What a Subway Breast-Implant Ad Can Teach Us About U.S. Health Care
The idea that people won't be able to afford medical treatment without Obamacare is simply wrong.
For sheer accumulation of elite institutional prestige, it's hard to top Atul Gawande. He is a professor at both Harvard Medical School and the Harvard School of Public Health and a regular contributor to the New Yorker magazine, where I've enjoyed reading and learning from some of his brilliant and fair-minded past work.
Gawande greeted the news of Donald Trump's election and its impact on heath-care policy with this gem: "eliminating Obamacare isn't going to stop the unnerving rise in families' health-care costs; it will worsen it. There are only two ways to assure people that if they get cancer or diabetes (or pregnant) they can afford the care they need: a single-payer system or a heavily regulated private one, with the kind of mandates, exchanges, and subsidies that Obama signed into law."
A few days later I was in the New York subway and saw a poster advertising plastic surgery. "Breast augmentation," the poster blared: $3,900. "Free consultation, 100% financing available—includes all fees."
On the health care financing question, I think the New York subway ad is closer to the truth of the matter than the New Yorker magazine.
If there's anything American capitalism is really good at, after all—for better or worse—it's figuring out ways for consumers to pay for things that they otherwise couldn't afford, and may not even need. That new iPhone? Pay for it over two years in connection with your cellphone service contract. A new house? How about a 30-year mortgage, or even an interest-only adjustable rate mortgage? A new car? Lease it for three years. College tuition? Try a section 529 tax-deferred savings account, student loans, and financial aid.
Leave cancer or diabetes aside for the moment. With all due respect to Professor Gawande, Harvard, and the New Yorker, it's just hard for me to believe that in the absence of Obamacare, the expense of pregnancy will suddenly become out of reach to ordinary Americans. Somehow, hundreds of millions of Americans managed to become pregnant in the more than two centuries that the republic existed before 2010, when the Patient Protection and Affordable Care Act was passed. If the law is repealed, we'll find a way to reproduce again afterward.
If anything, pregnancy and childbirth are fine examples of the way that government involvement, regulations, and subsidies increase the cost of medical care rather than decreasing it. When someone else is paying, all of a sudden any personal financial incentive a patient might have had to see a cheaper nurse-midwife for routine prenatal care rather than a more highly paid obstetrician/gynecologist disappears. Likewise, if the government requires insurance companies to pay for a two-night hospital stay, why go home sooner?
Much of the expense of modern pregnancy care—fetal echocardiograms, repeated sonograms, various other tests—relates to a policy agenda of preventing the birth of disabled individuals. That may or may not be a policy agenda worth furthering by making everyone's pregnancy more expensive, but if that is the tradeoff, let's at least be transparent about it, rather than pretending that it's the pregnancy, rather than the disability-birth-prevention, that is the expensive part.
The most expensive part of health care is usually a doctor's time. The supply of trained physicians is artificially constrained by limits on how many medical students, residents, and fellows are accepted each year in American medical institutions. Even highly competent and experienced foreign-trained practitioners often are required to repeat their training if they want to immigrate here and practice in America. If Americans were paying directly for their own health care, you might see political pressure build to increase the supply of physicians (and drive down the wages). Or perhaps "medical tourism" would increase, with pregnant patients choosing to schedule their labor or delivery at less-luxurious hospitals overseas, where doctors and hospital staff earn less money.
Even the billing might become more efficient if government and insurers were cut out of the picture. My local orthodontist, for example, has managed to figure out how to bill for braces in ten or twelve payments charged directly to my credit card. With other doctors, where, unlike at the orthodontist, an insurance company is involved, I seem to get at least four different bills or statements for each visit — a copay, a statement of benefits from the insurance company, a bill from the doctor, and then another bill from a lab or hospital or an imaging center.
Sure, health care differs in important ways from other parts of the economy. As even Donald Trump concedes, we don't want people dying in the streets because they can't afford health care. But health care is similar in important ways to other parts of the economy, too, in the sense that if people want something badly enough, the market will find a way to provide it.
The idea that without ObamaCare, people won't be able to afford pregnancy is an idea that is itself symptomatic of the syndrome known as elite post-election panic. There's no cure yet known for it, but one hopes for everyone's sake that it will get better with that time-honored medical technique known as "watchful waiting."