James Hamblin writes about the Cuban health system in The Atlantic:
Cuba has long had a nearly identical life expectancy to the United States, despite widespread poverty. …
As a poor country, Cuba can’t afford to equivocate and waste money on health care. Much advanced technology is unavailable. So the system is forced instead to keep people healthy. This pressure seems to have created efficiency.
It’s largely done, as the BBC has reported, through an innovative approach to primary care. Family doctors work in clinics and care for everyone in the surrounding neighborhood. At least once a year, the doctor knocks on your front door (or elsewhere, if you prefer) for a check-up. More than the standard American ritual of listening to your heart and lungs and asking if you’ve noticed any blood coming out of you abnormally, these check-ups involve extensive questions about jobs and social lives and environment—information that’s aided by being right there in a person’s home.
Then the doctors put patients into risk categories and determine how often they need to be seen in the future. Unlike the often fragmented U.S. system where people bounce around between specialists and hospitals, Cuba fosters a holistic approach centered around on a relationship with a primary-care physician. Taxpayer investment in education about smoking, eating, and exercising comes directly from these family doctors—who people trust, and who can tailor recommendations.
A rather different approach to the problem of competition between nations. It used to be that humanity spent a lot of time and lives invading other countries and taking them over. That was our “keeping up with the Jones'” analog – or perhaps it’s the other way around. Nowadays, though, rather than depending on God to show the superiority of the ideology of the Motherland, now we compete on statistics: life expectancy, GDP, percentage of adult population with a college degree, to name a few.
And it appears Cuba takes this all very seriously, with a result that that they are comparable to US results in healthcare while spending about 10% of Americans per capita per annum. It’s quite impressive, of course – but to an American, to think that you’ll have a primary care doc assigned to you based on your neighborhood will seem the height of anti-Americanism – where is our choice! we shout, even as diseases we would never choose assail us. Indeed, we often choose not to visit a doctor or dentist for years at a time, convinced that we’re healthy – we talk about it at McDonald’s while eating the fad of the month, after all.
So the USA tries to compete on healthcare using a system that is seriously broken compared to a rational system like Cuba’s. And, so long as we value choice over statistics, we never will win. At least not until someone comes up with the magic pill that solves everything at a dime per dose. (Anyone remember Carter’s Little Liver Pills?)
So we should work on being honest, instead. Rather than insisting we have the best health system in the world – it’s only the most expensive – choice should be emphasized, even fetishized. And then personal responsibility should be part of it, too. Not taking care of that diabetes? Hmmmmmm. You’ll look great in this commercial.
But don’t put any money down on winning that “best healthcare system in the world” bet. Our results will never prove it.
A point unhighlighted is that of knowledge. There is a an underappreciated facet of the fetish of capitalism, and it is that certain intangible resources are infinite: time & knowledge come to mind. When it comes to capitalism & healthcare, there’s an assumption that, of course, there’ll be time to sort out which hospital offers the cheapest service, and that you’ll have time to take advantage of that – which leads me to wonder if I want healthcare that competes on price? This is not a whimsical afterthought, as the latter might be an example of the problem of knowledge, in this case that the domain of knowledge best applied to the problem of selecting medical services; Mr. Weissman’s proclamation that forcing hospitals to publish price lists will fix the entire healthcare problem is, I fear, naive. Only fools select product solely on the basis of price unless the question of quality is not relevant to the product, but sometimes the domain to apply can be unclear.
The Cubans, for all that they appear to be using coercion, are achieving greater efficiency by putting the most knowledgeable in charge of the effort: the primary care physician, who best knows medicine in at least the neighborhood, sees the entire neighborhood on a regular basis, and apparently tries to be as proactive as possible. I fear that American citizens, made up of mostly amateurs and in charge of their own health, will never match the efficiency of Cuba.
WHICH leads to the pivotal question: efficiency or liberty? The latter is one of our most sacred words, but this scenario should be a teaching moment, that no particular concept will ever have universal applicability. As we watch the GOP disassemble the ACA, aka Obamacare, an institution which has already shown greater efficiency than our free markets (another sacred word) on, at least, the statistic (twitched didn’t you?) of percentage of the population insured, it’s worth keeping in mind that society is not a machine that will always run better if only it’s lubricated with the sacred oil, blessed by God or by the proper economists, who are often treated like gods – although why the Kansan GOP elite wants to worship a fellow named Laffer leaves me a trifle nonplussed; but I should be gentler, as they’ve already made their fellow Kansans pay the price for their foolishness.
Society, whether American or not, is not some perfect machine which merely needs a bit of the proper oil now and then, but rather a creaking pile of rivets and gears, mismatched and rusty, shiny but soft metal so easily bent, predicated on assumptions concerning the needs of society that have never been well thought out, thinking that the inhabitants are rational creatures with reasonable information about the world. Yet those creatures, poor and slack as they are, rarely reach those standards, and so we see domestic violence; deceit; medical needs unmet by private corporations; frightened people deprived of their guns; people frightened of neighbors with guns; patronization on the left, met by equal force of loathing and ignorance on the right, making for a soup with a hell of a punch; & etc.
If it all worked so well, we wouldn’t have prisons.
As engineers know, you can’t have all the bells and whistles. You can’t use a Ferrarri to tow broken-down tractors back to the repair shop. We can decide to have choice, but we should know the price: replicated effort, emergency room visits for preventable illnesses, lives lost due to incompatible records; poverty; etc.
Or you can enforce systems which save more lives, at the cost of losing choice, losing liberty; and that’s the up-front costs. Libertarians worry about development of new meds if prices are government controlled, and the fear is not unreasonable. But then, it’s not clear that the free market is doing particularly well even now. But lack of choice obviates the advantage of the privileged, to some extent, and what if you’re stuck with the incompetent? Choice puts pressure on such people, to improve or get out; without choice, I would wonder if the governmental mechanisms would be strong enough to force them out.
Give me liberty! Give me efficiency!
I doubt you get to have both.
