Posted tagged ‘Health Care’

What Doesn’t Make You Stronger Can Kill You

December 3, 2017

Bit of self promotion here:  I’ve got a piece in today’s Boston Globe, on one of the hidden consequences of failing to deal with the antibiotic crisis.  In it, I focus on the use of antibiotics as prophylactics in surgery. Nowadays, it’s standard procedure for a wide range of operations to dose the patient with antibiotics shortly before she or he goes under the knife; doing so has been shown to signficantly reduce the risk of post-surgical infections.

I took off from a study that modeled the consequences of increased microbial resistance for ten common procedures, mostly surgeries, along with chemotherapy for a particular set of cancers.

The results of that study were predictable:  more resistance leads to more post-op infections and to more deaths.  If the situation gets really dire, if common causes of infection associated with surgery become increasingly untreatable then the calculation behind all kinds of medical interventions will change:

That’s what scares Dr. James Maguire, an infectious disease specialist at Brigham and Women’s Hospital. “I think some of the worst feelings we have are when we have a problem with a patient and there’s nothing we can do.” Infections following joint replacements are bad enough. They are, Maguire says, “catastrophic in terms of what happens to the patient.” Were the risk of infection to go up enough, he adds, “having seen what an infected joint replacement is all about I would think twice.”

That’s a response to an operation that may be vitally needed to reduce pain and increase mobility — but, as Maguire went on…

…while someone contemplating a joint replacement can choose to forgo the risk, if they need a new heart valve or a ventricular assist device, “that’s potentially life and death.” In such circumstances, “if your life depending on having the device, even with great risk you’d do it. But more would die.”

Behind such specific possible horror stories, this is for me a deeply cautionary tale about the way choices our society — our politics — makes have much deeper effects than our usual debate admits.  Antibiotics are not just responses to disease; their use penetrates medical practice, to the point that basic expectations we may have about what how we can move through the stages of our life can be dashed, without our ever really grasping why.

That is:  joint replacements are part of our medical and mental landscape now.  There are over 330,000 hip replacements performed each year in the US.  We know (some of us, venerable as we are, more than others) that our knees, elbows, shoulders and so on won’t always work as well as they do today.  We know, most of us I’m sure, folks who’ve had the op and are now playing tennis again or whatever, and we have in the back of our minds (those of us fortunate enough to believe we’ll still have adequate health care available over time) that if and when that bit falls apart in our own bodies, we can look for the same outcome.

Except, of course, if the risks of surgery shift significantly in the meantime.

The last point I make in the piece, somewhat more gently than here, is that should the way we age, the way we give birth and so on deteriorates because of unchecked microbial resistance, that will be a more-or-less hidden consequence of political failure.

That’s because dealing with the antibiotic crisis boils down to doing two things:  regulating economic activity and funding research.  The GOP doesn’t want to do either.  And, as usual, people will die as a result.

So, on that note of cheer, a link, again, to the piece.

Oh…and open thread too.

Image: Follower of Jan Sanders van Hemessen, An Operation for a Stone in the Head, date unknown (to me).

It’s Baaaaacccckkkk (Sort Of, Maybe)

July 20, 2017

It is impossible to overstate the Republican commitment to ripping health care from millions, while taking a chainsaw to our medical system.

Rand Paul has just announced that he will vote “Yes” on the Trumpcare motion to proceed as long as he is given a clean vote on his amendment, which would simply repeal the ACA (which, given the CBO evaluation of a similar proposal, would lead to something on the order of 17 million without health care next year, and 32 million Americans left in the cold by 2026).

That’s still not enough to get Trumpcare to the floor if the other declared “Noes” hold out, but each senator McConnell can peel away significantly increases the pressure on those who remain opposed.  And certainly, Paul’s cave reminds us that counting on any Republican to maintain a party-base-unpopular position as a matter of principle is a mug’s game.

This won’t be over until the GOP loses its majority in one house or the other.

