You Can't Make Decisions for Yourself

A frequent topic of this blog is to point out situations where technocrats translate their distrust for individual decision-making into the justification for government control

Kevin Drum provides me with one of the best examples I have seen of late of this phenomena of using distrust of individual decision-making to justify government intervention, in part because he is so honest and up-front about it.  I usually try not to quote another blogger's posts in total, because I want to give folks an incentive to go visit the site, but in this case I need to show the whole thing (the extensive comments are still worth a visit):

If we treat healthcare like any other market, allowing consumers
free rein to purchase the services they like best, will it produce high
quality results? A recent study suggests not:

Researchers
from the Rand Corp. think tank, the University of California at Los
Angeles and the federal Department of Veterans Affairs asked 236
elderly patients at two big managed-care plans, one in the Southwest
and the other in the Northeast, to rate the medical care they were
getting. The average score was high "” about 8.9 on a scale from zero to
10.

....In the second part of their study, the medical researchers
systematically examined 13 months of medical records to gauge the
quality of care the same elderly patients had received....The average
score wasn't as impressive as those in the patient-satisfaction
surveys: 5.5 on a 10-point scale. But here's the interesting part:
Those patients who graded the quality of their care as 10 weren't any
more likely to be getting high-quality care than those who gave it a
grade of 5. The most-satisfied patients didn't get better medical care
than the least-satisfied.

Surprise! Patients are
poor judges of whether they're getting good care. And if consumer
preferences don't map to high quality care, then a free market in
healthcare won't necessarily produce better results or higher
efficiency, as it does in most markets.

Back to the drawing board. Perhaps a national healthcare system
would be a better bet to reduce costs, cover more people, provide
patients with more flexibility, and produce superior outcomes. After
all, why are we satisfied with allowing the French to have a better
healthcare system than ours even though we're half again richer than
them?

There is it, in black and white:  Most of you individual slobs out there cannot be trusted to make good health care decisions for yourselves, so the government should do it for you.  (And by the way, who the hell thinks the French have a better health care system, but that's off-topic for today).

Here is the false premise:  If the intellectuals who ran the study judged that the individuals involved were getting poor care when the individuals themselves thought is was good care, this does not necessarily mean the individuals being studied were wrong.  It may very well mean they have different criteria for judging health care quality and value.  In fact, what goes unquestioned here, and I guess the reader is supposed to swallow, is that there is some sort of Platonic ideal of "high-quality care" that the people who run this study have access to.

But this is ridiculous.   Does high-quality mean fast?  painless?  private?  successful?  pleasant? convenient?  I, for example, have all the patience of an 8-year-old who just ate three pieces of birthday cake washed down by two Cokes.  I need stuff now, now, now.  I hate gourmet restaurants where meals take 3 hours.  Many gourmands, on the other hand, would probably shoot themselves before eating some of the food I eat.  We have different standards.

Let's take an example from another industry:  Cars.  Every year, the "experts" at Consumer Reports and Car and Driver try out all the new cars and publish the two or three they think are the best.  So, does this mean that everyone who does not buy one of these cars selected by the experts as the best are making a bad decision?  Does this fact tell us the government should step in and buy their cars for them because they can't be trusted to make the right evaluations?   NO!  Of course not.  It means that the people who buy other types of cars have different criteria and priorities in judging what a "high-quality" car is.  Some want high gas mileage.  Some want a tight interior with leather.  Some want a big honkin' engine.  Some want a truck jacked way up in the air.  Some want room to carry five kids.   You get the idea.

There are at least two better explanations for the study results.  Let's first be clear what the study results were:  The study found that the patients studied graded health care differently than did the people who ran the study.  That's all it found.  This could mean that the intellectuals who ran the study and the individuals studied judged care on different dimensions and with different priorities.  Or it could mean that the individuals studied had incomplete information about their care and their choices.  Neither justifies a government takeover of the industry.  (In fact, to the latter point about information, markets that are truly allowed by the government to be free, which health care has not, often develop information sources for consumers, like the car magazines mentioned above.)

The thinking in Drum's post betrays the elitist-technocratic impulses behind a lot of the world's bad government.  Look at "progressive" causes around the world, and you will see a unifying theme of individual decisions that are not trusted, whether its a poor Chinese farmer who can't be trusted to choose the right factory work or an American worker who can't be trusted to make her own investment decisions for retirement.

Postscript:  In some past era, I might have called this one of the worst excuses for fascism I had ever heard.  Unfortunately, Brad DeLong recently took that title with his post that the government needs to take even more money from the rich because the rich are ostentatious and that hurts other people's feelings.  No really, I don't exaggerate, he said exactly that.  If somehow you have missed this one, look here.

  • Ryan Cupples

    Healthcare is significantly more objective. Don't get me wrong, I'm still for a free-market healthcare system of reasonable cost, but when rating healthcare, I'm pretty sure you can gauge what is good and what is not, regardless of your viewpoints (with a few exceptions).

    For example; fast is always better. Accuracy of diagnosis and cost of treatment are both one-way. Privacy is subjective, true, but all in all, it's not nearly as subjective as food.

    Remember also, that a lot of people buy cars with little to no research, and a lot of people put crap in their bodies day in, day out. These people would likely end up choosing useless healthcare.

