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Charles Wheelan, Ph.D. The Naked Economist

Charles Wheelan, Ph.D., The Naked Economist

Health Care and the R Word

by Charles Wheelan, Ph.D.

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Posted on Tuesday, April 3, 2007, 12:00AM

Here's a question to ask any presidential candidate from either political party: How do you plan to ration health care?

If the answer is "I won't," then he or she doesn't understand health care. Or, more likely, they understand health care and aren't in any mood to talk straight about it.

The C Word

"Rationing" has a bad connotation, which is odd, because we ration just about everything. In fact, that's what capitalism does best.

Not everyone gets an S-Class Mercedes-Benz or courtside tickets to the NBA playoffs or roses on Valentine's Day. Who does? People who are willing to pay for them.

We call that a market, which is just rationing with a more attractive name. Everything worth having is scarce to some degree, so we use prices to figure out who gets what.

The Big Question

Health care is similar to German cars and basketball tickets -- not everyone gets everything they want. But health care is obviously different in a crucial respect: People who don't get what they want may become sick, stay sick, or even die. Unlike roses or Lakers tickets, health care is literally a life-and-death matter.

As a result, the most fundamental policy question related to health care is who gets what kind of care -- or, put another way, how we choose to ration resources. Forget all the other complications, like aging baby boomers, malpractice lawyers, greedy drug companies, shockingly fat Americans, insurance forms in triplicate, and so on.

Do those things help to explain why our system is expensive and getting more so? Yes. But for anyone looking to control costs (e.g., a presidential candidate) those factors pale in comparison to the fundamental health care design question: Who gets what care and why?

Hurry Up and Wait

There's nothing inherently wrong with spending lots of money on our health. Many medical breakthroughs have huge price tags -- and correspondingly huge benefits.

Consider a recent example. The American Cancer Society is now recommending that women at high risk for breast cancer undergo a yearly MRI exam. The MRI can detect small tumors that a mammogram would miss. Of course, an MRI exam can cost 10 times as much as a mammogram. You get more, and you pay more for it.

But not always. The confounding problem with health care is that lots of unnecessary, ineffective, or marginally effective procedures are expensive, too. The wisdom lies in 1) being able to tell the difference, and 2) doing something about it.

Just Saying No

Every existing or prospective health care system rations care in some way. The Canadians and Europeans make people wait. Everyone has access to basic care, with two important caveats. First, the sickest get priority. You'll get your hip replacement or heart surgery, but you'll have to queue up for it. And when sicker people come along, they get to jump the queue.

And second, the government has wide discretion to deny or limit certain kinds of care not deemed cost-effective. Britain's National Health Service will deny payment for treatments that are known to be effective if the incremental benefits (measured in "quality adjusted life years") do not justify the costs.

That sounds heartless and terrible -- some bureaucrat telling Grandma she can't have a second open-heart surgery or the latest Alzheimer's drug. But remember, every time someone says "no," they're simultaneously saying "yes" to other patients. The resources freed up when Grandma gets denied can be used to provide asthma medicine for lots of children, or heart surgery for a younger, healthier patient.

Health Care Haves and Have-Nots

Our current American system rations care, too, though we do it primarily through access to health insurance. Those with good coverage get expansive health care -- the best, the brightest, the newest, the shiniest, the fastest. True, insurance companies sometimes say "no," but not often compared to other systems around the world. The general expectation is that health insurance ought to pay for anything that does anyone any good.

People without insurance get health care, too, but it's likely to be cobbled together from charity care, public hospitals, and whatever they can pay for out of pocket. The net effect is that millions of people don't get relatively cheap treatments that would have done them a lot of good.

And therein lies the fundamental inefficiency of the American system. We have no good mechanism for saying "no" to expensive technologies and treatments that provide marginal benefits. If you're a patient, that sounds terrific; your doctors will spare no expense. If you're a business trying to keep up with skyrocketing health care costs, or a family trying to pay for benefits, it's not. And, of course, as insurance costs go up, fewer people will have access to that kind of coverage.

At the same time, we don't do a very good job of saying "yes" to treatments for the uninsured that would profoundly improve their health.