Image: Workshop of Lucas Cranach the Elder, Massacre of the Innocents, c. 1515

A Modest Proposal

July 20, 2017

Most people know of Senator John McCain’s diagnosis with glioblastoma, an aggressive brain cancer.  I have just a couple of thoughts I’d like to add.

First, obviously, best wishes to Senator McCain and his family. This is a very tough diagnosis, as we all know.  The next several months and years will demand an enormous amount of McCain and all those close to him, and I wish them well in that fight.

Second:  John McCain is receiving the best of care, as he should, and as I would wish anyone in his position could expect.  That health care comes to him through his job as an employee of the federal government.

The immediate context, of course, is that this particular federal employee is one of those Republican senators who was, by all accounts prepared to vote yes on a bill that would have pulled federally mandated and supported health care from tens of millions of his fellow citizens.

The larger context is that John McCain has throughout his life relied on the United States government for his medical care — from birth to now.  He was the son of a serving naval officer, then a cadet at the Naval Academy, then a serving officer himself, then briefly a veteran in private life.

Then, within a year of his retiring from the armed forces, elected as a member of the House of Representatives.  Four years later he won his Senate seat, to which he has been re-elected five times, which brings us to the present day.

A whole life, all 80+ years of it, and John McCain has never for a moment had to wonder what he would do if he became sick, or if his wife or his kids fell ill.  For the first half of his life, he had access to a single-payer system; as a member of Congress, he received his health benefits through the same benefit package available to federal workers; since the passage of the ACA, members and their staffs have access to on-exchange subsidized plans.

And that’s great!  John McCain should have had secure, guaranteed and persistent care.  The injuries he suffered in Vietnam and during his imprisonment there should never have been eligible to be pre-existing conditions. He should have been, as he was, free of the choice-crippling necessity of working a secure gig to ensure access to insurance, thus enabling him to pursue his life of military and public service.

The kicker though: so should we all.  The health-care life John McCain has led is the one that’s right not just for him and his family, but for all Americans.  I won’t rehash here the moral and the practical reasons why — we’ve done that before, David can do it better, and we will be back at that by nightfall at the latest.  All I want to do here is to make a modest proposal.

The Democrats should come to the next round of manouvering on health care legislation with a plan that repairs ACA’s current weak points and lays out a path to full coverage.  And they should name it after one of the great exemplars of the power of guaranteed health care to liberate Americans into lives of daring and service.

Here’s to the John Sidney McCain III Universal Health Care Act of 2017!

Image: Doris Zinkelson,  No 115 British General Hospital, Ostend – Unloading Wounded, 1945

It’s Working. Let’s Work More

June 27, 2017

Following up today’s news on the delay in the Senate health care vote…

Keep calling, and don’t restrict yourself to your senators’ DC offices.  Each and every senator has several in-state offices. They’re populated mostly by actual staffers, not interns.  Real people answer the phones — and if the one nearest you doesn’t pick up, you can call on down the line till you find someone at home.  They’re often less crazed and more ready to listen, even to opposing views.

My own experience:  my wife’s family has a place in the Bath-Boothbay stretch of the Maine coast, and several family members who live up around the Penobscot Bay area.  So I used that as the base from which I called Senator Collins’ Portland office, the one she lists as serving the county in which my in-laws hang.  I told the nice lady who answered that I was grateful to the senator for coming out in opposition to the bill, that I agreed with her that it was bad for Maine, and that I was calling both to thank her and to emphasize that cosmetic changes to the bill won’t alter its underlying effects, which will still be bad for Maine.  We talked about this for five or ten minutes and it was an actual conversation.

How much effect will it have? Not that much. She knew I was only partly attached to Maine, so that’s a discount right there.  But at least it lets that office and perhaps the senator know that we’re paying attention, and that we will continue to do so.  And the fact that this was a conversation, an actual accumulation of reasons to worry about the bill matters quite a bit, I think.

So the moral of the story:  you don’t have to bash down the front door to reach someone who can reach closer to power.  There are back doors, listed (with phone numbers) on every senators’ web page.

Use them.

Image:  Gerrit Beneker Telephone Operator (A Weaver of Public Thought), 1921.

