Monday, November 8, 2010

Health Care vs. the Health Care System

I think it can be conceptually useful when discussing the problems that we have with health care in the US to distinguish between health care and the health care system.

Health care has been around as long as recorded human history and likely far longer.  No particular system was required for health care for most of our history, the market or other naturally occurring institutions were sufficient for providing most primitive health services.  The small exceptions would be the simple hospice care provided by early hospitals or institutions such as leper colonies.  But for the most part, little was required beyond the skill of the individual physician and some participation from the local community.

A great deal of modern health care is similar.  Delivering primary care and many health services, such as hospice and a range of simple surgical procedures, probably could be delivered effectively outside of a broader health system.  There are of course advantages to embedding these services in a broader system, and drawbacks, but for this rather broad (and here ill-defined) range of services there is no need for some overall health care system.

However, modern medicine has also developed a number of interventions that are very resource intensive and require some kind of dedicated system to keep running.  I don't have the knowledge to give an exhaustive list of these interventions but it is difficult for me to see how medical issues such as emergency care, especially when emergency treatment leads to a need for intensive care, could possibly function without a system in place to make sure that the hospital can almost always recoup its expenses without necessarily knowing if a given patient will in fact be able to pay.  While this system doesn't (theoretically) necessarily require government intervention, in practice existing systems have always involved the state. 

I believe this distinction is necessary to make because of how it effects the political discussion.  Most of our interaction with the health care system is with the parts of the system that don't really require a system at all.  This gives a massive political advantage to those that want to keep the system as weak as possible.  It isn't hard to think of reforms that can improve access and there is a quite wide array of ways to make it easier for someone to see a doctor and to easily pay for something simple like antibiotics, setting a broken bone, child birth, or simple outpatient surgeries.  These areas can no doubt be improved by reforms such as improved access or could be easily paid for by greater use of health savings accounts or other free market oriented reforms.

The hard choices all lie in the areas where a health care system is required that most of us have little to no interaction with through most of our lives.  How do we build a system that can pay for treating autism?  How can we pay for cancer treatment or organ transplants?  How can our system create the right mix of specialists and general physicians when years of education can be a decade or more?  This is where we need to focus our attention if we want to build a working system.  People are afraid of the possibility that a medical condition may bankrupt them or that they can't provide a newborn child with the care it needs.  However, dealing with this is difficult because they are angry about the day to day costs of the medical system and the frustrations and delays they run into with the general health care needs that are part of their daily lives.  Solving this requires acknowledging that people's fear and anger are pulling in different directions and that all the hard choices have to be made regarding the systemic issues that are the source of their fears.  Going after the little stuff that causes anger just derails the conversation and prevents us from moving forward.

I'll expand on this idea a bit more tomorrow with some numbers to back it up.

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