This is part one of a three part series on health care reform in the United States. The second part is a primer on how the health care system works and why it’s broken; the third will be about why I think we need a public option as part of any health care reform package. The third part will be published after I’ve had a chance to review legislation relevant to the speech and some of the broader reform efforts.
With President Obama addressing a joint session of Congress this Wednesday, September 9th, 2009, on the subject, health care reform is again a focus of national attention. We’re being asked again to evaluate the president’s claims on the subject in light of the testimony of a great many expert witnesses. Since health care reform became a subject of serious discussion in the 2008 election cycle, we’ve had the occasional opinion from some doctor, for instance, on what he or she thinks should be the way we do health care in the future. Even the American Medical Association, allegedly the body the represents all the doctors in the United States, has made its opinion known on the matter, supporting reform but not a public option. But I don’t think we should treat doctors as our expert witnesses on the subject of large-scale institutional reform in the health care system. Instead, economists are the most suitable expert witnesses when it comes to the health of our health care system and the institutional reform that we should be implementing. After the jump, I’ll try to explain why I think economists* are suitable and medical doctors are not suitable as our experts on the subject of health care reform.
We’ve all seen the expert witness on our favorite crime procedural on TV – the psychiatrist, the medical examiner, the crime scene investigator. These expert witnesses try to explain in terms we can understand who committed the crime, or how exactly the crime happened, or how the person who committed the crime didn’t have the mens rea, or necessary intent to commit the crime, to be held legally responsible.
When it comes to health care reform, we obviously bring our own political beliefs to the table. Whether you’re a Democrat, a Republican, a Libertarian, or an independent, you probably think there’s something wrong with the way we do health care in the United States and have a vague idea of what we might do to fix it – polling leads us to believe that we’re satisfied with the quality of our care but we’re getting it inefficiently. But, like me, you probably need some help determining the specifics.
If you’ve been reading newspaper editorials or watching cable news, you might have come across a doctor talking about the national health care system – that doctor might have even been a senator or a celebrity. You might also have heard opinions from a doctor in your community on the subject. How much weight should you give to the opinions of these doctors on the subject of health care reform?
In general, not much. While an individual doctor’s opinion on the subject might be worthy of your attention, I think there are three important reasons why opinions on institutional reform should be left to others, with one group in particular taking precedence as our preferred experts – I’ll get to them in a minute.
First of all, as a class of people, the doctors we all see on a daily basis aren’t necessarily all that smart. I don’t mean to offend the medical doctors in the audience who are brilliant examples of their profession, but consider the incentives. If you’re a smart person, you have a few career options toward which you get steered – attorney, scientist, engineer, and doctor (among other things). If you pick medical doctor from those, you get a few more options – internist, specialist in a variety of fields, surgeon, or researcher. The incentives structures are set so that the smartest people go toward the specializations that pay higher – things like researching pharmaceuticals or prosthetics, complicated kinds of surgery, and so on. The more you’re interested in a particular topic, or driven by profit, the less likely you are to be the kind of doctor who runs a quiet practice and sees lots of patients. Occasionally the smartest doctors will choose to stay in low-paying medical professions like internal medicine, but all the altruistic reasons to be an internist apply at the higher-paying specialties, too. Why not get paid better?
And that’s without considering the fact that there are hundreds of medical schools in the US and the world that accept, almost of necessity, hundreds of mediocre students every year. There’s a pretty good chance your doctor, the one who’s telling you their opinion on health care reform, just isn’t that bright, especially if they’re not in an advanced specialty. Put simply, if you’re talking to a doctor in y0ur community, there’s just no reason to believe she or he has the intellectual chops to criticize the health care system unless you have specific evidence that says otherwise.
Furthermore, for decades now, you might have noticed an important trend on American television: the hospital series. From St. Elsewhere to ER, from Grey’s Anatomy to Scrubs, from Hawthorne to Nurse Jackie, we’ve been inundated for as long as I can remember with the daily lives of the members of the medical profession.
Why would I bring that up? The key thrust of most of these shows, if there is one, is that these doctors, who, for whatever reason, we’re trained to treat almost as gods, live their lives as we do. They are fallible people who make ridiculous mistakes in both their personal and professional lives. Of course, that’s not to say that they’re bad at their jobs, or any less good than anyone else. But doctors are human just like we are. We shouldn’t hold them up as people whose opinions on every subject should be respected. On the subjects on which they are experts – medicine – they are indeed worthy of our respect, if they are in fact occasionally mistaken.