  • Frank Ch. Eigler

    > For example; fast is always better. Accuracy of diagnosis and cost
    > of treatment are both one-way. Privacy is subjective, true, but all
    > in all, it's not nearly as subjective as food.

    But those things are traded off against one another in a real setting.

  • Victim of French Healthcare

    I have evidence (my own right "ankle") that the French can not manage a simple open reduction/internal fixation (plates & screws) to fix fractures of the tibia and fibula just above the ankle. I had extensive necrosis (dead tissue - gangrene) post-op (I was about 30 at the time & otherwise in great health); worse, the screws extended into the ankle joint, the tibia side of the joint was out of whack by 30 degrees, the fibula was 1" out of position, and I was casted in the "ballerina position" (toes pointed).

    After several surgeries in the US, I ended up keeping the bottom part of my leg and foot. After the fact, the ortho team told me they figured I had a 10% chance of keeping the leg -- they didn't want to depress me since I was in such bad shape, so they didn't tell me before I "healed".

    I ended up losing about 3/4" in length, most of my range of motion, and significant mobility (run? are you mad?) but I gained chronic pain.

    You get what you pay for when it comes to medical care.

  • http://blog.luispedro.org luispedro

    Actually the French have a very liberal system compared to most of the rest of the world. They have probably the most liberal system in Europe. Not anything like the communist-style British ones.

    In France, there are (1) different insurance plans [they also depend on your employer like in the US, which is plain stupid, but there you go], (2) you get to choose your doctor [you have no idea, but in Europe, this is often not the case], (3) the doctor gets paid according to how many patients he has seen, (4) doctors can open practices where they want. None of the above is true in the British system (or Canadian). Results: the French have a better system. Of course, they will never believe that theirs is more market-based than the British and will actually claim that it just goes to show that dirigism works better than anglo-free-market!

  • Anon

    I personally think that different metrics of quality is not the correct explanation for the discrepancy. I suspect that the metric used by most patients is probably similar to that of the study.

    More likely is that a patient, in the current system, has difficulty in judging the quality of their care, except at a superficial level, such as how personable the physician is, etc.

    I think the real issue here is how to address the discrepancy. A market-oriented solution would be to de-regulate.

    There is a deeper question here, however. That question is: So what?
    Suppose it really is the case that patients make poor choices. So what? Should the government force me into something I don't want, even if it is better for me?

  • Galen

    Drum must believe that foisting a government run system on health care workers would not make it far less attractive a profession and cause it's ultimate degradation over the ensuing decades.

    He must also believe that a populations health is soley determined by its health care delivery system and changing the mode of its delivery would ensure uniform results.

    Or that castigating the US health care maket would have no impact on inovation and medical progress that the rest of the world is able to take advantage of.

    Or that the patient dissatisfaction could be overlooked in a new delivery system as they are poor judges in quality of care, provided it shows marginal benefits in some areas.

    Obviously, the government has done such and outstanding job with controlling almost 50% of health care spending, we should give it the other half.

  • Ryan Cupples

    "In France, there are (1) different insurance plans [they also depend on your employer like in the US, which is plain stupid, but there you go], (2) you get to choose your doctor [you have no idea, but in Europe, this is often not the case], (3) the doctor gets paid according to how many patients he has seen, (4) doctors can open practices where they want. None of the above is true in the British system (or Canadian). Results: the French have a better system. Of course, they will never believe that theirs is more market-based than the British and will actually claim that it just goes to show that dirigism works better than anglo-free-market!"

    That's Canada's system right there. It is free-market, but the government pays for it via government purchased health-care (subsidized for poor people).

    In fact, slowly people are winning the right to pay extra for better care. It's already occured and passed through Quebec, the ability to buy it from a private clinic.

  • http://shrimplate.blogspot.com/ shrimplate

    Here's how deregulation and free-market healthcare would play out if actually put into practice:

    Your kid gets really sick, so you take them to the hospital. We save his life and get him back to normal health, and in return you give us your house, your cars, and your 401(k).

    Simple. Everybody's happy. The invisible hand of the free market working its magic for the benefit of all.

  • BobH

    >difficulty in judging the quality of their care, except at a superficial level, such as how personable the physician is, etc.

    I disagree. I think most people judge their health care based on "did I feel better after taking the pills?", "did the rash go away?", etc.

    Reasonable criteria, in my mind.

    I add "did the doctor keep the appointment, or was I kept waiting for half an hour?"

  • JohnDewey

    shrimplate: "Your kid gets really sick, so you take them to the hospital. We save his life and get him back to normal health, and in return you give us your house, your cars, and your 401(k)."

    Why wouldn't a free market in health insurance allow the kid's parents to insure against that risk? That's exactly the function that health insurance performs right now, isn't it?

  • http://shrimplate.blogspot.com/ shrimplate

    JohnDewey,

    The function of health insurance is to take as much of your money as possible while paying out to you, or anyone else, as little as possible.

    So sure, you can buy insurance to balance the risk. But in a truly free market, we'd take everything you have in exchange for your kids' life, and you, being a good parent, would be glad to hand it all over, right?

    http://www.alternet.org/rights/21211/

    You are familiar with health care costs and family bankruptcy filings, no? and you know that even insured people have been busted by healthcare costs, no?