A Philosopher's Blog

Medicine & Markets

Posted in Ethics, Medicine/Health, Philosophy, Politics by Michael LaBossiere on March 22, 2017

As a point of ideology, many conservatives advocate the broad application of free market principles. One key part of this ideology is the opposition of regulation, at least regulation that does not favor businesses. Since health care is regarded as a business in the United States, there is an interesting question in regards to the extent that health care pricing should be regulated by the state.

Because of the high cost of health care in the United States, there have been proposals to place limits on the cost of health care services. Some areas have implemented such proposals, but there is a general lack of such regulations on pricing. Those who oppose such regulations often contend that pricing should be set by free competition between health care providers and that consumers of health care should be savvy shoppers. The idea is that savvy health care shoppers will take their business to providers that offer better services or lower costs, which will force the competition to lower costs or improve quality.

There are various problems with the idea of savvy health care shoppers. The first is the challenge consumers face in finding the prices that health care providers charge. While it can be difficult to predict what services a consumer might need, health care providers often have a range of prices depending on who is paying for the services. For example, insurance companies negotiate prices with providers and these differ from what consumers without insurance would pay. Health care providers, although they always have a database of billing codes and costs, are generally reluctant to provide this information. This makes savvy shopping difficult.

A second problem is that health care consumers typically lack the medical knowledge to make informed decisions about health care. While a person might have some challenge in sorting out what sort of phone or laptop they should buy, sorting out what sort of medical care they might really need is typically beyond the skill of most people. That is why people go to medical professionals. As such, being a savvy shopper is rather difficult.

A third problem is that it is something of a mistake to describe a health care consumer as a consumer; it is usually more apt to call them a patient. While this might seem to be a mere difference in labels, the difference between consumer and patient is significant.

A rather important difference is that a patient is typically in duress—they are injured or ill and thus not in a very good state to engage in savvy shopping practices. While an informed rational consumer will be looking for the best deal, a suffering patient is concerned primarily with getting better. As people say to not go grocery shopping on an empty stomach, it would be best to not shop for health care when one is not healthy—but that is exactly when one needs health care. There are also the more extreme cases. For example, a person who is badly injured in a car crash is not going to be shopping in a savvy manner for emergency rooms as they are being transported in the ambulance.

It can be countered that there are cases in which a person can engage in savvy shopping, such as elective surgeries and non-emergencies. This is a reasonable point—a person who is not in dire need can take the time to shop around and be a savvy consumer. However, this does not apply to cases in which a person is sick or injured enough to impeded such savvy shopping.

Another important difference between consumer and patient is that the consumer often has a reasonable choice between buying a good or service and doing without. In contrast, patients usually have a real need for the good or service and doing without would be a real hardship or even fatal. When one must buy the good or service and the provider knows this, it makes it much harder to be a savvy shopper. This also provides a segue into the matter of regulating prices.

While free market pricing can work when consumers can easily do without the good or service, it runs into obvious problems for the consumer when the goods or services are necessities. To the degree that the patient cannot do without the health care goods or services, the patient is at the mercy of the provider. So, while a person can easily elect to do without the latest iPhone if they cannot afford it, it is much more difficult for a person to do without their chemotherapy or AIDS medication. True, a consumer could do without liposuction or breast implants, but such elective surgery differs from non-elective treatments.

The stock counter to such concerns is that if a consumer finds the price of a good or service too high, they can go to a lower priced competitor. Assuming, of course, that there is real competition. In the case of health care, the opportunity to find a lower priced competitor can be problematic. A patient might not have the time to shop around on the way to an emergency room. In many places, there is not any local competition with lower prices. As such, this free market advice is not very helpful.

In the case of pharmaceuticals, patients often find that there is no competition. When a company has a patent on a medication, the United States’ government uses its coercive power to enforce that patent, ensuring that the company retains a monopoly on that medication. Because of this, a patient who needs the medication has two basic choices: do without or pay the price. There is no free market competition, so without regulation on the part of the state, the company can decide to charge whatever is desired—subject to the cost of bad press, of course.