But these fallible people aren’t experts on institutions, how they work, or how best to change them when they need changing. Why would we want their opinions on that subject? They are neither trained in the study of social institutions nor in the comparative benefits of different changes to those institutions when they become unhealthy.
And, of course, we must also be concerned with the fact that the opinion of a doctor on the subject of health care is a fundamentally self-interested opinion. Almost every medical doctor has a vested financial interest in keeping the health care system exactly as it is. After all, we all know that the average medical doctor makes more than the average American. If we go to a new system that threatens that status even slightly, of course the average doctor is going to feel personally threatened by the shift and will attempt to preserve the status quo however possible. And that might include giving advice that suggests we do something that’s not actually in the best interest of the country.
So if doctors aren’t necessarily the brightest, are fallible, and have a pretty blatant conflict of interest, who should we trust as our expert witnesses in the court of public opinion on the subject of health care reform?
I think the answer is obvious: economists.
While they’re no more or less fallible than doctors are, economists have three key edges on doctors when it comes to the subject of health care reform.
First of all, economists are specifically trained to diagnose the health of our political institutions. There are a wide variety of specialties in economics, too, but every economist gets basic training in assessing things like whether patients are satisfied with their health care, whether the care itself is being provided efficiently, and what kinds of remedies governments can and have taken to improve deficiencies on these kinds of scales. Additional specialization will prove even more beneficial – an economist who specializes in understanding our health care institutions and studying models of institutional change will be an even more beneficial expert witness in our reform project.
Secondly, while, like me, you’ve probably heard anecdote after anecdote about how health care in the United States is awesome and it’s terrible in Canada or the UK or somewhere else in the world, economists know better than to take these anecdotes at face value. They know to look at studies on efficiency here, and patient satisfaction there, and to do so not just based on what your cousin in Leeds told you, but based on the data. Very few doctors have training in understanding these sorts of studies, let alone using them in the context of political institutions.
Finally, to some extent, almost every economist has to communicate with the public to some extent, and so has experience explaining institutional concepts to the court of public opinion. Your doctor might be experienced talking about medicine to the layperson, but most don’t really understand all the intricacies of the health insurance industry – something I’ll be taking a stab at in my next post. Doctors don’t have to take classes in health insurance or even medical coding to get their Medical Doctor degree. An economist who takes the stand explaining the health of the health care industry will both have experience explaining institutions to the lay public, either in classrooms or in papers or elsewhere, but will have had to do so repeatedly to be able to be called an economist in the first place. While we might want to do a test screening before we put a particular economist on TV, we can still expect a better performance than we’ll get from a medical doctor.
You might be protesting at this point – WAIT! what about politics! All these economists are going to have political leanings, and so we can’t trust any of them. After all, the Democrats have their economists, the Republicans have their economists, and they all come up with their own different numbers, right?
That, my friends, is something you’re going to have to risk. If you listen to an economist explain the institutional health of the health care industry and suggest some institutional changes, then you’re going to have to pay close attention and then carefully weigh what they say against your own political beliefs before you come to your own conclusions. Just like in a court of law, you have to carefully weigh the evidence. You can’t depend solely on your own preconceptions. If you’re a conscientious voter, you shouldn’t be depending on them at all. Also, if you’re lucky and a bit industrious, you’ll spend some time tracking down reports from independent firms on what kinds of solutions they think are best.
In conclusion, I don’t think we want to completely ignore the viewpoints of doctors on the subject of health care reform, but we can’t treat them as anything more than well-informed citizens. They can’t be the experts we call to the stand to explain the problem or our options going forward. Their anecdotes, either on the success or failure of the practices of which they have taken part, will only be anecdotes just like any others. We cannot trust the fate of so important an issue where the lives of so many citizens are at stake on the misapplied training of a group of people. Instead, let’s look to the experts: economists.
* – While I am not an economist, I do have a substantial amount of undergraduate economic training and am friends with a couple of economists. However, I have no financial or other substantive interest in the long-term plight of the economist. Or The Economist, for that matter.
–Posted by Kevin S. Burke