Tuesday, August 8, 2017

Ethical Perspectives On Social Equality And Innovation In the US Health Care Debate

There are many reasons people favor market-based health care systems over alternatives like universal care and single-payer, and this post is about just one of them: the idea that the innovations produced by market systems are worth the trade-offs required by the deficiencies of market systems.

About a month ago, Vox ran an interview with health care economist Craig Garthwaite, who said that market-based solutions are important because competition drives innovation. Innovation creates new treatment options, so we can cure more diseases and help more people. In fact, he said, the health care systems of other countries -- like those in Western Europe and presumably Canada -- are sort of mooching off the innovation produced in the US and thus not paying their fair share. Acknowledging that health care for some people will suffer under a market system no matter what, he says that we should try to create an improved market-based system, making the ACA work better and properly funding Medicaid to take care of people who can't afford insurance.

Correctly inferring that the issues are fundamentally value-based, the author of the piece summarizes this way:

"Either we value providing adequate care to the most people possible or we value providing ideal care to fewer people in a system that produces more innovation. That’s the fundamental trade-off, and where you come down turns on what you value."

I don't know whether those empirical claims are true -- whether, in fact, innovation markedly suffers when you move away from a market-based health care system. It's a complicated question, because there are so many variables. But let's say for the sake of argument that it is true. In that case, how should we go about making these value-based trade-offs?

It's sometimes suggested that there are rational ways of calculating that would give you an answer. For example, in consequentialism, we evaluate actions and policies based on a calculation of costs-and benefits. You could estimate the QALY's -- quality adjusted life-years -- that would be produced or preserved by various policies and choose that way. This means directly weighing the negatives of under-treated people -- like women who die in childbirth or poorer people with long-term diseases like cystic fibrosis -- against the positives of new treatments like innovative cures for cancer, brain injuries, etc. You'd count how long people live, and how many people, and just add it up.

For a lot of complicated reasons, I think this wouldn't be the right way to judge the trade-off. One reason has to do with justice and fairness. What about the fact that people who are already the subjects of discrimination and historical injustice end up also being the "costs" instead of the benefits? For example, if you can increase the life-span of a few rich white people by worsening health care for poor black people, then cost-benefit analysis seems to say that as long as the increases are dramatic enough, that's a good plan. That must be the wrong answer. Another reason has to do with the idea of "quality-adjusted." As disability-rights activists point out, their lives are systematically undervalued in this framework. Because of the way "quality-adjustment" tends to be operationalized, improvements to able-bodied people count as more significant.

A more subtle way of making trade-offs is through the "interchangeability" concept associated with the work of John Rawls. Rawls suggests that to determine what is a just society, we should ask what we'd be willing to agree to if we didn't know who in that society we would be -- whether we'd be rich or poor, healthy or sick, educated or not.

This way of proceeding also faces problems and challenges, but it's interesting that the economist being interviewed says that in a Rawlsian framework he'd "probably want to be in another country." That is, if you didn't know whether you might be at the bottom, you'd choose to structure your society with more protections for more people -- even if that's at the cost of innovation. Given the cost of the ACA insurance, I expect a lot of middle-class people would prefer to be in the other systems as well.

I think a lot of people have a value-system that includes various potentially conflicting ideals, and that these ideals often include a commitment to the idea that someone who works hard should be able to afford a decent life. Prioritizing this ideal over others would also lead us to conclude that it's worth sacrificing some innovation to make sure everyone can access health care.

When I think about innovation and trade-offs, I sometimes imagine returning to the technology of the 1980s, when I was young. In the 1980s we had no internet. If you wanted to call someone on the phone, they had to be home. If you wanted to see them, you'd have to arrange in advance. If you wanted to buy something, you had to go to the store, and if you wanted to do research, you had to go to the library and track down bibliographies on paper and use these huge books that would index research articles. If you wanted to watch porn, you had to go somewhere and get it.

Would we sacrifice all the innovation improvements of the last few decades if it meant an improved way of life for people who are poorer and sicker? I don't know about you, but I would in a heartbeat. Sure, in a world where everyone has a cell phone, it sucks not to have one. But if no one had one, who cares? Were people really less happy in the 1980s? Given that modern crises of inequality and anxiety, especially for young people, we may well have been mostly better off.

In reality, there are no easy trade-offs like this, and slowing innovation would definitely be bad in some ways. For example, for some people who have health conditions and disabilities, the innovations of the last few decades may well have led to radically improved lives. But if it's really true that only certain kinds of systems produce that kind of innovation, then we need new solutions for ameliorating the costs.

And it's worth remembering that innovation isn't always technology. US maternal mortality is rising, and is three times that of the UK and eight times that of Norway. California recently bucked the US national trend of more and more US women dying in childbirth through innovative organizational changes in how pregnant women are evaluated and treated. Ultimately, those researchers also said that it comes down to a question of values: "a key driver of America’s maternal mortality problem is that America doesn’t value women."

These innovations came partly from Stanford University and partly through the California Maternal Quality Care Collaborative, not from markets.

Again, I don't know if it's true that the deficiencies of the US system are essential to its successes. But given that the costs of the deficiencies are so high, and given that the successes are mostly enjoyed by the already privileged, and given the many social factors that can bring about innovation -- we have to look for new alternatives.

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