How to Argue with Republicans about Healthcare Legislation

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*This is an essay co-authored by Matt and Josh

There are a lot of opinions about whether Obamacare is good or bad and how Trumpcare would compare. Typically, these discussions focus on either anecdotes or moral platitudes. A story about a person who is worse or better off—a raised or lowered premium—or else the moral obligation to care for the underprivileged.

Anecdotes and morality have their place in debate, mainly they supply the emotions. But with powerful emotions always surrounding us we sometimes never discuss actual policy. And at some point you might suddenly realize what I recently realized: I hardly know anything about the proposed health care systems. And the bad news is it’s not really something I can just read up on in a few hours and have a grasp of everything. I tried. It’s huge and complicated.

So rather than offering another argument, I’m doing the opposite. I’m going to tell people how to argue with me. I don’t want another story. I just want to spend some time talking about actual policies and the theories behind them. When I’m done talking to you, I want to feel like I understand something about the healthcare system better than I did before. So if you want to convince me about your specific platform, here are eight points that matter to me as a conservative. Here’s where you’ll score winning blows:   

1.  The goal of healthcare reform is to help as many people as possible live longer, healthier, and happier lives.

What’s important here is that success is not measured in access to treatments. There are many treatments that are ineffective and, particularly at the end of life, while they may minimally increase the length of life, they dramatically decrease standard of living.

Helping people live longer is not the sole purpose of the health care system. It is sublimely human to witness the passing of a loved one (or even a stranger in some cases) and feel we would give all that we have to save them from death. We are unable to count the cost, willing to give even our own life if such a trade was possible. In these profound moments, the logic of cost-benefit fails us, as the dwindling life manifests its infinite worth—the entire GDP of the United States would not be too much a cost for it.

And if it were not for the other elements of this metric, I do not know that we could ever justify losing a single life. If we did not believe that life is more than living and death more than dying, the human capacity for empathy combined with our passion for life would be unsatiatingly demanding. We would save a single soul and topple a nation—like Paris’s quest for Helen which was at once heroic and tragic. But health care is not an endless quest to extend life or outwit death. While this heroic imagination is sometimes actualized in ambulances and emergency rooms, it is not what health care is all about.

Health care is also meant to improve the quality of both life and our leaving of it. Most of the health care that makes the biggest differences in both length and quality of life is not the kind that miraculously saves a person from certain death, that scene we imagine when we purchase insurance. That sort of miracle care has done very little to actually increase life expectancy or quality. But what has increased life expectancy and quality in dramatic ways is cleaner water, better food, and vaccinations. That is because the vast majority of our health comes down to our hygiene, habits, and genetics, not access to the emergency room.

If we are going to see healthcare as more than death prevention and see it instead as something that increases an individual’s time, health, and enjoyment in life, we must measure success in ways larger than access to the emergency room, open heart-surgeries, and even doctor visits. Start here and you have my interest. Don’t start with access to care. Instead, start with how we can legitimately help people live longer, happier, and healthier lives. What will it take and how can we provide it?

2.  Policy should empower and encourage people to take responsibility for their health.

Most issues that doctors face from day to day are untreatable through surgery, medicine, or prosthetic. Most of what American doctors deal with are things like diabetes, chronic back pain, and migraines. Some of this is treatable and some of it is not. But the sharpest tool a doctor has in most cases is not a scalpel but the buy-in of the patient. In many ways, patients must be their own doctors, and must feel empowered to access and perform their own medical care. They must be the most involved party in diagnosis, treatment, and recovery.

I (Josh) have lived nine years with chronic pain radiating from my lower back. I spent a year going from doctor to doctor, with each doctor telling me they could find no problem. It was not until one doctor was honest enough to tell me that he could run a bunch more tests, but chances are he wouldn’t find anything. Pain like this often went undetected and unsolved.

It was something I had never really considered before. I had thought that if I had pain, there would be some way to diagnose the problem, and then (most probably) a clear treatment to make me better. But that is not how most health care actually goes. I was imagining something as simple as a broken bone. It’s clear, it’s easy to find, fix, and restore. But most health care is not broken bones.

