Thursday, August 13, 2009

Well, you asked him to do that! 

I did. I suggested that "you�re welcome to saw that limb from under me" regarding whether or not Section 1233 of the health insurance reform bill was an overreach of federal power, and Ed brought the Craftsman.
There is a large difference between a private entity incentivizing it and the government taking the same action as part of a nationalized system. Consumers would have other choices in the private-sector scenario, including using their own funds to find doctors less willing to sell you a bouquet of flowers and a shovel as part of your diagnosis, thanks to good commissions. In a government-run system, those choices get stripped from consumers, both directly and indirectly. If the ObamaCare system incentivizes all doctors through cash payments to make the hospice pitch, it�s effectively unavoidable. Thanks to the tax bite a national health-care system takes, most consumers won�t have the resources to opt for private care, just as we see in Canada and the UK.
But Ed misses the point of the part of my post that he quoted. We have two questions to answer:
  1. Is there a "market failure" in the provision of end-of-life care planning?
  2. Is this failure something that government action could improve?
The first limb I crawled out on -- intentionally -- is that there's tension between a doctor's Hippocratic Oath and her or his provision of advanced end-of-life care advising. It's not just that people are squeamish or unwilling to consider living wills and health directives, it's that a doctor could feel, and I think does feel, that her or his promise not to ever administer a lethal drug extends to not advising on advanced care. One's moral or religious views may also play a role. That seems quite plausible to me. I was hoping medical professionals would comment on this point (and I hope they yet do so.) Ed hasn't challenged that point, but I don't know if he concedes it.

Where this comes to is whether "government action" could improve the outcome, contingent on a 'yes' to the first question. If the first question is affirmed, though, you have an argument then that there is a failure insofar as people are deciding advanced care issues with incomplete and imperfect information. It is possible to improve it. If Ed's position is "government will mess that up; they mess everything up", I am sympathetic to that but it doesn't mean it's impossible to find a way to improve the outcome. I did not walk onto the limb that reads "government can always fix a market failure." It obviously doesn't fix them all. It may not fix very many. But I don't think one can argue categorically.

To discuss 1233 fairly, you have to read it and realize it does not drive any particular outcome. It simply says that if a patient has not had advising in five years, and if a doctor wants to provide information about advanced care, including end-of-life care, the government will provide a payment for that. You induce the doctor to give information. You do not induce a particular outcome. To suggest the latter is to impose one's views of "sinister government" on the bill. I see this as playing into the hands of Obamacare supporters who will accuse opponents as just being pro-insurers: "You just don't want the government to do anything."

Of course, it does my argument no good for the President to tell the elderly to take a painkiller or skip the hip replacement. And if it drives all the private insurers out of business, as I think it will eventually, then the elderly who simply do not want that kind of advice ever really won't have an ability to get away from their advanced care seminar. But if the public option disappears the ability to force people to the seminar goes with it. Without that force, what do you object to then?

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