A depressing feature of the debates about the Republican replacement for the Affordable Care Act is that both Republicans and Democrats pay lip service to so-called “market solutions” that will “empower” health-care consumers.
There are indeed some public services, like the provision of water, that lend themselves to market solutions, but the ethical constraints of health care make it highly unsuited for pure commercialism. Nor are patients properly categorized as “consumers.” For a number of years, half of all medical spending has gone to just 5 percent of the population. These are people who are very sick, mostly with one of five categories of illness—heart disease, major trauma, cancer, mental disorders, and pulmonary disease. Moreover, high-cost patients—especially the elderly—typically have more than one major disease. Pundits deplore the great expense often incurred in the last year of life. But people who die tend to be very sick, and doctors usually can’t tell in advance which ones will die. I once spent a year doing embedded research at a major heart center. The average age of their patients was about eighty, and virtually all of them underwent procedures that put them at high risk of death. But for many years, fatality rates had been under 2 percent, while more than 90 percent walked out of the hospital without a major injury.
As a practical matter, there are no “informed consumers” in high-end, high-cost, health care. The deep science and burgeoning technologies of modern medicine are beyond the average person’s grasp, while patients and families are often frightened and traumatized. In most cases, the participation of families is limited to the human decisions, like whether or not to attempt a new but dangerous surgical intervention rather than shift the patient to hospice care.
The other half of health-care spending—the half that goes to the other 95 percent of patients—does leave room for doctor-shopping. Dedicated consumers can check out doctor ratings for one-off conditions, like infections, dermatological issues, maternity services, and hip or knee replacements. They can also read up on the newest research. But that is mostly an upper-quintile-income activity, because in today’s semi-marketized health care only top-drawer health insurance allows a wide choice of doctors. The lower quintiles are usually limited to specific networks.
The furor over health-care costs is something of a red herring. Health-care costs per procedure, in general, have been falling for a long time, it is spending that is rising mostly because of the flood of new medical technologies. Fifty years ago, the standard therapy for a heart attack was weeks of bed rest, the more immobilized the better. The high death rates, at least, were counterbalanced by the modest spending.