Sometimes going to another doctor is not the best solution. That’s a hard pill to swallow. We like to believe that access to a doctor means access to health. But that was not the case with me or with most of America’s persistent health conditions. I eventually decided to spend my money on a better office chair instead of another doctor visit. And I am glad I did. It didn’t solve my problem, but it helped. Over the next several years I tried many stretches and workouts and eventually discovered that if I iced my back every night, the pain almost entirely disappeared. It took a month of nightly icing before it worked. It hasn’t solved everything, but it has dramatically increased the quality of my life.

So by all means we should encourage and enable people to see medical professionals when it will help. But simply increasing the number of doctor visits does not mean we have succeeded in making Americans healthier. We need to get people better not necessarily get them to a doctor. Whatever policies we enact, they need to allow people to take control of their health and feel empowered to do so. We need to look into how our policies impact the role of patients. Are they more involved, more informed, more empowered? Those are crucial questions and questions I want answered.

3.  Government intervention should be directed at fixing the market, not eliminating it.

Simply by having people pay for health care does not mean they will suddenly start making perfect choices. In many situations there is what economists refer to as “market failure.” The title practically explains the phenomenon: sometimes a capitalistic market fails to produce the ideal outcome.

There are many reasons this might happen. It can be caused by misinformation. Some treatments offer big promises but don’t deliver. If the assumed value is incorrect, people will make decisions they regret. This is a common market failure in healthcare because all the knowledge is on the doctor’s side. Even if the patients were well educated, and most are not, they would have a hard time becoming sufficiently informed about anatomy and physiology and treatment options to be a discerning purchaser.

Another example of market failure is vaccinations. If everyone else gets a vaccination, I don’t really need one because no one is spreading the disease. But if people don’t get the vaccination, we could potentially have a devastating epidemic. That’s why government often provides free flu vaccinations. They’re trying to compensate for market failure.

When the market fails, the government should step in and impose regulation that helps us come to a more ideal outcome. In these scenarios, government can help regulate deceptive or fraudulent treatments and impose helpful standards of treatment justification and informed consent. Government can also require and subsidize vaccinations. Market failure is a compelling reason for government involvement.

Of course Republicans generally believe that the government tends to regulate too much, but right now we could use a great deal more regulation in the field of mental health. It’s almost unbelievable that the majority of patients in America are paying to receive outdated and disproven mental health treatments. That’s a market failure. And much of it could be fixed if government and insurance agencies refused to subsidize ineffective treatments.

But whenever the government intervenes this should be a primary question: Is the market producing a better outcome? Answer that question and you’ve got my attention.

4.  Intervention should create more value than it costs.

The obvious example is birth control. It costs the government much less money to provide “the pill” than it does to expand the adoption and foster care programs. So by making birth control practically free, the government is actually saving money.

Abortion is a related and disputed example. It is much cheaper for the government to help a mother abort a child than for the government to raise the child (that is unless the child eventually pays a lot of taxes.) If the government’s adoption program consistently produced Bill Gates, the cost for an abortion would be astronomical. But for now, you can expect abortions to be practically free, and, at least according to this this criteria, they should be.

There are many ways the government could spend money to save money and that should always be an objective. According to Tom Insel, former president of NIMH, the de facto resort of the mentally ill in America is our prison system. Something around 50% of inmates are dealing with a clinical mental illness and the cost to the American taxpayer is astronomical.

If the government could create a policy that would keep mentally ill persons from going to prison and instead paid for effective treatments (as long as the treatments worked and helped the patients live more productively within society) our country could conceivably save a ton of money—say 40 billion dollars. That’s like trading a one hundred dollar bill for a one thousand dollar bill. Easy math.

If your policy saves money, I’m listening.

5.  Market pressure should be directed at healthcare outcomes not treatments.

Health care providers need to feel the sting of unsuccessful treatments. They should make money for the treatments that work and lose money for the treatments that prove ineffective. This is particularly important because currently 20% of healthcare spending in the USA does not lead to better health.

