American Consequences - September 2018

enterprise with the single-payer option, we can certainly bankrupt several heretofore major industries and replace the private sector’s function with that of the public sector. First slowly, then quickly. To do so in the name of Karl Marx would be one thing, but to do so in the name of efficiency is absurd. No municipal, state, or federal government has historically shown the ability to execute an undertaking so vast more efficiently than private markets could. It is the depth of naivete to rely on the benevolent wisdom of a state that has all too often demonstrated itself as neither good nor wise. As the profitability and international competitiveness of American industry is every day more impaired by escalating health costs, we must make a choice. Much like police or fire protection, public health has long been regarded as a public good – not an explicit right – and as such should be granted some exemption from the strictest market ideology. A purely socialist solution is inadequate, as is a purely capitalist solution. But today, it’s clear that a much greater degree of market forces is needed. There has already been progress in the marketplace in reaction to spiraling costs. For example, some far-sighted third-party administrators, pharmaceutical benefit managers, and other firms are harnessing the power of data to deliver genuine “managed care,” as opposed to just beating down the reimbursement rates for service providers. And giving employers true visibility into their health care costs – such as a dashboard of their top service providers, the most frequent and expensive procedures and morbidities,

and the delta among the providers for the latter – can provide powerful tools to bend down the cost curve and improve outcomes. Charles Silver and David Hyman recently wrote a thoughtful book, Overcharged: Why Americans Pay Too Much for Healthcare , which is in large part predicated on long-established economic data that more insurance leads to more consumption of health care, not less. They show how transparency and competition in the private pay sectors of the health care services market – such as LASIK and cosmetic surgery – resulted in decreasing prices and better outcomes. They propose an innovative approach to only purchase insurance for catastrophic occurrences. No one expects their auto insurer to pay for oil changes, the authors argue – only if a driver wraps a car around a telephone pole. Likewise, the health care market would respond to market forces if consumers were not acquiescing to a CAT scan every time they had a check-up if they knew they would be billed for it. This approach is well worth exploring. The old 80/20 Rule is nowhere more evident than in health care. For example, 25% of Medicare spending on seniors, which in 2016 was $672 billion, is spent on 5% of patients in their last year of life. This is roughly equivalent to the entire economy of the Rhineland in Germany or of New Zealand! And what for? Prolonging the inevitable end? Not to be confused with Jack Kevorkian, but I agree with Drs. Ezekiel Emanuel and Atul Gawande (authors of The Ends of Human Life and Being Mortal , respectively) that the indefinite extension of human life, by any means necessary and at any cost, presents a

24 September 2018

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