12 April 2006

'moral hazard' my ass

i missed the nyt op-ed by the administration flunky, although i did realize that bush was in bridgeport recently hyping his health-care nonsense. but here, in part, is what the op-ed said:

"Health care is expensive because the vast majority of Americans consume it as if it were free. Health insurance policies with low deductibles insulate people from the cost of the medical care they use—so much so that they often do not even ask for prices."

the quotation is courtesy of hendrik hertzberg's new yorker commentary of this week. as many people have pointed out -- some of the best examples, like a malcolm gladwell piece on dentistry from earlier this year, are also in the new yorker -- no one consumes health care 'as if it were free,' at least not in the sense the administration is trying so desperately to sell.

let's do the blogger thing and illustrate with personal examples, shall we?

(1) my primary care and reproductive health care are basically free through yale's insurance. i suppose that, in some sense, i am "insulated from the cost" of that health care. to be sure i do not ask for the price of a visit for antibiotics, or check that yale health plan uses the cheapest lab to process its pap smears. i go to the doctor when i am good and sick, or when it's time for a checkup. problems get avoided.

indeed, i have a tough time thinking about moral hazard counterfactuals in this context. if i paid, would i really opt for the wal-mart pap smear? would i, carless, make my way to another town in order to save x bucks on my yearly checkup? (would i bother with a yearly checkup?) are there people out there who are living unhealthy lives because they won't be paying for their open heart surgery? are there people out there who spend every third day in the doctor's office because that seems fun to them?

(2) my mental health care is only sort-of-covered. there have been times in my life when it's been less stressful to be in fairly serious distress than to look for the cash for a good therapist, or when thinking about mental health in a preventative-health-care kind of way was just not done (HELLO, adolescence-in-the-midwest!). the result? in 1995 the result was that i ended up physically sick, requiring specialists, surgery and a hospital stay. in 2004 it was another round of specialists and a pretty incredible loss of work productivity.

(3) i have a relative whose mental health problems are much more serious and who, if she had money, would probably be monitored daily. instead she is part of a vicious cycle of inpatient stays, poor aftercare, ineffective-but-expensive meds. in addition to being really fucking expensive, this merry-go-round, having already destroyed her quality of life, is going to kill her.

she's not unique.

(4) i have no dental or vision coverage. perhaps unfortunately, my dental problems (such as they are. who knows!?!?) and my changing contact lens prescription don't really impinge on my day-to-day life. the fact is, though, that i haven't been to a dentist since i left college, and i know -- i KNOW! -- that i am courting disaster. if i were consuming dentistry "as if it were free," i'd be getting a checkup every six months, not investing in a platinum grill. as it is, i consume dentistry as if it were precisely what it is: an extremely expensive service provided by well-educated professionals, a cost that doesn't fit comfortably into my budget.

i'll go to the dentist soon, and i'll probably put it on a credit card, and that will be that. (i can almost guarantee that the process, what with fillings and such, will be more expensive than three years of regular cleanings.) but there are people out there who can't do that. i will not wait until my teeth are rotting and i require surgery to go in. but there are people out there who can't make that decision. when their situations get dire, they will either receive emergency care, which is exponentially more expensive than a lifetime of regularly scheduled checkups, or they will go without. either way they will be marked as poor by their teeth.

SO: i suppose 'moral hazard' makes a certain amount of sense when insurance covers property that you can neglect at will. but applying the concept to health care of any sort is...well, it's wrong. it's factually wrong, because american health care is expensive due to poor preventative care and paperwork. it's a moral outrage, because it implicitly assumes that poor people deserve to be in pain. it is, in short, thoroughly representative of the general attitude and quality of bush administration policy proposals.