Matthew Holt writes, “reform of the way Medicare pays for care, and the way variation in care is to be removed, are subjects that will be tackled by a group of elites who actually understand this stuff, out of the view of the public eye.”
So under Holt’s ideal medical system, the practice of medicine will be governed by elite technocrats, far removed from doctors and patients. Concerning this approach, one may ask:
1. Is it moral?
2. Is it efficient?
3. Is it politically acceptable?
I believe that the answer is “no” on all three grounds.
It is immoral because it concentrates power in the hands of an elite, and it takes autonomy away from doctors and patients. The news today reports of Art Buchwald’s death, and the obituaries mention his difficult decisions regarding terminating dialysis. Taking those decisions away from individuals and their doctors is simply wrong.
It is inefficient because the best decisions are made closest to their point of impact. Are consumers perfectly rational decision-makers? No. Do they have all the information they need to make perfect health care decisions? No. But the alternative to imperfect consumer choices is not optimal decision-making. The alternative to imperfect consumer choices is someone else making mistakes that are, on average, worse. One of the essential insights about markets is that they process information efficiently, by getting information to the point of decision.
Let us assume that “a group of elites who actually understand this stuff” can come up with really well-researched guidelines about whether I should get an MRI for a back injury. (In my book, I propose establishing a commission to develop those sorts of guidelines.) Then the most efficient way to process this information is to give it to my doctor and me, and then to let me decide whether or not to pay for the MRI. If the guideline says that I should not get an MRI, but my doctor and I prefer to go against the guideline, then I should be allowed to do so. Especially if it is my own money that is paying for it.
Finally, Holt’s version of single-payer is politically unacceptable. He wants to reduce the power of physicians, not only in the political process but in day-to-day decision-making about medicine. That is going to meet resistance not just from the medical profession but from the typical consumer.
Holt uses the slogan “Medicare for all,” but what he has in mind is nothing like Medicare today. His political strategy amounts to bait-and-switch. Promise people cake, and then serve them spinach. If you can pull that off, then you can make anything politically acceptable. But if you are constrained to be honest, you could never sell Holt-Care to the American people.
Health care spending is going to present us with tough choices, and we need to be up front with the American people about that. As spending rises, it has an impact on the typical American, whether it comes through medical bills, health insurance costs, shifts in compensation from wages to health benefits, or taxes. Insulation does not take away the impact, any more than not telling a patient about a serious long-term illness takes away the impact of that illness.