Health Care Opus in The Atlantic

Monday, August 24th, 2009

This is the most thorough, clear elucidation of the problems with U.S. health care system and their causes that I’ve seen to date.

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24 Responses to “Health Care Opus in The Atlantic

  1. #1 |  Paul Krugman | 

    He’s just a racist.

  2. #2 |  Nick T | 

    Thanks for the link, Radley, read it today off of your facebook, and it’s really persuasive. It’s just so simple, and obvious that I think a lot of people need to see this because it will really make them think.

    Sadly this will never ever change anything.

  3. #3 |  Thomas Paine's Goiter | 

    Outstanding article, but it won’t change a thing.

  4. #4 |  Oregon Commentator » Blog Archive » Obligatory Health Care Post | 

    […] Radley Balko calls this “the most thorough, clear elucidation of the problems with U.S. health care” that he’s seen. I’m inclined to agree, even if I don’t necessarily buy the author’s prescriptions (no pun intended) for fixing the problem. […]

  5. #5 |  Lee | 

    On the internet that is an Opus and their servers seem to be exceptionally slow today.

    I’m about half thru and I am agreeing with most of his assertions (I’m waiting for page 5 to load).

    It seems he points out part of the problem is that insurance companies have no value to add to the healthcare system yet take a part of the revenue. They also distort the cost for the users since users lose sight of how much any particular treatment/test costs since the cost is distributed (Stossel made this point).

    I’m not going to page back and look when his dad was in the hospital. With elderly parents and in-laws I have spent a lot of time in hospitals in the last 5 years. The hospital he was at sounds incredibly primitive compared to the ones here in North Texas.

    The more I look into this I think the Swiss and Dutch systems are pretty good systems. Too bad the Republicans have been reduced to scare mongering and hand waving. They might have actually been able to suggest an alternative.

  6. #6 |  AJP | 

    Radley, thanks for posting this. I posted it on my Facebook page about a week ago, and those who read it were impressed. This issue of the Atlantic has been on the stands for almost a month, and I’m very disappointed that this article did not get more traction and attention. It is by far the best analysis I’ve seen, and I don’t understand why it is being ignored in the current debate.

  7. #7 |  Steve Clay | 

    I was fairly green to market-based reform ideas when I read it and I was thoroughly convinced. Walking through the system and history slowly helps, as does not peppering the piece with divisive rhetoric (like opening your op-ed with a quote about socialism). In short, Goldhill writes with respect for Democrat readers who might not have drunk the kool-aid.

  8. #8 |  Helmut O' Hooligan | 

    “We can’t imagine paying for gas with our auto-insurance policy…”

    I don’t know how many times I’ve said this recently. Even though I am sympathetic to the public option, and to those who advocate it, I believe it also misses the point. This article articulates many of the same concerns I have.

    I work in a hospital, and I see the controlled chaos, the overwhelmed staff, the overwhelmed staff turning on each other instead of criticizing the system, etc.. I see the ER full of people who might have been better off staying at home to rest and take over-the-counter meds. One example: Recently a girl came up to me and said, “where can I get a pregnancy test.” I wanted to say, get the fuck out of here and go to CVS! I couldn’t, of course, so I glumly said, ER is that way.

    Changing health care insurance options should go hand in hand with a new vision of health care delivery. This article expresses that very well, and I’m sorry I only had time to skim it. Thanks Radley!

  9. #9 |  Mario | 

    I think the distinction that needs to be understood is that when most people talk about “reforming” healthcare, what they mean is making healthcare into a right — of course, by “right” they mean entitlement.

    Any shortcomings of our current system is besides the point in the minds of reformers agitating for universal health care, a public option, or whatever. The Atlantic article, to these people, is just so much “blah, blah, blah.”

  10. #10 |  Les | 

    Any shortcomings of our current system is besides the point in the minds of reformers agitating for universal health care, a public option, or whatever. The Atlantic article, to these people, is just so much “blah, blah, blah.”

    I think you’re painting with a pretty broad brush here. There are closed-minded idiots on both sides of this complex issue.

  11. #11 |  Les | 

    And, I hasten to add, there are open minded people looking for practical solutions on both sides, as well.

