions to justify opposition to it.

Posted by: Stephen | Sep 7, 2007 5:01:41 PM

Yep, it's really efficient to have 300,000,000 people...babies to Alzheimer patients researching and suggesting treatment options to medical professionals

"people have to take responsibility for their own actions."

Yep, it's really efficient to have 300,000,000 people...saving for their retirement without a clue as to how long they'll live, so they all have to plan to live to 100 hundred even though the average age is 72.7

"people have to take responsibility for their own actions."

Yep, it's really efficient to have 300,000,000 people...devising tax strategies to maximize income.

"people have to take responsibility for their own actions."

Civilizations thrive when people with certain talents are allowed to concentrate their energies on the gifts God has given them.

300,000,000 people duplicating the same work over and over is not efficient, it's beyond stupid.

Posted by: S Brennan | Sep 7, 2007 5:14:25 PM

I live in Canada, I have used WebMD and after being given 34 possible illnesses that relate to the symptoms I had, I went to the doctor. A simple blood test later and I was using a cream to solve a non-lifethreatening skin condition. Information can only take you so far and then you need more information and a lab which is what having a medical infrastructure is for in the long run.

Posted by: Hawise | Sep 7, 2007 5:25:31 PM

My point is that the trends are moving in a certain direction: people wanting to know more and physicians (relative to the growth of medical knowledge) are knowing less and less. Greater consumer involvement is where our system is trending-- even without great tools or incentives to do so.

This reminds me of that House episode where the mother of a newborn who "did the research" refused to get her baby the necessary shots because "evil corporations were marketing unnecessary drugs to increase their bottomline". Just kind of funny. But to the point...

I have a hard time believing that the majority of people who don't even take 30 seconds to skim through the headlines in the paper are spending all this time doing credible quantities of research on medical prices. Hell, even with increasing consumer guides for products the majority of American's still do relatively little consumer research on the products that they buy.

I don't have a problem with increased consumer knowledge but it's hardly a solution to all of life's problems. Furthermore , sometimes you do the research and realize that the system has screwed you over.

Posted by: Phil | Sep 7, 2007 5:33:32 PM

. We should have a health-care system that can cater to people's different needs. (As an aside, that doesn't sound single-payer, does it?)

Why?

Posted by: Phil | Sep 7, 2007 5:34:50 PM

The problem with Megan's analysis of the situation is this:

"Government based health care that does a decent job by me. You know what doesn't make sense? For profit insurance agencies who do not have my best interests at heart."

Note the implication: government-based health care does have her best interests at heart.

Why?

Well, let's start with the insurance companies. Why don't they have Megan's best interest at heart? Because they are for profit (or, really, even if they were not-for-profit, they'd still need to make enough money to cover expenses. Profit's icing on the cake). Their interest in Megan presumeably ends when her medical expenses become greater than what she pays into the plan. That's a fair analysis, and we can agree with Megan that they don't care about her and that, in fact, insurance companies (of all kinds!) do often try to weasel out of paying out policies.

So how is the government different? Do they have a bottomless well of money? Well... sort of. They'd almost certainly be less price-sensitive than a private insuror. On the other hand, they will have a budget, and it's pretty likely that the people working in the Department of Getting Megan Healthcare will have incentives aimed at making sure they stay within budget. Unlike a private company, they'll have no fear that Megan will take her business elsewhere, either -- she can't stop paying taxes. So while Megan's insurance company (theoretically) may want to drop Megan if she gets cancer, and is going to cost them tens or hundreds of thousands of dollars a year for several years, and then die, they (theoretically) are probably pretty cool with paying out the $5,000 for her broken arm. Megan's going to pay a lot more than $5,000 into the system if she sticks with their company long term. The DoGMH, on the other hand, just pretty much wants to shave 5% off the top of everything. It doesn't matter to them whether Megan is particularly happy with the way they cope with her broken arm.

But actually, all of that is probably the less important incentive. Most people who are little cogs in big machines, be those big machines the Department of Getting Megan Healthcare or Megan's For-Profit Insuror, are pretty insulated from the straight up financial incentives. What they probably mostly want is to get Megan out of their hair. Depending on how the DoGMH or MFPI is set up, the path of least resistance to getting Megan out of their hair might be "pay out quickly," or it might be, "throw her file into a pile and ignore it until the heat death of the universe." If Megan finds that the MFPI is doing that, she can find MFFPI (Megan's Friend's For-Profit Insuror) and see if they're any better. If the DoGMH does that, well, Megan's only real recourse is to either navigate the bureaucracy of what's going to be a really huge agency herself (and if you think that people are bad at, and uninterested in, their own healthcare, let's consider how good they are at navigating federal bureaucracies), or trying to pressure her elected representative into reforming things (and hey, we're all anti-war here, right? How's it going getting our elected representatives to end a massively unpopular, ludicrously expensive, hopelessly immoral enterprise?)

Please note that my comments here are a specific discussion of Megan's and Ezra's argument above. The analysis I provided above isn't intended to speak to the worth of UHC as a whole, it's inteded to rebut a particular argument. And let's stipulate that the current American system is broken and needs changing in some fairly major way.

Posted by: Michael B Sullivan | Sep 7, 2007 5:39:42 PM

I like WebMD (and other free medical sites). They are most useful when you have been diagnosed and want find out more information about an injury or condition.

In terms of self-diagnosis, at most they can provide a person with questions to ask their medical providers. Hell, even if you were to self-diagnose yourself good luck "taking responsibility" by getting an insurance company to authorize and pay for the necessary treatment:

"No, my doctor didn't detect the melanoma. But I'm pretty sure I need surgery anyway. I read about it on WebMB. Oh, and I stayed in a Holiday Inn Express last night."

Also, to the best of my knowledge, WebMD provides little to no information about the relative costs of procedures, providers, or facilities.

Posted by: space | Sep 7, 2007 5:43:16 PM

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