Beyond False Promises

The combination of those two factors goes a long way toward explaining why the U.S. spends a ton of money on health care (15 percent of the GDP, compared to 8 percent for Britain and Japan and 10.5 percent for France) and gets relatively mediocre outcomes. Life expectancy is not only lower in the U.S. than in all three of those countries, it's below average for all industrialized countries.

In short, the rest of the industrialized world does a better job of rationing health care than we do.

Which brings me back to my original point. Every presidential candidate is going to talk about controlling health care costs. Most are going to talk about expanding coverage, too. Those goals are impossible unless we can design a system that says "yes" to the most cost-effective care -- even very expensive treatments, provided they have corresponding benefits -- and "no" to treatments with benefits that are too small to justify their costs. In other words, rationing.

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117 Comments

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  • One sane person - Monday, May 7, 2007, 12:09AM ET  Report Abuse

    • Overall: 1/5

    Come back when you are in your later years with failing health and are denied treatment because you are too hold. You are talking about controlled genocide for the elderly and frail!

  • Larry - Sunday, May 6, 2007, 9:28AM ET  Report Abuse

    • Overall: 5/5

    Made me look at the whole picture!

  • DAVID - Friday, May 4, 2007, 12:04PM ET  Report Abuse

    • Overall: 2/5

    The best way to control health care costs is to get people to stop smoking.

  • RobertK - Wednesday, May 2, 2007, 6:21PM ET  Report Abuse

    • Overall: 2/5

    He misses a huge point! Canada and Europe are able to afford their healthcare systems at the cost of Americans. They fix the prices of pharmaceuticals at a price that forces us to pay way more than our fair share. If they had to pay the same price we do, they wouldn't be able to afford to treat as many people and their life expectancies would drop below that of the US. If we put ceilings on our drug prices that were similar to those in Canada and Europe, we could easily afford a better level of healthcare than they have. The end result would be that pharma companies wouldn't be able to support the level of research that they currently employ and REAL life saving/improving drugs would be delayed by years or even decades.

  • Yahoo! Finance User - Sunday, April 29, 2007, 9:12PM ET  Report Abuse

    • Overall: 3/5

    I like the idea of rationing medical treatment. Most people seem to forget we tend to cause our own medical problems. Many of us smoke or have smoked and the governments, state and federal, still collect taxes from smokers and then sue the tobacco manufactures then spend the wind fall on some pork project for votes and favors. Get brave and ban smoking every where health costs will go down. Stop letting our desk workers sit all day make them get up and work out before work as part of their day it will save the insurance premium. Stop letting medical providers over charge the public, If the cost they will accept from and insurance company is the correct and acceptable cost of doing business it should then be the acceptable and legal billing price to the rest of the paying world. Think your medications are high priced, go to COSTCO or Walmart and find out how much you could be saving if you bought generic American Medicines. People wake up and do something for yourselves the government is yours, and you do not hold it accountable you don't even vote. and the government that is yours holds you in bondage. We have something a lot backwards here.

  • Michael - Thursday, April 26, 2007, 12:52PM ET  Report Abuse

    • Overall: 1/5

    The major fact that is missed by Dr. Wheeland is that the market doesn't fairly dictate cost in respect to medicine. While there are a finite number of doctors and beds in this world, fundamentally health care resources are not squandered by the consumer. America is being robed by pharmaceutical companies. Rationing implies scarcity. There is no scarcity of companies that want to create drugs. We need to reevaluate how we handle patients and drug cost in this country. In an ageing population demand for drugs is going to be terrific; all that needs to be done to skew costs is an artificial and protective governmental policy. On a totally different note: While I respect Dr. Wheeland’s opinions, I find his comparison of health care and cars repulsive. Excuses and caveats aside, I hope we as a culture can look at health in an entirely different perspective from luxury and demand. Maybe we, as a culture, can decide on a few less beamers and a few more Grandma’s. We shouldn't deny grand mom as a backhand "yes" to an asthma child. Life is immeasurable resource. Time and time again has shown that capitalism isn't the best judge of life and death. Lets look to the human heart to make these decisions. Together, lets try to squander less on the insignificant.

