Let me tag on to Marc’s excellent post on the recent Krugman piece. Seldom have I read a more internally incoherent argument (and for Krugman, that is saying a lot).
Krugman makes the highly relevant point that “We’re talking only about what will be paid for with taxpayers’ money. And the last time I looked at it, the Declaration of Independence didn’t declare that we had the right to life, liberty, and the all-expenses-paid pursuit of happiness” (this is a rare, lucid moment for Krugman, where he remembers his roots and sets aside his usual reverence for all conceivable government spending).
I couldn’t agree more. “One way or another, government spending on health care must be limited.” This essential point is ignored on both sides of the aisle. The looming crisis in Medicare cannot be solved without cutting costs, and cutting costs means purchasing less care. But how? And who decides?
It is at this point when Krugman’s argument devolves into a strange and antiquated world where where wise doctors give orders and patients follow. Nowhere does he even suggest that within this world, where the doctor-patient relationship is “almost sacred,” that patients are people whose autonomy and desires should be respected. He thinks it is appalling to treat them as “consumers,” but isn’t the heart of being a consumer the freedom to choose one’s own path. This is the world of Marcus Welby, where wise, benevolent doctors give orders to their trusting (but mindless) patients. Gives me chills.
Yet at the same time these doctors are not to be trusted. “We can’t maintain a system in which Medicare essentially pays for anything a doctor recommends…And that’s especially true when that blank-check approach is combined with a system that gives doctors and hospitals — who aren’t saints — a strong financial incentive to engage in excessive care.” So, patient preferences have no role, and doctors are not to be trusted. Who does get to decide, then? Well,… (insert drum roll here)…the all-knowing government bureaucrat of course! In Krugman’s world, government regulation is always the answer.
I’m actually a strong supporter of cost-effectiveness research and of the Independent Payment Advisory Board (or something like it, at least). When spending out of the public purse, we have to have ways to say no (Three Cheers for Death Panels!). Somehow in their recent attempts to oppose everything Obama-related, Republicans forgot who they were, and they became endorsers of unlimited Medicare spending (imagine if we ran food support programs the say way: “come to the supermarket and take whatever suits your fancy”). The fundamental principle for health care reform should be that everyone needs “skin in the game,” which is just a newfangled metaphor for the old idea that markets need to discipline behavior. A system where neither patients nor doctors face any consequences for unnecessary, ineffective, or excessively costly care cannot work.
Consumer-driven health care is not just about the benefits of “comparison shopping,” as Krugman claims. It is about individual responsibility and accountability. It is about getting what you pay for and paying for what you get. It is about putting the patient and his/her family—not the doctor, not the insurance company, not the government bureaucrat or legislator—at the center of the medical decision-making process.
So, Paul, the reason we want to refer to patients as consumers is not that complicated. It is because we all deserve the dignity that being autonomous human beings accords us, and we all should be expected to take responsibility for the consequences that autonomy will bring.