Paying To Be Cruel

October 22, 2015

Balloon Juice’s own presidential aspirant, ¡Baud! 2016, reminded me of something I meant to FP yesterday:  how red state Republicans have chosen to pay — hugely — for the privilege of denying their fellow Americans access to health care.  Let me turn the mic over to Kevin Drum:

In 2015, according to a survey by the Kaiser Foundation, spending by states that refused to expand Medicaid grew by 6.9 percent. That’s pretty close to the historical average. However, spending by states that accepted Medicaid expansion grew by only 3.4 percent.

In other words, the states that have refused the expansion are cutting off their noses to spite their faces. They’re actually willing to shell out money just to demonstrate their implacable hatred of Obamacare. How much money? Well, the expansion-refusing states spent $61 billion of their own money on Medicaid in 2014. If that had grown at 3.4 percent instead of 6.9 percent, they would have saved about $2 billion this year.

Two billion eh?  Pocket change!  Take it away, Kevin:

The residents of every state pay taxes to fund Obamacare, whether they like it or not. Residents of the states that refuse to expand Medicaid [22 of them — map here] are paying about $50 billion in Obamacare taxes each year, and about $20 billion of that is for Medicaid expansion. Instead of flowing back into their states, this money is going straight to Washington DC, never to be seen again.

So they’re willing to let $20 billion go down a black hole and pay $2 billion extra in order to prevent Obamacare from helping the needy.

V0017593 A surgeon extracting the stone of folly. Oil painting by Pie Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org A surgeon extracting the stone of folly. Oil painting by Pieter Huys. By: Pieter HuysPublished: - Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

Ladles and Jellyspoons!  Your modern Republican party!  Ready to fork over handsomely to make sure the wrong people suffer.

PS:  Let me call out the could-be great state of Texas for vicious derp on a grand scale:

Statewide, Texas hospitals had to eat 5.5 billion dollars in uncompensated care last year. The reason is this – after the Affordable Care Act passed, the amount of money the federal government provides to hospitals for uncompensated care was significantly reduced. It’s cause and effect; if 9 out of 10 Americans have health insurance, the amount of uncompensated care hospitals have to provide goes down. But when the U.S. Supreme Court gave the individual states the option to opt out of part of the Affordable Care Act, then-Texas Governor Rick Perry could not opt out fast enough.

Vote, folks, as if your life depends on it.  ’cause it very well may.

Image: Pieter Huys, A surgeon extracting the stone of folly, before 1584.

Today’s Republicans: Traitors Or Psychopaths?

March 22, 2015

On the treason side, I give you Steven King, who is, of course, of interest to any GOP presidential aspirant as a major figure (FSM save the Republic!) in first-in-the-nation-caucus-state Iowa:

“…here is what [one] thing that I don’t understand, I don’t understand how Jews in America can be Democrats first and Jewish second and support Israel along the line of just following their president…”

Speaking as a Jewish-American who thinks Netanyahu is a corrupt, power-for-power’s sake bigoted hack whose policies are a clear and present danger to Israel, let me first say to Representative King:

Fuck you.

With that reasoned and considered reply out of the way, let’s parse this.

“I don’t understand”

Considering the speaker, that clause doesn’t narrow it down very much.

“how Jews in America”

Not, notice, “American Jews.”  This line is the tell, the crack that lets you see into what smells to me like a very familiar trope of anti-Semitism.  I don’t want to be paranoid, but King’s plain text tells you he sees within America a group defined by an affiliation, an bond of connection to a country or a cause that is not native to their home.  We are Jews sojourning in America, and it may come to pass (how appropriate for the season!) that there will arise in Washington a King who knows not Moses.  Or so this false prophet suggests.

“Democrats first and Jewish second.”

First,carnally know you again, King.  I for one, am a Democrat at least in part because of my Jewish education.  Specifically, Isaiah 58 v. 1-12.  I may have lost any belief in a sky god — but tikkun olam* and that strand of the Jewish tradition remains a touchstone.