  • Yahoo! Finance User - Wednesday, April 18, 2007, 3:37PM ET  Report Abuse

    • Overall: 1/5

    There is a reason that most Economist are conservitive. Economics centers around math. Until Liberals like Mr. Wheelan can figure out how to convince us that 2 2=5, they have no shot in convincing us that the government taking over 1/7th (at last check) of the US Economy is a good thing. He tries, but it just doesn't add up.

  • Donald F - Tuesday, April 17, 2007, 2:17AM ET  Report Abuse

    • Overall: 1/5

    The main problem with the healthcare system is that the end users are not the payers and, therefore, unconcerned about what things cost. If everyone had only safety net insurance provide for themselves by themselves, people would make wise choices as to what is necessary and what they can live without. But instead, there is no incentive at all for anyone to save money because they don't pay for it. The second big problem is that the population is so stupid and getting more so that when a politician tells them that there is a problem and they follow that up with government should do something, the people believe it. They have been brainwashed into thinking that if there is a problem and government does nothing that it is being ineffective by not doing all it can. Our founding fathers set limits on government and one of the reasons is so they didn't try to fix every problem for everybody. It's not their job, they don't do it well, it costs too much, and it's too subject to corruption. But today's ignorant masses don't know that. Yet those idiots outnumber those of us that know what the founders meant and why they did it. The tipping point is coming soon if we don't do something.

  • Russ - Sunday, April 15, 2007, 7:02PM ET  Report Abuse

    • Overall: 1/5

    what crap.

  • Yahoo! Finance User - Thursday, April 12, 2007, 3:14PM ET  Report Abuse

    • Overall: 1/5

    Mr. Wheelan appears to me to be more socialist than capitalist. What's more, would he sacrifice his premium health insurance for some waiting list in the name of lower cost if he has that insurance? What has he said other than hospitals bill a lot. That is not a profound piece of knowledge from a PhD. I like expedited health care and capitalism and think there are more fundamentally sound capitalistic ways to deal with it than do what the Canadians are doing.

  • Yahoo! Finance User - Monday, April 9, 2007, 12:23PM ET  Report Abuse

    • Overall: 5/5

    A year or so ago I had a defibrillator put in. The doctor billed the insurance company $128,000, the insurance company paid $68K and the sales rep for the device told me they run about $25K. They bill for as much as they think they can get away with, and get paid for well more than they need to - guess that makes up for those that don't pay.

  • S - Saturday, April 7, 2007, 9:27AM ET  Report Abuse

    • Overall: 4/5

    The uninsured get healthcare. They get excellent healthcare in most cases, only they don't pay for. They do access it in the most expensive way possible, fail to comply with medications or follow up and fail to go for routine preventative medicine visits at the local resident or government clinic. They have to pay up front to get in to specialists but their finances are usually hampered by cell phones, the jewelry they buy their 8 month old, new hubcaps and cigarettes. They can either make an appointment to have their kid seen at the pediatrician's office where the visit will cost the system $50-$90 (it will cost the patient NOTHING) but they have to make plans for it, call to make the appointment, arrange transportation, etc. Or they can go to the ER where an ER physician who can't stand taking care of kids in the first place will see them and possibly provide suboptimal care. This will cost the system $200-$500. But again it will cost the patient NOTHING and since it was more convenient... Say there's a tobacco, alcohol and drug using 48 year old who refuses rehab routinely. He does not take his medications as prescribed for high blood pressure. He does go to the hospital where he complains of chest pain 3 or 4 times a month so he can spend the night there to sober up instead of the drunk-tank at the jail. After years of abusing the system he has actual chest pain and the system repays him with a $50000 bypass surgery. He will not take his meds, follow up or join a cardio rehab program and he will continue to refuse treatment for his substance abuse issues. He will be dead within the year but his coronaries will be fine. We spend billions upon billions of dollars trying to take care of people who will not take care of themselves. Insured or otherwise, medical care for anyone who does not participate in their own healthcare on a daily basis is futile. If you don't help you, your doctor cannot help you. . But this is America. We will continue to demand that the responsility for high quality, affordable healthcare remains with our government, the system and the doctors. Since the last of those three are the only ones vulnerable, we will make our physicians ultimately culpable financially, legally, socially. We are doing it already. As for us, we will accept no responsibility for ourselves whatsoever. So fatten up America! Let's all get The Diabetes and put our kids on blood pressure medicine by puberty! Go America!