  12. #12 |  freedomfan | 

    Thanks for the link, Radley. I am not through the whole piece yet, but I knew I would read it all when I saw this on the first page

    Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value. [emphasis mine]

    There, Goldhill nails the biggest problem with our current system, both in terms of quality and in terms of cost. Third-party payer systems tend to disconnect the patient from his normal incentives to determine if he is getting quality and value from the treatment he receives. In the discussions, people are bamboozled by the idea that “health care is different from other things we pay for” and by the claim that people aren’t educated enough to understand their medical care. That’s irrelevant. One could as easily observe that computers are different from potatoes and that not one person in a hundred could explain how a transistor works, much less a modern CPU. Nevertheless, consumers get phenomenally better value from their PCs every year because they care about performance and reliability (quality) and they care what they pay for it (cost).

    We won’t see substantial improvement on quality and price in health care from more regulation/mandates or by a massive expansion of the role of the largest third-party payer, government. The most effective reforms will be the ones that engage the health care consumer with decisions about what he is buying. Any proposal whose premise is to further separate costs and benefits is moving in the wrong direction, especially those that take things to the extreme of trying to trick people into thinking they are going to get health care “for free.”

  13. #13 |  James D | 

    The article is great but I’m a pessimist:
    1) It will never change most people’s “free health care for me paid by the rich” minds.
    2) It requires the dreaded ‘personal responsibility’ that is so highly lacking in modern America.

  14. #14 |  supercat | 

    Suppose a doctor were amazingly good at back surgery–he could fix essentially any back problem in a week, such that unless the patient did something else to his back, the patient would never need any further medications or treatments for back pain. The only “problem” with this doctor is that he will see no more than 48 patients per year. Who should the doctor treat?

    The market-based solution would be to have the doctor treat the 50 patients each year who are willing to pay the most for treatment. If there are 50 patients who are willing to pay $25,000 or more for the treatment, anyone who might consider the treatment would have a very strong incentive to pursue other options first. Only those patients for whom no cheaper alternative showed promise would vie for this doctor’s time; his unique services would be used by those who would most value them.

    Adding fractional-pay “insurance” to the mix would complicate things, but would do nothing to really help anyone. Someone who would have been willing to pay only $5,000 without insurance may be willing to “pay” $50,000 if insurance will cover 90% of it. Thus, some of the doctor’s services will be used by people with insurance who value them less than some other people without insurance. While insurance will make the doctor’s services available to some people to whom it would otherwise not be, it will also deny the services to some people who would have valued them more.

    Suppose a single-payer system is put in place so nobody has to pay out-of-pocket expenses for the services they use. How should one measure how much prospective recipients of the services will value them? If someone’s pain could be treated pretty well with $40/year of pills, but the person would rather not have to take them, is there any reason the person wouldn’t want to have the surgery if it wouldn’t cost him anything extra? Is there any reason such a person wouldn’t overstate his pain level if doing so would get him the surgery?

    The major problem in medicine today is that consumers are sufficiently insulated from price that many services are allocated to people who don’t particularly value them, thus creating a scarcity of such services for people who do.

  15. #15 |  Mario | 

    Supercat — Under a single-payer system that doctor will marry either a politician or a lobbyist (working in any industry), and his or her services will be “allocated” according to who is better connected than the rest of us.

    See? Problem “solved.”

  16. #16 |  Mario | 

    Les — I’m not sure just what your point is. My point is that howsoever good the analysis of the harm interventionism is causing in the healthcare market, some people just don’t care. There point is removing healthcare from the market and guaranteeing it to everyone, just like those “civilized countries” in Europe.

    Again, the Atlantic article will do nothing to change their minds; their minds are closed because of their antipathy to free markets.

    As to being closed minded on the other side of the issue: I’ll agree that people who fear the socialist bogeyman, because socialism is something those “godless commies” cooked up, are closed minded. However, those who have studied the problem of economic calculation under socialism, and who understand the moral failure of collectivism and wealth redistribution, cannot in good conscience stay “open minded” to the reforms being proposed.