But more seriously, look at what King does here: he assumes a reflexive Jewish duty of allegiance to a political movement in Israel he conflates with Israel as a whole (not as bad an error I as I would wish right now, alas), which cannot be met as a member of the Democratic party.

“along the line of just following their president…”

Well, intercourse you some more, Congressman, sideways, with an oxidized farm implement.  Barack Hussein Obama is America’s president.  Yours too.  Suck on it.

Diving a little deeper, what strikes me is the combination of hostility to Jews — American Jews — and the smell of treachery.  We U.S. born and bound remnants of the Kingdom of Judea are failing Rep. King.  We are unsatisfactory to him in the failure of our allegiance to a foreign power.  He here explicitly advocates Jews in America form a fifth column for Israel.  Failing to do so, we are to him twice the “other” — Democrats and the wrong kind of Jewish.

Budapest_kunst_0043

To which I say:  beware of the demagogue who starts to define you out of commonwealth.  The next steps…we’ve seen them before.

But even more, what do I see in King himself?

Treason is a nasty word.  But there are clear US interests at stake in controlling any Iranian ambition for a bomb. Conspiring with a  foreign leader to undermine US government efforts to that end?….

Next up: psychopathy, in the form of erstwhile blog favorite Paul Ryan.  Here is his view on the appropriate state response if the Supreme Court were to gut subsidies on Healthcare.gov:

“If people blink and if people say this political pressure is too great, I’m just going to sign up for a state-based exchange and put my constituents in Obamacare, then this opportunity will slip through your fingers,” Ryan said, per the Journal.

That would be the opportunity to wait for Congress to enact a “reform” that would (on the evidence of the latest GOP budget fraud) gut Medicaid, erode Medicare, and leave millions of Americans (twenty million or more, as of this writing) without the health insurance they so recently gained.

In other words, the opportunity Ryan wants state governments to seize is to allow their citizens in great numbers to face the inevitable reality of illness and accident without a net.

Pure psychopathy.  I’d use the word “evil” but I wouldn’t want to be accused of being shrill.

Beyond labels (see what I did there?) this is the message I take from the juxtaposition of Messrs. King and Ryan.  This is the Republican party. These aren’t fringe players. They’re leaders, major shapers of policy, rhetoric and belief for just about half of the country, and much more than half of those with money enough to move power.  And they are freaking crazy.

We have nothing but work to do between now and 2016.  Not just the United States but the world can’t take the punishment of these guys holding all three branches of the government in Washington.

One last thing:  to the question at the head of this post.  To channel the wisdom of Reb Chevy Chase, they’re both.

*F**k you WordPress autocorrects olam to loam, just so you know.

Image:  Rembrandt van Rijn, The Old Rabbi1642.

Flop Sweat, GOP edition

March 30, 2014

At least some Republicans have grasped what it means — maybe for 2014, certainly later — if/when Obamacare is and is seen to be a success:

“I don’t think it means anything,” [Sen. John]Barrasso said on “Fox News Sunday” about the news that 6 million people had signed up for health care plans. “I think they’re cooking the books on this.”

Barrasso, (R-Not-Liz-Cheney’s-real-home-state) is not your garden variety Republican talking horse. He is, in fact, the chairman of the Senate Republican Policy Committee — which is a post that puts you on the GOP leadership team in the upper house. This is, in other words, someone taken seriously by people who have plenty of evidence to suggest they shouldn’t. And this Very Serious Person is telling the Most Misled Viewership™ in America that any reports that might have troubled their spotless minds about the possibility that Obamacare may succeed are skewed, false, nothing-to-see-here-move-along lies of the sort they’ve come to expect from the Kenyan Mooslim Usurper.

Frans_Hals_-_Regents_of_the_St_Elizabeth_Hospital_of_Haarlem_-_WGA11139

Given that the argument for the last several months has been that the new health care law is an obvious and abject failure, just waiting for that one last shove to send it crashing on to the ash-heap of history, evidence of the law actually functioning pretty much as designed is a disaster.

