This shouldn't be a surprise. An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life. They're going to usually tend to underspend on preventative care (which has the highest ROI) and tend to overspend on end-of-life care (which has a lower ROI). You can see this played out in things like the US's infant mortality rate (3X other developed nations) and life expectancy (31st worldwide, declining).
I think this "conclusion" depends strongly on how you define "worse outcomes".
> An individual is going to not make very good decisions about how healthcare dollars are allocated over the course of their life.
Not if they have no incentive to learn how, no. And our current system gives them no such incentive, since they don't control the dollars to begin with.
In other words, the system complains that people don't do something that the system prevents them from doing.
> In other words, the system complains that people don't do something that the system prevents them from doing.
Uh, this has nothing to do with the system, and mostly everything to do with behavioral economics and risk pooling. People are poor at investing in preventative care, because the benefit is extremely hard to perceive at the individual level. And they over-invest in end of life care, because, well, they don't want to die. That's not the result of "the system", that's human nature. Attempting to build a healthcare system on how we "should" act instead of how we actually do isn't a plan.
This also ends up being a pretty unfair way to apportion care because a rich man couldn't care less about a $100 fee and a poor man can find it prohibitive.
One example would be how the US has one of the worst infant mortality rates in the developed world.
If you stratify by income then the lower end of the income scale have it far worse than equivalent cohorts in many other developed countries.
I mean sure if you are upper middle class and work for a large national or international company then healthcare is probably up there with world class but that's not a lot of people percentage wise.
The person who has the most skin I the game, the patient and premium-payer, is not in the room when payments are negotiated. I don't think the U.S. is an example of enforcing skin-in-the-game.
Because if you wait until you need it, it's going to be a pretty bad time to negotiate.
Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.
> Further, "skin in the game" is mostly a euphemism for increasing out-of-pocket prices for care to encourage patients to be "discriminating consumers," a concept I've already detailed my objection to.
First "euphemism" implies some ulterior motive. I don't think people are trying to make people poorer. Hanlon's Razor would have us presume everyone at least thinks they have a mostly good idea.
Next, if people were somehow using their own money, they'd also have the option of choosing something 10 or 20 percent more affordable, keeping the difference for other valuable things, like paying off a house, paying for grandkids' college, buying those plane tickets to see their cousins, etc. The reason there is no downward pressure to save on individual things (even predictable, non-emergency things like deviated septums) is because there's no best viable alternative. We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.
But don't take my word for it; here's the Rand Corporation offering a studiously even-handed assessment and giving a definition of the term matching the one I suggested: https://www.rand.org/pubs/research_briefs/RB9672/index1.html
> These plans are intended to give consumers more "skin in the game" — that is, to make them responsible for a greater share of spending. Proponents of this approach contend that consumers in such plans will have more incentive to make prudent, cost-conscious decisions about using health care, which, in turn, should drive down overall health care costs. Critics, however, have voiced concerns that consumers lack information needed to reduce spending without reducing quality of care.
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> We don't keep the three grand we save by saying, "Hmmm... maybe I'll just lose 15 pounds instead." That's how things are supposed to work.
Well, first of all, that's false, in the sense that, increasingly, deductibles are substantial (a few thousand, at least), co-pays are higher, and co-insurance (where it's difficult to even predict what you'll owe) is becoming more common. Almost nobody has a plan where they don't have to pay something for medical care.
But besides that, maybe in your scenario someone decides to lose weight. But let's think of another scenario. I start to experience some pain but I haven't really got the money for the doctor's visit. I decide I can tough it out. I keep doing this until the pain is truly unbearable and then I go to the doctor and find out I'm terminally ill and I waited too long to be treated. Or I forego preventative care and miss an opportunity to catch and treat cancer early. There aren't outlandish scenarios; they're the result of a system where patients have to shoulder more of the cost of care out-of-pocket, especially when combined with a state of affairs where a great many Americans do not have the savings to pay an unexpected expense of a few hundred dollars out-of-pocket.
No. They are just cherry picked. There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors. Single payer doesn't solve that. They just have an unelected government official saying no. And the patient doesn't benefit in that case. I haven't heard any reply about the moral hazards of turning healthcare decisions into lobbying efforts. Do we not think the well-connected and otherwise favored will still benefit over people in poverty? I'm skeptical.