This monopoly system does create something of a quandary for a principled proponent of the free market. On the one hand, without such patents a free market of drugs would make it irrational for for-profit companies to invest in costly research. This is because as soon as the drug was developed, the competition would just duplicate it and can sell it cheaper because they would not need to recoup the cost of development. A solution, which would not be very free market, would be to have the state fund the expensive research and then provide the results to companies who would then compete without monopolies for consumer dollars. Another “solution” would be to let the market remain free and hope that medications would somehow be developed.

On the other hand, if the state stepped in to regulate prices as part of the agreement for using its coercive power to protect the monopoly, then there would also be no free market competition. But, the state could see to it that the companies charged prices that allowed profits while not gouging patients.

My own view, as might be suspected, is that since patients are essentially a coerced market when it comes to health care and medication, the state should act to regulate prices. In the case of pharmaceutical companies, this should be part of the bargain with the state that allows them to maintain their monopolies. After all, if taxpayer dollars are to be used to protect monopolies, then they should get something in return—and this something should be reasonably priced medication. In the case of health care providers, while they do not usually have a monopoly, they do have a coerced market. Just as the state justly steps in to prevent price gouging during large scale natural disasters, it can justly do so in regards to personal disasters—that is, injury and illness.

I am certainly sensitive of the desire of health care providers and pharmaceutical companies to make a profit and, as such, I would certainly advocate that the regulations on pricing leave them a reasonable margin of profit. While it might be objected that a reasonable margin of profit it hard to define, my reply is that if price gouging can be recognized in other areas, it can (and is) be recognized in the realm of medicine.

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Behind Closed Doors

Posted in Politics by Michael LaBossiere on January 13, 2010
This is a 2x8 mosaic of the dome of the US Cap...

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Obama promised that the health care discussion would be held out in the open, but the folks in Congress are pushing to keep the dealing behind closed doors.

Some might suspect that the folks in Congress want to have secret discussions because they intend to make morally questionable deals that they would rather not have the voters know about. Of course, other reasons can be given.

One commentator asserted that such talks could be held in the open if Americans were more politically mature. It is interesting to speculate about what this might mean.

One possibility is that most Americans are on par with children. Just as adults sometimes need to discuss matters that are for adults away from the ears of children, so too must Congress discuss matters in private. In the case of adults, this is rather reasonable. After all, children typically lack the maturity and knowledge to make reasonable judgments about some adult matters and it can be for the best if such discussions take place without children being present.

A less extreme interpretation is that while most adult Americans are not on par with children, Americans lack the political sophistication to understand and accept the  realities of politics.

Of course, there is the obvious question of whether or not the American public  lacks the maturity and knowledge to a degree that justifies such paternalism. If it does, then Congress could be justified in such secrecy. After all, the ignorance and immaturity of the public could lead them to fail to see the necessity of the sort of deal making that is required to create viable solutions in the realm of law.

There are some good reasons to believe that this is the case. For example, consider the birthers, the tea party folks, Code Pink and others. The shouting and poor reasoning of such people tend to show a distinct lack of political maturity. These folks do not, of course, represent all Americans and hence to justify secrecy based on them would seem to be unfair to the majority.

Another way to look at this alleged immaturity is to see it not as immaturity but as a moral concern. Interestingly, holding to moral expectations is often cast as a form of immaturity or of being unrealistic. While it is certainly tempting to believe that ethical standards should be swept aside by political realities, it should be carefully considered. After all, is what is presented as mature and realistic really mature and realistic or is this simply a way of hiding misdeeds under a mask?

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Health Care Reform Behind Closed Doors

Posted in Politics by Michael LaBossiere on October 21, 2009
Max Baucus, U.S. Senator from Montana.

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When Obama was running for office, he spoke about how he would handle health care reform: “I’m going to have all the negotiations around a big table,” and it all would be “televised on C-SPAN, so that people can see who is making arguments on behalf of their constituents and who are making arguments on behalf of the drug companies or the insurance companies.”

As they say, that was then and this is now. Now, Reid, Baucus and Dodd are meeting in private to hash out health care. It might be around a big table, but there will be no C-SPAN or any access allowed to the general public. Naturally, various excuses have been given as to why this will be handled in secrecy.

Naturally, there can be legitimate grounds for secret meetings. If , for example, matters of national security are being discussed by Senators and a leak could actually be harmful to the people of the United States, then such a meeting should be secret.

In the case of the health care reform, there is clearly no such justification of secrecy. In this case, I would infer that the folks choosing to take action in secret are doing so because what would be revealed to the people would be more damaging than the fact that the president is breaking his word.