I suspect Barrasso grasps the difficulty he faces. Facts have a habit of willing out — and the many millions covered by the new health marketplaces, by Medicaid, by extended access to their parents’ policies — are going to be acutely aware if their health insurance falls under renewed threat. So (in a rhetorical move that might confuse the uninitiated) Barrosso adds the inevitable “numbers are irrelevant” dodge:

Barrasso said people care more about what kind of plans people are purchasing and whether they can keep their doctors, not how many people have signed up for new plans.

Maybe so. Fox News viewers (and anchors) may continue to believe this kind of nonsense. But those who have the good fortune to live in places where denialism isn’t what’s for breakfast know better. And they vote. As do their kids, their friends, the whole shooting match.

I just hope they do so this November.

Image: Frans Hals, Regents of the St. Elizabeth Hospital of Haarlem, 1641.

 

 

 

Your Daily Apocalypse, Outsourced Antibiotic Edition

November 21, 2013

Go read this piece by Maryn McKenna — who is, in my never humble opinion, one of the handful of very best reporters on matters of infectious disease, global health, and really scary stuff.

I was born in 1958, fifteen years into the era of clinically-available antibiotics.  I was my mother’s third child.  Had we shifted that timeline back a few years, that would have meant that there would have been a measure of luck in mom simply making it to and not through her third lying in.  As Maryn writes, before antiobiotics, five out of 1,000 births ended with the death of the mother.  No worries by the time I popped my head out into the maternity floor at Alta Bates.

But this a must read not because of any remembrance of the pre-antibiotic era, but because Maryn plausibly analyzes a post-antibiotic future.

Plaguet03

Here’s a sample:

Doctors routinely perform procedures that carry an extraordinary infection risk unless antibiotics are used. Chief among them: any treatment that requires the construction of portals into the bloodstream and gives bacteria a direct route to the heart or brain. That rules out intensive-care medicine, with its ventilators, catheters, and ports—but also something as prosaic as kidney dialysis, which mechanically filters the blood.

Next to go: surgery, especially on sites that harbor large populations of bacteria such as the intestines and the urinary tract. Those bacteria are benign in their regular homes in the body, but introduce them into the blood, as surgery can, and infections are practically guaranteed. And then implantable devices, because bacteria can form sticky films of infection on the devices’ surfaces that can be broken down only by antibiotics

Dr. Donald Fry, a member of the American College of Surgeons who finished medical school in 1972, says: “In my professional life, it has been breathtaking to watch what can be done with synthetic prosthetic materials: joints, vessels, heart valves. But in these operations, infection is a catastrophe.” British health economists with similar concerns recently calculated the costs of antibiotic resistance. To examine how it would affect surgery, they picked hip replacements, a common procedure in once-athletic Baby Boomers. They estimated that without antibiotics, one out of every six recipients of new hip joints would die.

As Maryn reports, the problem is tangled and complex — but there are clear actions that could be taken and aren’t, most obviously ending the reckless use of antibiotics in agriculture, which consumes something like 80% of the total produced.  But don’t waste time here: go read the whole thing. Get scared; get mad; call your congressfolk.

Image: Josse Lieferinxe, St. Sebastian prays for plague victims, 1497-99.

Republican Health Care Plan (Die Sooner) Implemented Via Shutdown — Salmonella Outbreak edition

October 9, 2013

Ok.  That title is a bit of hyperbole (you think?–ed.).  No deaths have yet been reported from this:

This evening, the Food Safety and Inspection Service of the US Department of Agriculture announced that “an estimated 278 illnesses … reported in 18 states” have been caused by chicken contaminated with Salmonella Heidelberg and possibly produced by the firm Foster Farms.

Vincenzo_Campi_-_Chicken_Vendors_-_WGA3826

The news and its context (and lots of links, now updated) comes from the invaluable Superbug blog written by the equally prized Maryn McKenna (known to her friends as the internet’s Scary Germ Girl, perhaps for books like this one.)*

That’s not the punch line, though.  Something else makes this latest demonstration of the risks inhering to the US food supply system so infuriating and so scary — something with a distinctly GOP reek wafting through it:

 [The Food Safety and Inspection Service] is unable to link the illnesses to a specific product and a specific production period,” the agency said in an emailed alert. “The outbreak is continuing.”