Who wants doctors out of the loop? I want them more in the loop.
Doctor-patient relationships don't work that way. If they did, we wouldn't have people getting illicit prescriptions from doctors. Doctors, surprise, do listen to their patients wishes and accommodate them when they're OK with what the patient wants.
Doctors should be advising us, "Here are your options (with prices). What do you want to do?" One option on the table for "laceration on your back" should be "have an uglier scar and give a big check to your son as a wedding present". Right now, with good insurance, there's no incentive not to treat you like an underwear model that needs scar-free skin and do experimental scar-lightening UV treatments.
If a procedure (or doing nothing) is foolish, of course good doctors won't put that on the table. But single payer doesn't have doctors and patients making these decisions. They would instead look at a pre-determined schedule of options as handed down from the Bureau Of Wellness. Maybe, because of lobbying and political infighting, "uglier scar" is the only option. "Check for my engaged son" certainly isn't on the schedule.
A guy with a minor cut on his back is bombarded with a 24/7 targeted ad campaign for ScarAway!TM, that convinces him this experimental...er..."cutting-edge!" UV treatment is the only thing standing between him and a constant stream of fawning, eager females twenty years his junior. He then obtains this treatment from his "true believer" local doctor at the low, low price of a $2,000 "co-pay" for himself and $20,000 from his insurer. After three months of ScarAway!TM his back is of course completely disfigured and looks far worse, at which point his own wife refuses to sleep with him, necessitating years of therapy. A decade passes and he is diagnosed with melanoma from the UV he was exposed to and dies one year and one million USD in healthcare costs later. The most memorable moment of his son's wedding is a tearful toast to his deceased father, whilst each of the doctors involved in his "treatment" as well as the ScarAway!TM salesman cut checks to their engaged children.
> I don't know why people keep setting up false equivalences and false dichotomies in these discussions.
Maybe it's fun? I honestly don't know. This scenario is certainly vivid. It's not the only option other than... I'm not sure what alternative people are planning, as I said above. They tend to gloss over who actually decides when a procedure isn't worth it. And they gloss over how normal people without lobbyists get the system changed when it stops working.
>There are very few scenarios now where the consumer benefits from saying "no" or "less" to their doctors.
is totally off base. The primary benefit to saying "no" is avoiding damage to your health from dangerous and unnecessary treatments that American doctors have a financial incentive to sell. People in the U.S. have their life expectancy reduced every day because we, almost uniquely among developed countries, have removed nearly all limits on the cultural acceptability of medical professionals and the medical industry as a whole treating patients as sales marks rather than patients. If you would like to experience this firsthand, respond to any AdWords or TV advertisement for a medical treatment. The sleaze is limitless.
>They tend to gloss over who actually decides when a procedure isn't worth it.
Salaried civil servants with advanced degrees who have an interest in cutting through BS to protect the health of the country. If you want to reduce people like Frances Kelsey to "unelected government officials" be my guest, but you're only showing how naive you are.
Could it be that the model is wrong?
The example of an automobile doesn't seem apt. Are you going to trade in Grandma for a new one when the treatments prescribed get too expensive and they can't figure out what's wrong with her?
No, the idea that people who have no skin in the game--regulators and bureaucrats--can make better decisions than the people directly involved, particularly about matters with as much at stake as health care--is one of those zombie ideas that just don't die. No regulator or bucreaucrat ever suffers any negative consequences because of bad decisions about other people's health care.
As for people being poor at judging for themselves whether procedures are necessary, another comment upthread already addressed that: there are plenty of other areas (auto repair, for example) where most people don't have the technical knowledge to judge for themselves whether procedures are necessary, yet markets seem to function in those areas. Furthermore, under the current system in the US, people have little incentive to become more knowledgeable, because they are not going to be given a choice anyway; they're going to get whatever their health insurance provider says is the standard care. Under a market system, people would have much more of an incentive to actually learn about the various options. And there would also be much more of an incentive for independent third parties to provide information, particularly information that health care providers might not want people to know.
More generally, the reason market advocates, like me, advocate markets is not that they always give optimal outcomes. They don't. But in cases where they don't, non-market alternatives give outcomes that are even worse.