While I can only speculate on what is happening behind the closed doors, I would suspect that it is the usual thing that politicians do behind closed doors. No, not cheat on their wives. Rather, it might be the case that they are working on various dirty deals that that would outrage many people.

Since Obama promised an open process and there seems to be no legitimate reason for such secrecy, what is being done is simply not acceptable. This process should be out in the open, with the full light of public scrutiny upon it.

Yes, I do know that politics is all about secret deals and back room machinations. But, obviously enough, this sort of behavior allows and encourages corruption and misdeeds. I was critical about the secrecy in the Bush administration and consistency requires that I apply the same criticism to what is happening under Obama. It is far past the time when we should demand proper openness in our government. The Bush administration made it quite clear what can happen in the darkness. While the Obama administration will probably commit different sins, keeping a light in things can help keep that sinning down to a minimum.

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Joe Wilson & Obamacare Emotions

Posted in Medicine/Health, Politics, Reasoning/Logic by Michael LaBossiere on September 10, 2009

In an interesting coincidence, on the same day that Joe Wilson shouted out “you lie!” during Obama’s speech I was teaching about persuasive communication in my Critical Inquiry class. According to the text, one should avoid being strident and use a calm and reasonable tone when communicating. While I did present how being confrontational and strident could be used, I emphasized that a critical thinker should also be a civil thinker (and speaker). Apparently Joe Wilson never took this sort of class.

While critical thinking does not (and should not) involve getting rid of emotions, it does require keeping those emotions in control when assessing claims. Critical thinking also involves making a proper assessment of claims before making judgments about such claims. Wilson apparently never learned this (or chose to ignore this). After all, his claim that Obama was lying turns out to be a false claim. Since lying implies a malicious intent, I will not accuse Wilson of lying. Rather, I will say that he had his facts wrong. His anger might have been rather sincere, but this would merely serve to show that a person who cannot control his emotions tends to make rather poor judgments.

In the next section of my class, we will be moving on to talk about fallacies (errors in reasoning) and various rhetorical devices. Not surprisingly, much of the focus of the discussion will be on how emotions can lead people to believe claims that are simply not supported by reasons or adequate evidence. The battle of Obamacare seems to be such a case. After all, it is all too common for people to accept claims about health care reform that are either unsupported or clearly false (like the Death Panel flap).

That people have strong feelings about health care reform is fine. After all, it is a serious issue that touches on the fundamental beliefs of many people. However, the debate (like all debates) is not served by letting emotions run unchecked and by people speaking out before they do even some basic investigation of the facts. After all, the mere fact that something makes a person afraid or angry does not entail that it must be true. In the case of the Obamacare battle, many folks seem to easily fall into those errors by simply assuming that Obama plans to do whatever it is that they fear he will do. Of course, it does not help that folks are being manipulated by interested parties. It also does not help the country to have folks in leadership position (like Wilson) fall victim to these errors and behave in ways that are unacceptable.

Fortunately, there are some folks who are willing to call for a civil discussion of the matter. As always, John McCain has been a leading figure in calling for civility and I hope that his call is heeded.

There are, of course, points in the health care proposals that are problematic and there are reasonable grounds for dispute. However,  angry outbursts over claims that are not true (such as the claim that Obama plans to give health care to illegal aliens) create confusion and waste our time.

It is certainly interesting that a significant portion of the attacks on the health care proposals have been based on factual errors (I will restrain myself from calling them lies). If the proposals are as bad as the critics claim, surely they can point to real problems rather than to problems that do not even exist. What is needed is not more rumors of Death Panels or mistaken cries of “you lie.” What is needed is a clear and rational presentation of the possible problems with the health care proposals.

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The Ugly Jog

Posted in Humor, Running by Michael LaBossiere on August 23, 2009

I’m now twenty weeks out from my quadriceps tendon repair surgery. I have been pool running for a few weeks and can walk almost completely normally now. I even started jogging a bit, just to see what my leg can do.

As you might imagine, my attempt at jogging is rather ugly. I call it jogging because 1) it sure ain’t running and 2) I am jogging in the literal meaning of the term. The main thing is that my left leg doesn’t quite recall how to run, so it sort of catches a bit-thus the jogging.