This is the exact situation that CDC and other about-to-be-furloughed federal personnel warned about last week.

As Maryn emphasizes:  we are confronting a potentially deadly public health crisis with legally enforced ignorance:

 At the CDC, which operates the national foodborne-detection services FoodNet and PulseNet, scientists couldn’t work on this if they wanted to; they have been locked out of their offices, lab and emails. (At a conference I attended last week, 10 percent of the speakers did not show up because they were CDC personnel and risked being fired if they traveled even voluntarily.)

To mix metaphors — when you have a political party determined to spin the cartridge on the whole country, eventually the hammer will find a loaded chamber.

Go read the whole of Maryn’s reporting.  This isn’t skittles. It’s illness and misery, the possibility of life-long diminishment…and maybe deaths too, as always with the most vulnerable, kids and the elderly, squarely in the cross hairs.

Even if, as I deeply hope, the current outbreak passes with minimal harm to our fellow citizens, that just means we got lucky.  As long as Republicans see the shut down as a game in which they must put “points on the board” we’re on the hook for the news we know will come.

To take it one step further:  the dominant view within the modern Republican party is one that in essence denies the existence of society.  In the Tea Party view — the one shaping the entire party’s vision — the US is and must be a nation of individuals, atoms; there is no concept that we might act in concert to ends other than those we can address one by one.

From that perspective deciding we don’t need food safety inspectors makes sense.  It’s my job or yours to make sure we cook that chicken breast all the way through, that we sterilize our cutting boards, that we never forget to soap off our knives between cuts, that we never eat with friends less cautious than ourselves. (I’m following Maryn’s argument here, btw.)

One could choose to live that way.  Kids would die, from time to time, and maybe grandpa too, before he needed to go.  Such deaths would be the price of my freedom, a definition of liberty renders every other person around me a kind of ghost: there, but not so much so that I need act as if they are just as real as me.

That’s what’s at stake in the current impasse in Washington.  I don’t want to live with ghosts. I want friends, I want colleagues, I want a society — civilization.  Hell!  I want chicken inspectors, and it’s a privilege, not a burden, to live within a system that’s figured out how to  have them.  That the Republicans don’t seem to get that is why the current version of the party (no longer) of Lincoln must be ground into the dust.

Factio Grandaeva Delenda Est.

Update:  Per Mike the Mad Biologist, this news:

A sweeping salmonella outbreak has become so serious that the Centers for Disease Control and Prevention has called back 10 furloughed staff members to monitor this and other outbreaks.

Progress.

*You can get the word directly from Maryn via my conversation with her on the Virtually Speaking Science podcast.

Image:  Vincenzo Campi, Chicken Vendors1580.

By The Way, David Brooks Is Still Always Wrong

November 13, 2011

I know this is already long since fishwrap, but amidst the many disembowelings of David Brooks discovery that he has always been at war with Eurasia   always  loved Mittens, I have to rage, rage, at the relentless, endless, fetishization of the deepest, most degrading fantasy of the right.  No, not that one.  Nor that one either.  Nor this.

No it’s the almost touching faith evinced by Mr. Brooks and the entire GOP presidential field in the existence of a free market in health care.  So, just to flagellate a truly dead horse, let’s take a look at one specific passage from Our Lady of Perpetual Broderism’s Romney tongue-bath:

True Medicare reform replaces the fee-for-service system with premium support. Government gives people money, rising slowly over time, to shop around for their own private insurance plans. The system would reward efficiency and quality, not just quantity. Competition between providers would unleash a wave of innovation.

The only problem is that the marketplace for health care that exists in the world real people inhabit bears little or no resemblance to Brooks’ pleasant vision of informed consumers, with full information in hand, shopping around for the perfect combination of benefits and price they need — not just now, but through the life (and death) cycle all of us endure.