Imagine a contractor agreeing to add a deck to your house, only completing 80% of it, and then demanding the full payment. That’s hard to imagine, because in most cases, if a contractor fails to deliver what they promised, they won’t even send you an invoice. And if they do, it will be largely discounted. That’s why contractors are careful to analyze the cost of a proposed project and make sure they are equipped to handle it before giving a bid. Sometimes their cost estimation is short and they have to cover some of the cost themselves. That hurts and because it hurts they become very good at estimating costs, streamlining services, and keeping to a budget.

When doctors and healthcare organizations are paid based on outcome, they are much more likely to do their own cost-benefit analysis. This is one aspect I really like about the Obama initiative to move from a pay per service to value-based compensation.

If doctors get paid for any treatment no matter the success, there is no incentive, beyond personal ethics, for them to not perform any requested treatment even if that treatment will statistically hurt rather than help the patient and even if there are more promising treatments available. And there is no incentive for doctors or hospitals to improve or form reliable cost and recovery projection.

Of course there are many complications here. Some treatments have no guarantee. Think of a cancer patient who is willing to try even the most experimental treatments because the other, more evidenced treatments, have proven ineffective. Of course we don’t want to take away the ability for people to experiment. People will take risks. But the key here is those risks need to be forefronted. And if the doctors are not consistently providing the best treatments or if their treatments are not working, there should be monetary consequences.

I believe this will force greater transparency, honest evaluation of risks and benefits, and more accurate cost estimation.

In Taiwan, I (Matt) had an inflamed knee. I went to the hospital 3 times to get the liquids drained from my knee, and each time they told me that if it didn’t stop swelling I would have to get a surgery, and each time they gave me a new prescription drug I hadn’t tried yet. So I finally decided I should get a surgery. I told my mission leader, and he had an American doctor call me. The doctor told me if I didn’t run, or kneel, it should slowly go down, and I could use Benadryl instead of what they were prescribing. The American doctor was right. I never needed surgery.

So why were the Taiwanese doctors saying something totally different? I now realize the doctors were incentivised to give me expensive drugs and procedures. That was how they made money. It didn’t matter if it was necessary. If they sold the drug, they got a cut of the profit. If they performed a surgery, they billed a surgery. I don’t believe these were evil doctors. They were just people responding to incentives.

If you can show that new policy will incentivise better outcomes and not simply pay for treatments, I’m all ears. But right now people like a cushy health care plan and Medicaid and Medicare pay most of the cost for almost every treatment for which they qualify. Together these programs constitute about 1/3 of the healthcare market. For the government to make a change, they’d need to do more than legislate. They’d have to successfully market a vision based around outcomes, not treatments.
This is actually a fascinating part of Obamacare that no one has ever talked to me about. Obamacare planned to switch from a pay-for-service to a pay-for-outcome system. Over the next ten years, the plan was for the government to reimburse medical centers based on how much healthier they made people, not how many procedures they performed. That’s worth mentioning next time you find yourself debating the same old points.

6.  People should purchase health care like other goods.

I recently listened to a Harvard professor on NPR discuss how people do not purchase health care like other goods. He discussed an experiment of purchasing a high deductible health care plan and the way it caused him to avoid going to the doctors even when his chest was hurting.

I believe the professor was entirely right, just maybe not in the ways he believed. Avoiding unnecessary expense is a good thing, that is not market failure. But taking a health risk that is greater than the actual expense associated with mitigating that risk is not a good thing. So why would someone not go to the hospital when they might be having a heart attack?

I think it’s the same reason I don’t buy a carton of milk without a price label. Instead, I choose the brand next to it, with the price clearly demarcated. Of course there’s a good chance the unmarked milk carton will actually be cheaper than it’s counterpart, but I (and people generally) tend to be risk averse. I have a chance at a lower price but the possibility of a higher price scares me more than the possible savings excites us.

There are many studies that document this phenomena. One of the more fun studies shows how when Tiger Woods has the possibility of a birdie, he typically doesn’t go for it (this is true of most golfers). Instead he takes par because he fears hitting the ball too far and getting a bogie. So instead of taking the risk he plays it safe and judging by his averages, he loses nearly $700,000 a year because of it.

