Last week, I wrote that current attempts to expunge for-profit influences from American medicine are doomed because that simply involves reshuffling the medical bureaucracy. I came in for some mild criticism, suggesting I missed the point. “If we funneled a lot of the money that we put into welfare for corporations into helping people get the medical treatment they need,” a good friend wrote, “we could reduce a LOT of the bureaucratic harmful determinations.”
I understand the appeal of this argument, but I don’t believe it’s true. Yes, I’d love to see some of America’s massive federal subsidies to, say, hydrocarbon mining and tech giants, redirected to serving ordinary citizens’ interests. Certainly we need to stop using public funds to protect the wealthy while ordinary people lack access to common-pool resources. But I’m not sure that’s what’s really happening in medicine. It’s something more subtle and insidious.
All economies are structurally organized around some resource that forms a bottleneck. Something that’s scarce and desirable forms the foundation of every economy. Whether it’s gold, or land, or human labor, every economy needs something that exists in finite amounts; the medium we use to value and exchange that resource, we call “money.” The key to unlocking and reforming an economy lies in identifying that bottleneck resource.
What, in medicine, is the bottleneck? Two or three years ago, I might’ve said “human labor.” Because medicine is highly specialized, and requires years of technical training to begin a career, doctors and nurses will always be a finite supply. And while for-profit hospitals can outbid for the services of experienced, highly-skilled professionals, access to quality, affordable medical care for numpties like me will always founder on money.
But recent news makes me question this assumption. To give just one example that’s gained recent news-cycle traction, we’re also facing a potential shortage of Earth’s helium supply. When I say “helium,” you possibly think of party balloons and silly voices. But much highly specialized technology, including, say, MRI machines, relies upon helium, which is so scarce on Earth that we risk running out in about 35 years.
Therefore we must make valuable decisions about allocating our finite helium, and other nonrenewable resources. Simply turning free markets loose sounds desirable to strict libertarians: if doctors need helium more than party planners, let them outbid. But forcing doctors to compete in resource auctions will increase already-staggering prices, ensuring that ordinary people can afford medical care even less than we do now. Some authority needs to intervene.
One cannot overvalue the importance of scarcity. Those of us old enough to remember the Clinton Administration’s attempts to reform health care, derisively dubbed “Hillarycare,” will recall conservative anger at the attempt to nationalize one-seventh of the American economy. But by the time Obamacare rolled around, that number had risen to one-sixth. The cost of medical care is growing faster than the overall economy, apparently.
Somebody has to make life-or-death decisions about allocating limited resources. Conservatives want private corporations to make those decisions, while progressives trust the altruism of the state. In both cases, some poorly-paid underling with looming deadlines will have to make decisions, about which they might be under-informed or even ignorant, based on one-size-fits-all metrics handed down from authority. That’s the living definition of bureaucracy.
Not only is medical technology limited and expensive, so is skilled labor. So is physical space for providing patient treatment. So is decision-making to determine who receives treatment: a Dutch study found doctors widely agree that older patients are under-treated compared to younger patients, while the American Medical Association prizes “duration of benefit,” which privileges the young. So, despite our best efforts, we’re still asking bureaucrats to make important decisions.
Though I recognize the limits of a layperson’s thought experiments, I cannot separate bureaucracy from medical treatment in a capitalist structure. Hospitals were invented by Christian monks during the Crusades, and hospital treatment was initially a form of religious devotion. Perhaps we could separate money from medicine if we recaptured this sense of spirituality, but how? Money changes people’s values, and the change usually can’t be reversed.
Please don’t misunderstand: I dislike the status quo greatly, and believe it abuses poor and minority people in its lopsided distributions. But, unless we remove all resource bottlenecks, which cannot happen if we want high-tech treatments available, I can imagine no remedy that isn’t just another reorganization of the bureaucracy. Whether you prefer state or corporate bureaucrats more, they’re still bureaucrats. And we’re still running out of helium.
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