  • Yahoo! Finance User - Saturday, April 7, 2007, 3:26AM ET  Report Abuse

    • Overall: 5/5

    A wonderful and thought provoking article. Definitely a hot button topic with all the spirited posts too. Is our high percentage of GDP spent on healthcare, at least in part, a reflection on the value American culture places on the individual lives within our citizenry? Is this bad? Unsustainable? Are there not shining examples of once expensive miracle cures that have become routine, cost effective, even commodotized over time? Are we not advancing the art of healing with this combination of culture, diligence, and frankly bad habits that put it all to the test? Unless there is a cultural shift, I'd submit that we'll only ration back to threashold of sustainability and no more. It's just the way we work in practice. It's an oddity of American culture to be sure. Oh, and yes, In America the threashold of sustainability is negotiable too.

  • JohnN - Thursday, April 5, 2007, 5:37PM ET  Report Abuse

    • Overall: 5/5

    Wheelan has a remarkable knack for putting things in very concise, clear terms. One or more of us may not always like his ideas, but they are clear enough for even a sleazy ol' history hack like myself to understand.

  • Yahoo! Finance User - Thursday, April 5, 2007, 12:24PM ET  Report Abuse

    • Overall: 4/5

    OK, good start. I work in healthcare (no, I'm not saying how) but a good portion of the expense is generated on the vendor side. For example: Company A charges, say $3500 for a shoulder replacement, while another, Company B, charges, say $2200. The hospital has no idea what the profit margin is on the vendor side - and they would be shocked to discover it. Most orthopaedic products carry a 500 to 600 percent markup. Those markups are paid to salesmen and their Distributors, as well as the makers themselves. Many medical sales people make better than $250,000 annually, and work about four days a week. Some make much, much more - and it’s the patients who pay their salaries. Doctors are to blame here, too. Quite a few Docs spend a lot of time in Aspen, Vail, New Orleans, Miami or other vacation hotspots attending "seminars" thrown by the medical device vendors, where equal amounts of real work and real play happen... this is perfectly normal, and it goes on all of the time - and patients pay for these vacations every time they go to the hospital. More surprisingly, these same Doctors have private parties thrown for them, and have gifts given to them, in direct violation of AVAMED and other ethical standards that these companies say they hold so dear. Don’t forget, these salesmen are the Doctors personal friends. I have known several cases where the Doctor has allowed unnecessarily expensive implants to be used because the salesman has a contest going at his office, or they just want to "help him out". These components don't hurt the patient by any means, but the same case could have been handled without all of the extra expense. Ironically, these are the same companies that claim, "Patients come first." The fact is that these companies answer to their shareholders first - i.e., they are out to make money and nothing more. Hospitals negotiate their prices without knowing what other facilities are paying for them. There needs to be real transparency in the medical supply market that allows prices to be driven down. Patients also need to know what their surgery is going to cost before they have the work actually done. Ask your Doctor to compare vendors. If he or she won't, get a second opinion until you are allowed to. You'll be surprised to find out what the cost difference is. So will the hospital. Now, not all doctors are like this, nor are all salespeople so cynical. I have met some of the finest people on God's earth working in healthcare. These are the people who dedicate themselves to curing the patient, not making a reputation, or collecting cars, or publishing books. Some doctors will tell you that they don’t care where the implant, device or medication comes from, as long as it’s the best choice for the patient – and they really mean it when they say it. However, an equal number are in this for the money – period. Alert consumers who understand the product they are buying, and demand value for thier dollar can tackle the spiraling cost of healthcare. More government regulation will take us right back to square one. If we want to drive costs down, then let's start with the "underground economy" that drives device sales.