To me, that explains the main reason we don’t buy medical treatments like other goods. The process we go through to buy a medical treatment exploits our risk aversion. Perhaps that’s why it seems absurd in any other context. Imagine buying a car this way. You test drive the car, you like it, you know it’s going to be expensive, but they won’t tell you how much. Instead, after you’ve bought the car, they’ll send you a bill, actually several bills, arriving at undisclosed times and in undisclosed quantities.

That’s how we are asked to purchase healthcare. So it’s no wonder that people don’t purchase health care like other goods. What else are we asked to purchase like this? It rubs us the wrong way. But what if we made purchasing healthcare more like purchasing a car. Change could be something as simple as giving treatment a clear price label or allowing people to visit any doctor they’d like? Maybe people would start buying it when they need it and avoid buying it when they don’t—just like they do with everything else.

If you can convince me that your policy will help people purchase healthcare naturally, I’ll be more likely to vote for it.

7.  Insurance needs to be honest about costs and benefits.

Insurance needs to be clear that people are purchasing security not health care. You will most likely lose money. In any functioning system insurance does not save you money most of the time. Mathematically, only a small percentage of people will ever end up ahead because of their insurance policy. Otherwise, how would an insurance company survive? It’s simply impossible.

Honesty about what insurance is and isn’t can help people make better decisions (which is ultimately individually determined). But in most cases, people should be educated that large deductible plans are smartest and best for their wallet as well as the economy.

It seems to me that insurance should not be part of most healthcare transactions. People should be paying for healthcare, not for insurance companies. A simple doctors visit should not involve insurance. Why are you paying to insure yourself against a one hundred dollar expense? That isn’t going to ruin you. Almost everyone can insure themselves against that sort of minor inconvenience. And odds are you’ll save a ton of money if you do.

People are monetarily best off if they pay out of pocket for most of their medical needs. If you need to, keep a savings account for medical expenses throughout the year. And then buy a deductible insurance plan just incase something really tragic happens. Insurance should begin just before you are ruined. Whatever amount is too much to rebound from, that is where insurance should start.

But insurance agencies have a lot to gain from getting us to insure ourselves against risks we can handle on our own. Any manipulation of the market by insurance providers should be discouraged and, in some cases, punished. Whatever we can do to educate the public and regulate insurance that helps people to select wiser policies could save the average American a lot of money, and the country as a whole, something astronomical.

But instead, insurance is in the business of encouraging people to increase their healthcare coverage so that we are all insured against every possible healthcare expense, which would be the least cost-effective healthcare plan imaginable.

If government regulation of insurance leads to people selecting more high deductible plans, I think that’s a good thing.

8.  The field should make room for disruption.

The greatest problem with government regulation is not that it ruins the market but that it stifles innovation. Currently health care is hyper-regulated. Doctors go through insane amounts of school, hospitals jump through hoops, and everyone (patients and hospitals alike) pay for insurance.

The barriers to entry are so high that any doctor must charge an exorbitant amount of money simply to pay back student loans. In America we waste about 750 billion dollars each year simply through medical inefficiencies: bad policies, running unneeded tests, bloated administration, etc.

Whatever regulations we create to address market failure, we must not stifle innovation. I do not believe there is any industry so in need of innovation as the healthcare industry. A basic reality proved time and time again in the capitalist market is that a bunch of experts gathered together making a plan does not always come up with the best solution. Sometimes Joe Schmo on the street has a new idea, and sometimes it’s better than the Harvard professor’s.

Sometimes the people who are most educated and would seem most equipped to create policy are also the most entrenched and least flexible. Clayton Christensen has disseminated the term “disruptive innovations” to describe how well-established industry leaders are often toppled by outsiders and entrepreneurs. And it’s more than just David beating Goliath again. There are real benefits to being an “outsider” because an outsider is able pursue new ideas even if they are originally less profitable—something large firms struggle to justify. “Disruptive innovations” are not not rare occurrences. They happen again and again. Outsiders with less to lose and eyes to see things differently change the world.

So whatever we do, let’s not lock up a bunch of healthcare experts and then assume that the system they produce is necessarily going to be the best. Even if it is now, it won’t be in the future. We must always leave room for innovation.

If you can show that your plan will welcome innovation, enable innovation, and promote innovation, then even if I don’t love the state of things, I will at least have hope that some entrepreneur can make it better.

 

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