... Or Maybe It's Culture!

Problem exists between Juneau and Miami. Unless it doesn't.

Let me get the red-faced walk-back out of the way: earlier this year I posted an article about perverse incentives and the costs of insurance. I thought it was very clever and insightful and I was very proud of myself until somebody pointed out that the 80/20 rule I highlighted only applies to maybe a third of all insurance plans. Derp. I promptly edited a broad disclaimer into the head of the offending post.

I was, in fact, guilty of a thing I often criticize the ratsphere for¹: I acquired some limited knowledge and assumed that, because I am cleverer than average, that limited knowledge constituted a unique insight into a complex system with which I had only superficial familiarity. But I don’t feel too bad, because this is common when discussing health care. Health care, as I have mentioned before, consumes an absolutely stupid percentage of our resources and employs something like one in six Americans last I heard. It’s ginormously complex and you can’t possibly take in more than the tiniest part of it at a glance. And everything anyone says about it will be contradicted, quite convincingly, by something you read somewhere else.

Everyone knows that the US spends more money than everyone else for worse results. That’s the foundational fact everyone starts with. It might not be true, though, or it might be true in a misleading way; defining what constitutes “worse results” is tricky and difficult to disentangle from weird confounding factors like Americans just being monstrously fat. Being monstrously fat makes all health problems worse² and (at least pre-Ozempic) health interventions don’t seem to do much about it, unless you blithely assume that Americans are fat because other countries’ doctors nag them more effectively, or define healthcare so broadly as to encompass everything that might influence weight gain and assume that’s all tethered to healthcare spending somehow.

There’s also a link floating around the internet where some dude claimed to prove, with a series of like ninety pages of graphs, that America’s healthcare costs are perfectly consistent with its greater wealth relative to other nations³. Nobody ever refutes it because very few people are in a position to refute or even read ninety pages of graphs. When I see ninety pages of graphs, I feel depressed and defeated without even reading them. That’s like Lovecraftian horror for your intellect: the facts are vast and indifferent to your puny ability to take them in. Is it true? Shit, I don’t know.

It’s widely noted that healthcare isn’t an efficient market because there’s no price transparency; nobody has any idea how much any given procedure really costs until they go and do it and get the bill. So there’s a push to require up-front pricing. But the other day Marginal Revolution posted an interesting comment from some reader who is apparently quite smart and works deep in the bowels of healthcare. He notes, among many other points, that our proposed solution won’t work because even the people doing procedures often don’t know how big a problem they’re dealing with until they open the patient up⁴. Even if a procedure is well-done by a competent and properly informed specialist, you can always have a weird reaction to something, or develop an unexpected complication, etc. For everything beyond the utterly simple and routine (like a chest X-ray), physicians can only give rough estimates with tons of strings attached.

So, yeah. In my honest moments, I am Job, confronted by the angry whirlwind of the Health-Industrial Complex. No, I was not there when FDR made health insurance tax-deductible. I have not plumbed the depths of Medicare, nor read the Affordable Care Act and the eighteen most relevant studies on its reforms⁵. I am utterly ashamed and disgraced before all the world, and I have no answer to give.

That said, this post isn’t that long yet, and I am stubborn. So I’m going to express some dumb ignorant opinions anyway.

There are some factors which obviously contribute, to some extent, to bloat and waste in healthcare. The opacity of prices is one of them. Another is the natural temptation to get as much as you can out of the pot relative to what you put in, even if it’s wasteful and unnecessary and involves choices you would never make if you were paying for them yourself. A third, which I don’t really see brought up that much but which has been on my mind a lot over the past few years, is that American health care is expensive because it has to work with Americans, and the weirdness of American culture is at least partly to blame.

I want to focus on that last one because it’s the sort of explanation wonks tend to ignore. We like dry, technical answers about money, and trends, and rational actors responding to incentives. We want to hear that the answer to the problem is to adapt a given set of policies⁶. But America is weird. Really, really weird. Usually that’s awesome. I like that almost all of the world’s most powerful corporations started here, that you can start a business and grow it as big as you please. I like that, apparently, our crappy joke state is still richer than the country we split off from two hundred years ago. I like that, beefs about cancel culture notwithstanding, you really can say most any jackass thing here and be protected, by centuries of precedent, from punishment by the government. I am a classical liberal⁷ and really I think America is pretty neat.