Not surprisingly, the effect is a rather ugly one. No, I don’t mean how I look, although my jealous detractors might say otherwise (yes, I mean you Brad Pitt). Mainly it is ugly because it is, well, ugly. Being sensible and sensitive to others, I try to practice my jogging out of the sight of others by sticking to the woods. Of course, sometimes people do see me.

Person:“Say, son are y’all okay? Did a possum bite your leg or maybe a rattlesnake? Or is you having one of them there seizure things? I hope not, you know that Obama’s health care plan is to euthanize sick people. Just like those Nazis.”

Me: “Nah. I’m just trying to learn how to run again. I had knee surgery a while back.”

Person: “Well, you sure look awful doing that. It a’hurts my brain to see you. Like watching some sort of messed up bird caught in a lawn mower or something like that.”

Me: “Hey, it isn’t that bad.”

Person: “Son, if y’all could see it, you’d know I’m a’speaking God‘s own truth. Its a wonder He doesn’t put you down. You know, in all His mercy and that. If ya want, I kin get my shooting iron and put yer down.”

Me: “I’m good.”

Person: “Suit yerself son. I’m goin ta avert my eyes now while ya hobble away. My dawg is to.”

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Health Care Rhetoric I

Posted in Politics by Michael LaBossiere on July 21, 2009

As the battle over health care continues, the usual pattern of political talking points has emerged. Each side has its own set of bullet points that it fires out at its opponents and rational discussion is kept to a minimum.

One point made by the side against government health care is that the care will be awful. The usual argument is that anything the government does is big, costly, and ineffective (at best). This is supported by various anecdotes from other countries and analogies with other government programs.

A second point is that government based health care will unfairly destroy competition and this is unfair to the insurance companies.

Not surprisingly, those who are not against health care point out the apparent inconsistency: if the government health care is going to be so awful, then it cannot unfairly destroy the competition. After all, if it is bad as they claim, then only the sort of folks who buy viagra from spammers or send their bank account numbers to Nigerian princes will buy it.

It is, of course, possible to reconcile these claims. After all, if the government mandates that people buy their health care from the government or if the government applies pressure to companies and individuals to buy into this, then they can be unfair competitors even if the product is truly awful. After all, some very awful products have been able to do well because those selling them are able to use unfair advantages. The government certainly has the power to push an inferior product on a large enough scale to constitute an unfair advantage.

Of course, the Obama administration’s position seems to be that they will not force people to give up their current insurance. So, people who already find their insurance acceptable or who prefer the private health insurance over the state plan will be free to buy that coverage. If this becomes part of the plan, then those who are against the plan will seem to have little to worry about: if private health care is vastly better than the incredibly awful state health care, then only complete idiots will buy it. This will mean a fairly small number of folks on the government plan thus keeping the cost lower than expected and leaving the current sort of competition in place (that is, you can buy any health insurance you can afford that happens to be available where you live).

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Soak the Rich for Health Care?

Posted in Ethics, Politics by Michael LaBossiere on July 20, 2009

Jack Cafferty asked a rather loaded question in his latest Cafferty File: “Is it fair to soak the rich to pay for health care reform?”

On the face of it, the answer to this loaded question is easy. Since “soak” implies an unfair treatment, then it would not be fair to soak the rich for health reform or for anything. This is a bit like asking whether it is fair to cheat at a game.

A more balanced question would be whether it would be fair or not for the rich to pay a larger percentage of their income to help pay for health care reform.

Since the current income tax system is progressive, having the rich pay a greater percent for health reform would be simply applying the same sort of approach that is already taken. Of course, not everyone regards a progressive income tax as fair.

This, of course, leads to the difficult question of what counts as fair. One way to look at it is that health care insurance is a purchased good  and it would be fair to charge people based on what they receive. If the rich receive the same benefit as the poor, then they should pay the same. After all, if a rich person was charged more for a Big Mac or a gallon of gas just because she is rich, that would be unfair.

Of course, health care is not being seen as a purchased good but is being cast by the Democrats as a social service that is owed to people. This would put health care in the same basket as other social services like education, roads, and such. In these cases, the rich do pay more for what they receive. For example, if a kid from a rich family and a kid from a poor family go to the same public high school, the rich family is paying more for the same service because they pay more taxes. This is seen by some as fair, based on the principle that those who have more should contribute more to the general good. Others, of course, see it is unfair based on the principle that the same things should cost the same price.

