Monday, September 04, 2006

The Health-Care Piper Calles the Tune

The BBC has a report on a proposed plan by Britain's National Health Service (i.e., British taxpayers) to refuse to pay for fertility treatments for women with excessively high body mass indexes:

Dr Gillian Lockwood, who chairs the BFS's ethics committee, told the BBC that "unfairness" was the aspect of the NHS provision which people objected to most.

But Dr Lockwood said there were clinical factors which affected the success of IVF and, as well as weight concerns being over the age of 40 meant that "even very high-tech treatments like IVF are really very unsuccessful".

She added: "For £2,500, you have at least a 50% chance of producing a much wanted, beautiful healthy baby - the same cost as stripping varicose veins.

"I think the fourth richest country on earth should be able to afford effective fertility care for its citizens."

Clare Brown, chief executive of Infertility Network UK said: "From our own surveys and from the many, many calls we receive from patients, we know only too well that there are still unacceptable inequalities in the funding of treatment around the country and couples face huge difficulties in accessing services."

But Josephine Quintavalle, of the organisation Comment on Reproductive Ethics, told BBC Five Live limited NHS budgets needed to be focused on treatment for groups which would benefit the most.

"If it's a proven fact that it's very difficult to get pregnant when you're overweight, then the logical cure for that kind of infertility is to encourage the patient to lose weight."

Economics is about not what "we should be able to do" but what we can do. The takeover of health care by the state to varying degrees in most Western societies has unavoidably meant that politics has become the arena of decision for what kind of health care services are provided at what cost, rather than competition among buyers and sellers, the normal way of making such decisions for most goods.

When health-care decisions are made by "the market" (i.e., by such competition), whether or not heavier women should get fertility treatments depends only on whether the providers of such treatments and such women can strike a mutually beneficial bargain. This in turn is a question of whether or not the resources needed to provide such treatments can be had any cost less than such women's willingness to pay for such treatments. When health-care decisions are made by the British government, a lot of time is spent demarcating what everybody's "rights" are, with no one's claims having an ironclad logical priority over anyone else's. Thus, it falls to politicians to make these choices, and they make them on the basis of maximizing political support -- votes, campaign contributions, or whatever else contributes to their continuance in office. The market trades off one individual's health-care claims against those of someone else (or even something other than health care) strictly on the basis of the cost to society of providing one or the other. Politicians make that decision on the basis of, well, some other criteria.

Politicians will then tend to make all-or-nothing choices. Either fertility treatments are banned for everyone with a BMI over 36, or everyone with a BMI over 36 is entitled to fertility treatments. There is no room for adjustments at the margin -- the idea that some such women might have better prospects than others, so that we examine each case isolation. In addition, political pressure groups are far more likely to persuade the government to impose certain measures in the name of "better health" then they would private providers of or payers for healthcare services. Taxes on high-fat food and sugary drinks are commonly proposed. One could easily imagine the imposition of taxes on obesity itself, on people who live in low-density neighborhoods that discourage walking, or on any other principle but violates the rule of law simply because the government is now the health-care paymaster. State domination of healthcare provision is dangerous not just because it discourages innovation but because it subordinates everyone's lifestyle choices to whichever pressure groups can most effectively mobilize political power. In a private health-care system, an individual who wishes to live in a risky way finds that he internalizes the cost of that through higher health care costs. (When I say "private health-care system," I do not refer to that in the United States, which is a Rube Goldberg hybrid of public and private provision three) in a public health-care system. He is almost certainly deprived of the ability to make that choice.

Providers too will undoubtedly find the increasing intrusiveness, bureaucratic arbitrariness, and all-or-nothing nature of public decision-making frustrating. Already in the United States doctors are opting out of the lower-paying Medicaid system for the poor, and they may soon begin opting for more out of the Medicare system for the elderly as well. Some doctors are increasingly resorting to cash-only businesses where they do not even accept health-insurance payments. In the US, perhaps this will be the entrepreneurial magic bullet that encourages health insurance to be what it used to be -- insurance against an unlikely but catastrophic eventuality. People could pay cash for ordinary health services -- colds, checkups, broken arms and so on. Insurance can be purchased against the possibility of cancer, appendicitis, and other major calamities. That system has much to recommend it from the perspective of providing the most healthcare for the most people (i.e. from the perspective of efficiency), but it will have to wait for the breaking of the current logjam of a system that we have.


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