25 October 2009

Cato Podcasts w/ David Goldhill

Here are two good Cato Daily Podcast episodes interviewing David Goldhill about health care:

American Health Care Kills

Failed Promises in Health Care Reform

I think Goldhill talks a lot of sense, but mostly what I appreciate is that he gets down to the underlying questions in this whole brouhaha. Not "Is this legislation a good idea?" or "What will this proposal do to insurance premiums?" but things like "Why don't we trust prices when it comes to health care? What makes it different than the rest of the economy?"

This is what bothers me as a scientist and engineer about the health care debate (and so many other policy debates). We haven't established our starting points yet. We don't have any axioms or postulates to build our system on. We don't know what the requirements are, or the objective function, or any of the other things that give structure to a decision making process. People are just gung ho about diving in head-first and having at it with the biggest legislative wrench they can lay their hands on. Most of the time we not only lack agreement on the answers to those basic questions, we don't even ask the questions in the first place.

Here are the kinds of questions I mean:
  • Why do we conflate health with health care with health insurance?
  • We put health care spending on an economic "island," isolating it from the the standard consumer & price mechanism. Why? Is this morally defensible? Economically defensible?
  • Why is health insurance so unlike every other form of insurance, covering routine and predictable expenses?
  • If evidence-based medicine and IT infrastructure will lead to such good outcomes and save so much money, why haven't they been implemented yet? Is this symptomatic of deeper flaws?
  • Would more spending on lifestyle improvements like vacation time be more beneficial than comparable spending on health care procedures?
  • Hospital bills seem unmoored from reality. Is this so? If so, why?
  • Why is my dry cleaner better at tracking my shirts than hospitals are at tracking their patients?
  • Why do so many people hate the health care system generally, but really like their own plans?
  • Why do we conflate rising health care costs with rising health care expenditures? Are rising expenditures bad? Are higher expenditures than other countries bad? Is socialization of costs a cause or solution to our problems?
  • Is misfortune in the form of chronic poor health something we must remedy through a social contract? What differentiates it from other forms of misfortune which go unmitigated or partially mitigated?
Some of those questions are about establishing first principles and some are diagnostic in nature, but they all need to be asked and answered. Even if I don't agree with the answers that Baucus or Pelosi or Obama have to them, I want them to be addressed in a rigorous, structured way.

(They also ought to be answered by anybody fighting for the status quo, but the greater burden falls on those wishing to change things.)

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