 

That is: most evocations of the free market in just about anything call up spherical cows, simplified (and dangerously convincing) models of what actually happens in the world.  But to imagine a genuine Ec. 101 free market in health care — and to praise someone as “serious” for building policy on the assumed reality of such delusion — that takes real effort, a true commitment to avoid knowing inconvenient facts.

At least, so says such a DFH as Daniel McFadden.  That would be the 2000 Nobel laureate in economics who has taught at such dens of raving lefty lunacy as USC, UC Berkley, and (ahem) MIT.  And that would be the same fellow who has spent quite a bit of time analyzing the notion of consumer driven health care.  Here’s what he had to say in 2008 in a working paper co-authored with Joachim Winter and Florian Heiss:

Most, but not all, consumers are able to make health care choices consistent with their self-interest, even in the face of novel, complex, ambiguous alternatives. However, certain predictable irrationalities appear – excessive discounting of future health risks, and too much concentration on dimensions that allow easy comparisons, such as current cost and immediate net benefit. Some consumers are inattentive, particularly when prior choices or circumstances identify a default “Status quo” alternative.

These behavioral shortcomings imply that some degree of paternalism is essential if Consumer Directed Health Care is to allocate resources satisfactorily. Health care markets need to be regulated to keep out bad, deceptive products, particularly those that offer “teaser” current benefits but poor longer-run benefits. Consumers need good comparative information on products, and they need to have this information brought to their attention. Consumers appear to underestimate the probabilities of future health events, [or] anticipate the resulting disutility, and as a result they systematically underspend on preventative or chronic care. Socially optimality will require that these services be subsidized, or choices regarding them be framed, to induce desired levels of utilization.

[From the second paper listed on McFadden’s website, linked above: “Consumer-Directed Health Care: Can Consumers Look After Themselves?” pp. 19-20]

Note what McFadden et al. do not say.  They don’t say market mechanisms can’t work.

They do say that human beings display predictable behavior that makes it impossible to rely on an unregulated market to deliver health care.  They point out that those irrationalities fall most heavily in the area of guessing what you or I might need some years down the road…i.e. when we are likely to need good care the most.*

Hence, the need for what the authors above call “paternalism,” and what I would term the normal function of the concept of universal insurance — mandated if necessary under the particular policy choice — against risks all members of a society face.

McFadden and his colleagues are hardly the only ones who get this.  This paper is exemplary, not determinative.  And again, it’s not that these writers represent some radical wing of anti-classical economics clinging to the margins of the profession.  In fact, McFadden and his co-authors display some familiar, reflexive thinking.  I’d argue with the Nobel laureate in his offhand dismissal of a different approach, what he terms “a government single payer/single provider program.”

Partly, the difficulty I have with the expert here is that single payer is not the same as single provider.  Conflating the two allows one to damn one with the flaws of the other — which is hardly cricket in a serious policy discussion.  And when anyone — even a distinguished fellow like McFadden — says that he “believes” the problems of such a system will be the same as for private plans, then I become an honorary Missourian: “Show me.”

But that’s an aside.  The core point is that even folks with a deep institutional and disciplinary engagement with the idea of markets understand that you can’t run health care on the principle that the customer knows best.  We don’t — we can’t, really.  And that’s why Romney, and Ryan, and all the other GOPsters trying to transfer risk to the American people and profits to American insurers are never, ever “serious.”

Which is just another long way round to repeating the obvious. David Brooks is always wrong.  He kind of has to be, given how he has dedicated his career to the notion that Republicans belong in power, no matter what.

*Brooks — like the GOP candidates — might argue at this point that they never have contemplated an unregulated private market in health care.  Which may be accurate, but not true (to channel my inner Sally Field).  That is — the degree of regulation in the market to which all calls to repeal Obamacare would return us was the one in which a host of problems along the lines McFadden et al. point out, and many more besides.  More broadly — even if you take the GOP as sincere in its stated principles, they oppose “paternalism” in individual decisions.  Which means they oppose exactly what is needed in the delivery of health care.

Images:  Edouard Manet, The Dead Bullfighter, 1864-1865

Pompeo Batoni, Time Orders Old Age to Destroy Beauty, c. 1746