Still, there are always tradeoffs. The culture of maximal individual liberty is also the culture of maximal self-indulgence, and when you’re dealing with a system of collective responsibility and individual benefit, that sometimes means we look at a commons and our first thought is, “I bet that could take a little more tragedy.”

When the other countries were doing their Covid lockdowns and dutifully masking up, social distancing, getting shots, etc., we were propounding insane conspiracy theory rubbish about worm medicine and pool bleach⁸. Our hostile overreaction to official mendacity in the early days of Covid also seems to have supercharged our existing hostility to vaccines⁹ so now we’re getting the measles back faster than ever. Whenever somebody proposes adopting another western nation’s healthcare model, it’s pointed out that those countries tolerate rationing and delays much more than we do—because Americans don’t defer to authority, and they don’t sacrifice for the collective good, to anything like the same extent as other western states¹⁰.

So, yes, culture definitely has implications for healthcare. The only question is how much. There are a lot of little factors you can point to—but in many cases, it seems to me, the common factor comes down to culture, to America’s general weirdness. We pay higher drug prices because we don’t have our government impose cost controls like other countries do—which means we’re effectively subsidizing other countries’ drug prices, since most of the cost of a drug is going to be R & D. And America is the land of free markets! We’re much more resistant than most western countries to the idea of price controls¹¹¹².

My own experience confirms this general picture. I have often observed that, when a doctor tells an American something he doesn’t like, the American usually gives one or both of these responses:

1. “That’s not what the internet said,” and

2. ”You’ll be hearing from my lawyer.”

That is, they refuse to accept the doctor’s authority, and they reach for the nearest hammer to make him do what they want instead. I … don’t picture it working that way in Canada¹³? How do you say “The customer is always right” in French or German? Not that we outright say “the customer is always right,” but that’s the mentality. When it comes to the end of life, in particular, I’ve already noted on here that the family, not the doctors, make the decision on when to withdraw care even when it’s clear that there isn’t much hope. Scattered news stories I’ve heard from other countries over the years suggest to me that this is not typical of western democracies. But it’s not limited to that. Aside from the well-known practice of defensive medicine—which is itself a reaction to America’s profusion of lawyers and willingness to sue over anything—a bewildering amount of patient care is driven by patients themselves. Patient gripes to doctor, doctor orders this or that to shut them up and keep them happy, even though he knows it’s a placebo. The internet told them it would work.

Does it work that way in Australia, or Sweden? I don’t know. I don’t know everything. Maybe I don’t know anything, except that America is a weird, weird place full of weird, weird people.

1. In my less charitable moments, I feel the wiki for “rationalism” should redirect to “Engineer’s Disease.” I was in the middle of respiratory school when somebody rat-adjacent confidently said that, since ventilators do not improve outcomes for Covid, Covid patients should never, ever go to the ICU. Even as a student, I knew that was an asinine thing to say, and told him so, but it made sense based on the understanding he had developed as a smart person reading a bunch of articles.

2. I didn’t appreciate how starkly true this is until I worked in healthcare. Everything about us is optimized for a specific weight level, so obesity simply wrecks all body systems. Aside from diabetes and the cardiovascular stuff we all know about, it puts strain on the skeleton, the muscles, the skin (folds of fat get gross infections), and yes, the lungs; there’s a thing called “obesity hypoventilation syndrome” where patients will go around with chronically acidic blood because it’s too much work for their lungs to take in big breaths and exhale CO2. I see it routinely. I get that obesity is a deep-rooted problem and incredibly hard to beat, but being “fat-positive” is a simply monstrous position from a healthcare perspective. It might be less grotesque to cheer for epilepsy. That really only screws you over one way

3. Another Thing I Just Read On The Internet claims that average income in the UK is worse than any American state’s, even Mississippi which is famously that state we only keep in the Union to make the rest of us look good. I made a cursory effort to confirm this but it seems our countries track differently defined variables of national income derived by stapling words like “per capita,” “median,” and “average” together in different orders, so hell if I know. The figures I could find seemed to more or less confirm that Brits make lousy money but that’s probably misleading too.