  • rags - Thursday, April 5, 2007, 8:43AM ET  Report Abuse

    • Overall: 4/5

    Good article but he should have added comments on the best compromise. I think 1) AMA restricts the number of doctors produced in the country. This leads to artificial shortage of doctors. Let market forces determine the number of doctors needed. 2) One reader reccomended basic health coverage for all and premium for those who can afford it. Seems ideal but is this possible ? How does a doctor decide what is basic and what is preminum ?? Once the govt takes over there will be a lot of inefficiencies. What about lawsuits ?

  • Yahoo! Finance User - Thursday, April 5, 2007, 7:01AM ET  Report Abuse

    • Overall: 1/5

    What a joke. Wheelan is obviously a socialist/fascist. What passes for "health insurance" in the People's Soviet Socialist Republik of North America (aka USA) is in reality a cost sharing plan. REAL insurance covers financial risk of a remote hazard, like your house burning down. A routine office visit to the doctor is like the sunrise. It's gonna happen. REAL insurance would not cover that. All this "government health care" baloney is just an attempt by the slackers (GM, Ford, Chrysler) to get some other sucker to pay for their own healthcare; i.e. cost shifting. The gubmint can do better at healthcare? Can you say "Walter Reed Army Hospital"? If that's the best Uncle Sam can do for people who have truly earned gubmint health care (the hard way), the rest of us will be down the toilet. (Yes, I'm a veteran, and no, I don't use the VA for my medical care. It's a sick joke. Been there, waited, waited, waited, waited...) When the Party takes over health care, rationing will be done using political criteria. If you are a member of an unpopular group, like the Kulaks or the Jews, you're a goner. How does it FEEL to know you will be "eliminated" for the good of the Party? Last thought to leave in your mind. When you are on the operating table for open heart surgery, and the surgeon is leaning over you with scalpel in hand, ready to cut you wide open, do you want a doc who is treated like a head of cattle and paid a pittance or a doc who is treated as a professional? Want the truth? Go to www.onthefencefilms.com for more.

  • WPaul - Wednesday, April 4, 2007, 11:54PM ET  Report Abuse

    • Overall: 4/5

    Excellent beginning advice. Health care delivery can and must become vastly more efficient than it is at present. Is this too complex for a national solution, requiting state actions? Is our population's insight and the quality of our leaders now adequate to effect change?

  • Yahoo! Finance User - Wednesday, April 4, 2007, 11:28PM ET  Report Abuse

    • Overall: 2/5

    THE REAL SOLUTION IS MORE DOCTORS AND MORE HEALTH CARE WORKERS AND LESS MONEY WASTED IN BUREAUCRACY,AND ADMINISTRATIVE COSTS!

  • Yahoo! Finance User - Wednesday, April 4, 2007, 9:08PM ET  Report Abuse

    • Overall: 5/5

    Living longer does not mean that a person is in good health. Some other measures like being a useful member to society, mobility and intelligence till the end should be considered

  • Mark - Wednesday, April 4, 2007, 8:37PM ET  Report Abuse

    • Overall: 4/5

    HSA's have no insurance or cost sharing element and therefore cannot be the major underpining of the "new healthcare paradigm." People contribute to insurance to cover catastrophy that they would otherwise not be able to survive financially or physically. Young people will opt out of insurance in favor of HSA's just like insurance companies try to insure only the healthy and least risky. Insurance companies in their present form add no value to the healthcare equation. The country and its citizens can not afford the escalation in the delivery of healthcare costs created by the for profit interests of health insurance companiies, their highly paid CEO's and stock holders. The added costs of technology and drug benefits are bad enough. And doctors are getting paid less and less so the caliber and number of graduating physicians is getting worse as the baby boomers get older. IT"S GOING TO GET WORSE IF THE GOVERNMENT CONTINUES TO PRIVATIZE HEALTHCARE. Look at the VA fiasco. Medicare is the most efficient administrator of healthcare benefits in the country if not the world, and it does this WITHOUT DISCRIMINATION OR AVOIDING RISKY BENEFICIARIES. Insurance companies make money by exclusion, national healthcare removes the costs of the for profit sector and will be inclusive not exclusive. I am a physician and have concluded that we must move to a paradigm that treats "basic" healthcare like we regulate public utilities. There has to be a universal basic coverage and then allow those that can afford it to add to it. Watch carefully how the government will try to pay the health insurance companies to be the hatchet men and further ration the care. Politicians in the US do not have the guts to recognize the futility in perpetuating the current healthcare paradigm while those in the healthier contries have already fessed up and made progress. National heathcare has it's faults and limits, but it is working. Who do you want to make those rationing decisions for you, for profit corporations or national panels of doctors. One key element is that the insurance sector will survive to underwrite the "premium" coverage that goes beyond the basic coverage.