Since the health care plan is not in a finished form, any discussion about it is speculation. However, I am against the proposals that do call for putting what seems to be an undue burden on the rich. While I do agree that those who have more should contribute more (that is something I practice in my own life), I am against the “soak the rich” mentality. At most, I would agree to the same sort of progressive scale that is used in the current tax system (although I think that system needs considerable reform as well). The reason is that soaking the rich is no more just than exploiting the worker. True, the rich would still be very well off even after the proposed “soaking”, but to justify the soaking that way is a bit like saying that slicing a chunk of a big person is not as bad as slicing a chunk of a small person because the big person still has more flesh left.

I’ll close with a question: what would be fair for people to pay into such a system, rich, poor or in between?

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CPR and the Health Care Battle

Posted in Medicine/Health by Michael LaBossiere on May 23, 2009
Hospital room (Denmark, 2005)
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If you watch TV, the odds are that you have seen the advertisements from Conservatives for Patients’ Rights (CPR). In one ad, they have doctors and patients sharing their anecdotes about their terrible experiences with national health care systems. They speak of long waits, being denied treatment and so forth. The point being made by these ads is that national health care is a bad idea because it will hurt patients.

It is reasonable to assess the health care plans of other countries and see what has worked and what has not. If there are serious problems with certain aspects of national health care in these countries, then we would be wise to be aware of them so as to avoid them when (if) we reform health care. As such, the sort of cases that CPR presents in its ad should be duly considered and assessed.

It is also reasonable to properly assess such claims. First, while examples are relevant, to simply rely on anecdotes would be to fall prey to the fallacy of anecdotal evidence. While such unfortunate tales are worrisome, what must be determined if such problems occur at a significant level. Naturally, someone might say that any problems are significant. This is true-but there will always be problems in any system. This leads to the second matter.

Second, there is the obvious question of whether these problems also occur in our health care system or if they are specific to national health care plans. If our system suffers from comparable problems, then the fact that national health care systems also have such problems would not be a mark against them in favor of our system. In short, the question is this: does our system have its own comparable horror stories?

The answer is, sadly, yes. Even a cursory search of the web will reveal a plethora of problems within our current health care system: gall bladder surgery, misdiagnosis, waiting for care, botched surgery, and denial of treatment.

My own medical experience here in the US would fit nicely into the CPR commercial. When I went to the first doctor after my fall off the roof, I was x-rayed and told I did not have a broken leg. I was not given a referral or any additional advice. I went on the web and did research on my own. Based on my findings, I inferred that I had a quadriceps tendor tear. I then returned to another doctor, hoping to get treatment. After a quick look, the doctor did not make any diagnosis. He did give me a referral, though. A week after my accident, I finally got to see a specialist. As such, I was hobbling around for a week with a disabling injury. The specialist did the diagnosis in a few minutes, something I wish had been done a week earlier. I was lucky that there was an opening the next day for surgery. After my surgery, they did not have the right sort of wheel chair, so I left the hospital with my immobilized leg held up by a few pillows. Luckily, the person wheeling me out did a good job keeping my leg from flailing about.

I have good insurance, so I only have had to pay about $700 out of the $12,000 for the actual surgery and hospital costs (so far-but the bills keep coming in).  I did have to pay $500 for my brace (not covered) and I have to pay for the PT as well. But, if I was like many Americans and did not have insurance, then I’d be in rather dire financial straits.  After all, the leading cause of personal bankruptcy in the United States is medical bills. So, we have plenty of horror stories.

But, don’t take my word for it simply accept the few links I’ve given above. Google it yourself and see the results. This is, of course, an empirical matter and well documented.

My point here is that the horror stories presented by CPR seem to be the same sort of thing that happens in our health care system. As such, these hardly seem to be special problems for national health care plans and especially not a special problem for the plan Obama is working on. Rather, these problems seem to be part of our health care system as well.

I do agree that the problems presented in the CPR ad are problems-but they are problems within our current system as well. As such, they give us no reason to worry that things will be worse for us under Obama’s health care plan. In any case, the ad does not even really attac Obama’s plan-it is just a general swipe at the straw man of national health care.

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