4. A point reinforced just today, when I asked how many open-hearts we’ll have to do tomorrow and the RN said there was one planned. We know he’ll be a multiple bypass, but the surgeon simply won’t know how many he needs to do until he’s started. I don’t know how that works, I guess you can’t see how many arteries are totally borked until you’ve got the exposed heart right there. Not a surgeon.

5. But I still think it sucks. Fight me.

6. I really hate arguments of the form “[Foreign Country neither of us has ever visited] has solved this problem, so we just need to adopt their system.” First because that kind of statement, in my experience, is inevitably based on reading simplistic internet factoids published by boosters with relevant facts stripped out; one of the Psmiths has noted that “look at this obscure culture which accepts trans identity” is essentially an updated version of Tacitus’s “look how virtuous my rosy portrait of distant barbarians seems in comparison to the more familiar Romans I wish to criticize!” Second because it’s like the guy with the ninety pages of graphs, but worse, because I would have to do a full-on research project into every factor that might affect that country and its policies to know whether you’re right or not. And you didn’t even have to go to the effort to make ninety pages of graphs. Bugger your lazy shortcuts to a Gish Gallop. Third because it’s irrelevant because countries and cultures are not fungible. “You know what would fix Afghanistan? If it just adopted liberal democracy.” Give me a Nobel Prize!

I will now take several minutes to remember where I was going with the main post because writing this footnote has made me angry. Grr.

7. The exact label varies depending on my mood, but I like “classical liberal” right now for its emphasis on history and the American tradition and lack of ties to Ayn Rand or quixotic crusades to promote horrible edgelord things nobody likes in the name of absolutely maximal freedom at all costs. I am not a principled liberal but a practical liberal. I have observed that, all else being equal, things work better when we are allowed to make and learn from our own mistakes instead of having other people take our money and make the different mistakes on our behalf. Individual choice just works better, as a rule. I called this Substack “Breathing Free” first because it lets me get stuff off my chest and second because there really are libertarian lessons for healthcare. It’s just that the flipside of freedom is responsibility and health insurance is a situation where individuals are made free by offloading responsibility onto the group.

8. This is not to say that I believe lockdowns were the way to go; the sheer number of “essential workers” needed rendered all that rather farcical IMO. But it says something that America was the place where everyone felt freest to say “hell no, we won’t stay.”

9. Which is based, so far as I can tell, largely on a subset of the population being hostile and skeptical with regards to healthcare, and refusing to engage with vaccines or most anything else unless forced to. Such people being statistical neutrinos from the perspective of the healthcare system—if you don’t interact, you don’t exist—they generate weird statistical artifacts due to hardly ever being diagnosed with anything. And since they’re the only possible control group, and self-selected, they’re utterly impossible to thoroughly refute without doing a grossly unethical multi-decade study and looking at all the kids who don’t die in infancy from resurgent epidemics. I believe other countries solve this problem by sitting on these people until nothing remains but the most pathetically tiny minority of diehards and fanatics. The Land of the Free doesn’t have that option. Alas.

10. Europeans also take much more aggressive action on climate change, complete with miserable individual burdens like, infamously, not being allowed to own a damned air conditioner in many places. You’re wrecking the climate, you selfish person! Yeah, and so’s everyone else, it’s an insoluble collective-action problem and all your selflessness is doing is making you miserable when it’s not outright giving you heatstroke. I’m baffled by the naivete of people who believe we’re all going to wreck our economies and give up our comforts to forestall a very roughly defined future evil. This is an example of the American approach simply being more sensible.

11. I don’t believe in price controls either, they’re a bad solution, but in the immediate and limited context of relative drug prices they benefit other countries since drug companies are faced with a choice between selling drugs cheaper than they like and recouping some of their development costs or standing their ground and maybe seeing those other countries retaliate by refusing to honor their patent. However you look at it, the American patient is making up the shortfall.

12. It’s unclear to me how much of this is the FDA’s fault. A lot of blame gets heaped on its approval process, but I read something (which I can’t find now) that actually it’s a matter of drug companies having too much riding on any individual drug these days, so they insist on redundant double-checking of every single figure the testers record, which drives up costs to an insane degree. Don’t know who’s right.

13. There is just no way Canada has nearly as many lawyers per capita as we do.