  • Rogue Trader - Wednesday, April 4, 2007, 8:25PM ET  Report Abuse

    • Overall: 5/5

    Life expectancy has a lot of factors contributing to it and health care system, while definitely being a contributing factor, is not enough for a "regression analysis" :) This is the only weak point in the argument. Wheelan for president!

  • James - Wednesday, April 4, 2007, 8:16PM ET  Report Abuse

    • Overall: 3/5

    He doesn't bring much value with this article, but it's 100x better than the crap Kiyosucki writes about.

  • Yahoo! Finance User - Wednesday, April 4, 2007, 7:56PM ET  Report Abuse

    • Overall: 5/5

    I totally agree with the author's comments. Another reason why our health system costs more is care for the illegal immigrants. Our "democratic" system is also ironically a big obstacle to cost saving changes. How do we say no to big drug companies, armies of lawyers, and dedicated but also self-serving doctors. This simple but complex question is quite relevant on other arenas of our society as well.

  • La Marque - Wednesday, April 4, 2007, 7:36PM ET  Report Abuse

    • Overall: 5/5

    The USA needs a basic universal health care policy for every citizen financed by a payroll tax with no limit on earned income. Then employers can offer additional coverage. The government (medicare, medicaid, and the VA) should also pay the 'cash price' of health care instead of an arbitrary percentage. Insurance companies can then cover the add-on policies. Healthcare is expensive because of the government required 'cash price'.

  • Yahoo! Finance User - Wednesday, April 4, 2007, 7:20PM ET  Report Abuse

    • Overall: 3/5

    There should be more emphasis on innovations such as Health Savings Accounts (HSA) which provide incentives to consumers to shop around. Second, get employers out of the healthcare game. They don't provide auto insurance, why should they provide health insurance? As an employer, I would rather compensate workers more than to spend several days a year shopping around for health plans. Free us up to focus on the business. Employees get the benefit of health insurance that is portable and not tied to employment. No more dealing with COBRA either.

  • AlG - Wednesday, April 4, 2007, 7:20PM ET  Report Abuse

    • Overall: 5/5

    This analysis is exactly correct, but I wish the author had mentioned Health Savings Accounts, the only really good part of the bill creating the Medicare drug plan. Good in the sense that HSA's might be the best way to ration health care. I have one, and I think very carefully before spending money on health care. That is the way it should be.

  • Yahoo! Finance User - Wednesday, April 4, 2007, 7:08PM ET  Report Abuse

    • Overall: 3/5

    Not brilliant, but the issue is worthy. Health care has a cost and the U.S. spends a higher fraction of GDP per person on health care. Can we provide the same level of care and expand coverage without bankrupting the system? I believe so. I also believe that we will end up with a single payer system (read: government managed). The Boomers will vote this in when they can't afford the costs of care due to having not saved enough for retirement and simply by being the largest single demongraphic group. There are massive inefficiencies--like the Medicare drug benefit that currently does not allow the government to negotiate lower rates for drugs--this is pure lobbying in action by the pharma industry. Everyone cannot demand every service and expect there not to be a cost. Of course, it also helps drive up costs when a fresh-out-of-residency anesthesiologist makes $275,000 per year, too. The bottom line is that the doctors blame the insurers and the pharma firms and the insurers and the insurers blame the litigious society and the phram firms blame the high cost of getting drugs developed. Something must give.

  • STEVE - Wednesday, April 4, 2007, 6:56PM ET  Report Abuse

    • Overall: 5/5

    Why isn't the main stream media talking about this ?

  • brrrrrrrrrrrrr - Wednesday, April 4, 2007, 6:52PM ET  Report Abuse

    • Overall: 5/5

    Very good article. There are some very strong points. Keep up the good work of frightening the masess

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