Monday, August 22, 2005

Lamest Gladwell article ever?

Generally I like Malcolm Gladwell, but I think his latest New Yorker article is really stupid. The article discusses why America does not have universal health coverage and says it is because it is overly concerned with moral hazard and therefore is pushing health risk onto individuals, not taxpayers.

Ironically, he begins with an example that undermines the rest of his argument -- teeth. In typical sappy New Yorker style, we get a list of unfortunates who have bad teeth which then results in a series of bad outcomes:
Gina, a hairdresser in Idaho, whose husband worked as a freight manager at a chain store, had “a peculiar mannerism of keeping her mouth closed even when speaking.” It turned out that she hadn’t been able to afford dental care for three years, and one of her front teeth was rottingDaniel, a construction worker, pulled out his bad teeth with pliers. Then, there was Loretta, who worked nights at a university research center in Mississippi, and was missing most of her teeth. “They’ll break off after a while, and then you just grab a hold of them, and they work their way out,” she explained.... “It hurts so bad, because the tooth aches. Then it’s a relief just to get it out of there. The hole closes up itself anyway. So it’s so much better.”
But dental care is one of those things that is cheap and entirely within the budget of even the poorest people. If you don't eat sugar, brush regularly, and occassionally floss, you will never have to go to the dentist for cavities. All of these are cheap and easy.

My wife is an ER doctor and once or twice a month someone walks into her ER at 3am with a toothache. They inevitably have an absess that has been growing for months and they inevitably don't brush their teeth. Gladwell may think this illustrates someone who has been cruelly left behind by the heartless capitalist healthcare system, but it's really just some poor schmoe who has lousy life skills, made hundreds of bad decisions by not brushing their teeth, and is now paying the painful consequences (and being treated at tax payer expense). In Gladwell's world, the only thing between this individual and pearly whites is money. In reality, this person had the $4 a month toothpaste and floss costs, but lacked personal responsibility and life skills. Since subsidies of any sort, certainly government subsidies, tend to undermind personal responsibility and life skills, Gladwell's "fix" for the problem will only make it worse. The sad fact is that universal health coverage (with dental!) would not have helped this person have better teeth unless it also came with a personal nag who would follow you around and make sure you brushed and flossed every morning and night.

The moral hazard issue in healthcare is a real issue with insurance in general, but "solving" it through "social" insurance isn't a solution at all -- it eliminates the moral hazard by eliminating the insurance. Universal health care takes money from young (healthy) people and gives it to old (sick) people, which to me is not insurance since it does not pool any risk. You can argue strongly the other way since plenty of us need medical care because we get unlucky, but healthcare dollars in the US are spent on extending the lives of very old, sick people by a week or so, so to me the true risk-sharing benefits are swamped by the straight generational transfer, but I can see both sides.

I was dissappointed that Gladwell did not discuss the two, larger issues in healthcare spending -- research and rationing. It is a fact that the rest of the world freerides on American's investment in modern medicine. Canada enjoys the drugs America discovers, but does not pay for that discovery. To the extent that universal health coverage reduces the incentive to invent new drugs and treatment, it is simply a transfer of welfare from future generations to us. I understand why this is politically possible and good for us, but I don't see why this is good per se. I would like Gladwell to discuss why grandchildren, and great grandchildren should have less healthcare than they would get otherwise.

Secondly, any discussion of healthcare boils down to rationing. There is a finite amount of healthcare and it has to be rationed. The arguments Gladwell included on this topic were the second lamest thing in the essay (the upfront section on teeth was the first lamest):
“Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?”
But the issue is not "do I go to the doctor or do I play golf?" The issue is "do we keep this 98 year old senile, hypertensive, demented woman alive even though she's just had another heart attack" and "do we try to save this 9 week premature baby alive even though it will have developmental disabilities throughout it's life, if it even survives". These are really hard questions -- the rest of the world rations through queueing and so lets the old demented women and premature babies die (care never gets to them in time) but in the US, since we ration through willingness to pay, we get to decide. Lucky us.

Any serious discussion of healthcare must focus on rationing and how to get people to take better care of themselves. It must answer who does not get healthcare, and how we can get people to eat better, excercise more, and yes, brush their teeth regularly.

Updates More reactions to this on Marginal Revolution. They don't seem too impressed either. Arnold Kling mentions it, and get's a great comment (4th one down). I guess you can't open an article about dental hygeine and then argue for a British style national health service without making people snicker.


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