  17. #17 |  Eric | 

    in general, he notes several good issues. Unfortunately, he completely misses how government doesn’t enforce safety standards or protect the poor. That these same “distortions” also affect not only the healthcare industry, but most industries (CPSIA, USDA, FDA, OSHA). He’s a hell of alot closer that most Dems I know.

  18. #18 |  emerson | 

    I’m boycotting whatever store this guy owns.

  19. #19 |  Lee | 

    Another great article looking at the various healthcare systems in the world.

  20. #20 |  Andrew | 

    I hang out at hospitals a lot, my wife is a surgeon so if I did not go there every once in a while I may not see her for days at a time.

    As someone who works in the Quality Industry (ISO, APQP, Six Sigma) I am amazed that so many simple tools are basically ignored. The example was given about a hand washing check list as it is some sort of industry revolution. How is it that simple checklists solutions are overlooked?

    There is a lot of talk in the American Society for Quality ( on how we can help develop systematic solutions to the bureaucracy of health care. There is a lot of chatter on the ASQ website if anyone wants to take a look at how some of the proposals are taking shape.

  21. #21 |  Ben | 

    My next door neighbor used to be the president of a hospital in Rhode Island. Fairly high pressure guy, but good to talk to.

    When he left his position, he went to head up a healthcare IT company. They were developing a software that took an infection and suggested the best antibiotic to treat it. If that med didn’t work, it suggested the next one, taking into account patient allergies and such.

    I was amazed that nothing like this existed. It’s a simple flow chart, basically.

  22. #22 |  Richard Bottoms | 

    The biggest problem with coming up with a fix to the health care system is the party Democrats have to bargain with, the GOP, is full of insane people, or at least you think so. No, what they are is a group of people willing to flat ou tlie coupled with a segment of the American public too stupid to see it:

    Jonah Goldberg, editor-at-large of National Review Online, went on Fox News today to fan the flames of the latest fabricated “death panel” controversy.

    Goldberg equated a Veterans Affairs pamphlet — one that’s reportedly no longer being used — with Nazi eugenics, saying “death panels may not be too far off the horizon.”

    The pamphlet in question is one that, Fox reported this weekend, encourages disabled veterans to decide whether their lives are worth living. Tammy Duckworth, an assistant secretary of the VA, told Fox on Sunday that the department instructed VA doctors to stop using the pamphlet in 2007.

    But Fox has ignored that insistence, saying soldiers returning from Iraq are given the pamphlet.

    “This goes into the realm of valuing whether life is worthy of life, as the Germans used to say,” Goldberg said today.

    Idiots, and the idiots who believe them.

    It’s a political ploy to whip up more “outrage” by foaming at the mouth, ill-informed fools.

    Love to see Libertarians raging about that sometime.

  23. #23 |  Nick T | 

    #22 you’re not serious.

    Look, everyone hear agrees that Republicans are just god awful cretins with their lying and their fear-mongering, (trust me I often fantasize about punching Dick Cheney in the nose or kicking Tom Delay in the junk, assholes) but when pressed to give an honest discussion they are the only ones who have ever brought up HSAs. Dems, if left to entirely their own devices would insist on more government involvement and oversight, not less.

    THE problem is that both Dems and Republicans are totally owned by insurance companies and any solution that leaves them out is entirely untenable. I will be shocked if insurance companies don’t literally write every word of the health care reform bill.

    If the debate was so dishonest it would still be completely stupid.

  24. #24 |  Scott | 

    I read that whole piece on a flight home to visit family. It was really the clearest examination of this whole muddled issue I’ve come across so far. Few reports on health care reform can hold my attention … this one really did.

    Where he details how insurance companies are actually the customers and not the patients themselves is very useful, and I plan to use that argument in the future. I have to deal with that as a type II diabetic. I take very good care of myself and my blood-sugar levels are fine. But my doctor is constantly trying to get me to take more blood tests than I actually need because it’s easy money for him. And the insurance company is pushing me to take more tests as well because the nature of the insurance doesn’t allow them to trust me to take care of my own body. They have to treat me like an idiot, because they’re the ones on the hook if I go out and eat a dozen donuts and end up in a coma.