Doran: A health care bubble about to burst

By Terry Doran, January 15, 2011

Editor’s note: This op-ed is by Terry Doran, a resident of Montpelier. His wife, is Dr. Deborah Richter, a single-payer advocate.

When we talk about health care reform, what are we really talking about?

Reform says there is something to correct. What is it?

There are a lot of answers. The quality of care. The delivery of care. The cost of health insurance. The wildly discrepant charges by doctors and hospitals. Those are some, and they break down into narrower and narrower topics, all of which could do with some correction, perhaps.

By now few, if any of us, believe the costs of health care are sustainable much longer. There are clear signs we are in huge trouble. This is widely, clearly understood.

We seem to be living in a health care bubble about to burst. The alarm grows more urgent year by year, and yet nothing close to the scope of the problem is attempted. Vermont has tried tiny corrections with tiny discernible effects, not all of them good. What now?

Could it be that it goes much deeper, this problem? Everyone knows there are selfish interests who want corrective change kept to between none and the minimum.

It looks like what is needed is a kind of religious conversion. We’ve allowed something to happen in health care because we had faith and now that faith has been thoroughly discredited.

It goes like this:

Our health care is an admixture of a market-model (health care stores for individual buyers with enough money) and a public good (health care services financially supported by society).

In Vermont most health care professionals and the services, hospitals, etc., act as though health care is a public good, which is the same thing as saying its primary reason for being is to benefit the public as a whole.

Our faith, delirious you could argue, was to believe that a market model could solve – mysteriously, magically – any problem thrown in its way. You can decide if this was true in big banking and Detroit auto manufacturing.

There is now a mountain of evidence that our awkward coupling of the health care stores idea to the health care services idea is a really bad idea. It doesn’t work.

One good reason for this is that a public good isn’t limited to one segment of the population, however you define that group. It excludes no one. A market-model does. It excludes some, the some usually being those without enough money.

Our deepest problem is to understand a public good, how it works and why, and what it can mean for health care. We don’t exclude some youngsters from public education; we don’t exclude some families from fire and police protection; we don’t exclude some drivers from full use of roads and highways.

Characteristic of all these, and other public goods, is that they are collectively funded by us all for us all. The implied agreement is that individually we know we are unlikely to be able to pay for a school, fire department, police force, or a road without the help of everyone else.

Health care is exactly the same, except that we have mostly fallen into the trap of looking at it as an individual purchase and not a public good. When we use it, we tend to think we’re up for paying for it, or our insurance is. But in fact the very existence of the services (a hospital, a nurse, a doctor) we intend to buy from depend on collective financing.

At this moment Vermont stands at a unique point in time. It’s the only state on the cusp of adopting a health care system that is coordinated to benefit the whole of the Vermont public. Our legislature has asked a highly-regarded health economist, William Hsiao of Harvard, and his working group to design three systems to study and perhaps legislate from.

We won’t know what the designs look like until Wednesday morning. But if what eventuates does not move us clearly and in a step-wise manner toward health care as a public good, then our unique moment will have been lost. And the next sound you hear could be the sound of a bubble bursting.