Re: the moral hazared myth: malcolm gladwell on U.S. healthcare (7000 words}


fresh~horses wrote:
> The New Yorker, August 29, 2005 v81 i25 p44
>
> THE MORAL-HAZARD MYTH. Malcolm Gladwell.
>
> Full Text: COPYRIGHT 2005 All rights reserved. Reproduced by permission
> of The Condé Nast Publications Inc.


Condé Nast Publications Inc. really gave you permission to reproduce
this across the net? Do tell. How did that work? You email the New
Yorker and ask to reproduce this article from 2 months ago?

> People without health insurance have bad teeth because, if you're
> paying for everything out of your own pocket, going to the dentist for
> a checkup seems like a luxury.

COMMENT:
Only part of the answer, of course. People have bad teeth at least as
much out of fear of dentists and laziness. They have bad teeth for the
reason they are late on their tax returns and don't get their oil
changed, and have sinks full of dirty dishes and lawns full of
dandilions. In short, because they're lazy and human.

Note that if we accepted the premise of the article, we'd have to
accept that in countries where the government paid for more dental care
(for example the UK), the population had better teeth than in America,
where many are uninsured. Hmmmm.


>They are an
> outward marker of caste. "Almost every time we asked interviewees what
> their first priority would be if the president established universal
> health coverage tomorrow," Sered and Fernandopulle write, "the
> immediate answer was 'my teeth.' "

COMMENT:
But they don't mean: to have my teeth CLEANED. They mean to have their
teeth fixed with all kinds of expensive stuff, because they'd let them
get absessed or lost, which hurts. Not the same thing.

> The moral-hazard argument makes sense, however, only if we consume
> health care in the same way that we consume other consumer goods, and
> to economists like Nyman this assumption is plainly absurd. We go to
> the doctor grudgingly, only because we're sick. "Moral hazard is
> overblown," the Princeton economist Uwe Reinhardt says. "You always
> hear that the demand for health care is unlimited. This is just not
> true. People who are very well insured, who are very rich, do you see
> them check into the hospital because it's free? Do people really like
> to go to the doctor? Do they check into the hospital instead of playing
> golf?"


COMMENT:

In fact, some people do. Which is one place where the economists (as
usual) need to climb down out of their ivory towers and talk to some
people in the real world. This paragraph was one of the funnier ones in
the article, because it was so entirely clueless.



>
> For that matter, when you have to pay for your own health care, does
> your consumption really become more efficient? In the late
> nineteen-seventies, the rand Corporation did an extensive study on the
> question, randomly assigning families to health plans with co-payment
> levels at zero per cent, twenty-five per cent, fifty per cent, or
> ninety-five per cent, up to six thousand dollars. As you might expect,
> the more that people were asked to chip in for their health care the
> less care they used. The problem was that they cut back equally on both
> frivolous care and useful care. Poor people in the high-deductible
> group with hypertension, for instance, didn't do nearly as good a job
> of controlling their blood pressure as those in other groups, resulting
> in a ten-per-cent increase in the likelihood of death. As a recent
> Commonwealth Fund study concluded, cost sharing is "a blunt
> instrument." Of course it is: how should the average consumer be
> expected to know beforehand what care is frivolous and what care is
> useful? I just went to the dermatologist to get moles checked for skin
> cancer. If I had had to pay a hundred per cent, or even fifty per cent,
> of the cost of the visit, I might not have gone. Would that have been a
> wise decision? I have no idea. But if one of those moles really is
> cancerous, that simple, inexpensive visit could save the health-care
> system tens of thousands of dollars (not to mention saving me a great
> deal of heartbreak). The focus on moral hazard suggests that the
> changes we make in our behavior when we have insurance are nearly
> always wasteful. Yet, when it comes to health care, many of the things
> we do only because we have insurance--like getting our moles checked,
> or getting our teeth cleaned regularly, or getting a mammogram or
> engaging in other routine preventive care--are anything but wasteful
> and inefficient. In fact, they are behaviors that could end up saving
> the health-care system a good deal of money.


COMMENT:

Indeed, indeed. But this has been thought about, and it has a simple
solution. No deductables on preventive medicine, which is usually
cheap, but more and more deductibles on expensive boutique treatment
which is of questionable saving value. Dental plans mostly work that
way NOW: Cleaning and checkups and covered completely, but deductables
scale up as you need more and more work done, as a result of ignoring
your mouth. Many HMO plans have similar features--- no copays on
immunizations and BP checks and so on. More work needs to be done
here.

"Ms. Smith, your grandmother is 93 years old, demented, and has severe
emphysema from all the smoking she did."

"Yes, doctor, she doesn't recognize us any more, but we can't bear to
lose Gamma. So do whatever it takes"

"You do realize that if we put her on the breathing machine for her
pneumonia, that she probably won't ever get off the machine?"

"We want you to do everything, doctor."

"It's $2000 a day, and your co-pay is $500"

Silence.

"Doctor, now that I think of it, Gamma DID always say that she never
wanted to be a burden on the family..."

SBH

.

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