From people who subscribe to Marxism, I oftentimes hear about healthcare being "commodified" in the U.S. They believe that healthcare is a human right, and that it is somehow immoral to put a monetary value on human life. They claim that it dehumanizes both doctors and patients, and converts what should be a "public service" into a corporate relationship.
As an example, it is cited that performing a procedure is more profitable than communicating with or counseling patients for an entire day; hence, the shift from patient-centered care to disease-centered care. The patient is "objectified" as a "medical problem" that needs to be "fixed." Thus, the patient qua person is alienated from his body.
Here's one argument from a physician decrying the market model of healthcare:
Given the unique characteristics of the medical field, to what extent is the Marxist claim correct? Don't people become doctors to serve the public in the first place?
On a side note, I've noticed a trend in Marxian arguments: why do Marxists use words such as "commodification","alienation", "objectification", and "medicalization"? These words always seem to have a negative connotation, but I don't know why.
One of the enormous ironies of Marxists is their (apparent)1 utter cluelessness of their defense of the unempowered. Their premise, of which this healthcare argument is only a specific example, is that some people are at an economic disadvantage in reference to other people. This represents disempowerment and exploitation and the irony is this: to fix this perceived lack of empowerment on the part of the individual, we will now make that same disempowered individual face the same issue with economic power AND political might joined in opposition to his ends. And, as with all other species of this false premise, the object is not the empowerment of the poor individual, but to use that same poor individual as the pretext for seizing power over his very life. 2
As an example from history, look at the takeover of educational financing by the government. In the late 1970's and early 1980's the Left and their useful idiots were making the same points about education that this statist doctor is making for medicine. Specifically, that one did not have a choice but to get an education if one were to succeed in life particularly given the disparity in income between those who were college degreed as opposed to those who were not; that a student was ill-prepared to judge the quality of education he would receive in relation to its expense; and that the possibility of finding jobs after the education was complete was problematical in regard to these previous points. Oh, yes, and that going to school while working part-time to pay for it was a huge financial and mental burden on the student. Government financing through loans and grants and the like would "solve" these problems.
While there are numerous problems with the medical system in the United States, characterizing it as a model of Free Market Healthcare is as fundamentally dishonest as claiming that the system of higher education - with the astronomically high percentages of state institutions and government funding - is a Free Market Educational System. The non-essential difference is that in the first, we have opted for a Fascist form of collectivization with a nominally private 3rd party payer system, whereas in the second, we have opted for a Socialist form of collectivism with, until recently, a Fascist form of 3rd Party payer (through gov't programs administered through private banks) until that was obviated by the direct takeover of the student loan system by the government.
And in both systems, we have prices rising far faster than inflation and dubious and obscure outcomes regarding the quality that that increasing amount of money can buy.
Now regarding the commoditization of medicine; I'm with Mr. Perkins here in saying that that is a "consummation devoutly to be wished." And it ties in with two real world phenomenom that we can look to for comparison.
In the first, the example of commoditization provided the cosmetic and lasik medical fields versus the illness and eyeglass medical fields. At one point in time, cosmetic surgery, and briefly, lasik surgery were only for the very wealthy - socialites and Hollywood actors and the like. But because there was no 3rd party payer system, consumers at the margins exerted downward competitive pressures that impelled the suppliers of these services to seek efficiencies to remain competitive. And now cosmetic surgery is relatively inexpensive and widely sought. The same with lasik where prices for the procedure continues to drop and quality rise, while in the traditional eyeglass industry - which some insurance plans pay for - the prices do not. Is anyone going to seriously argue that grinding composite lenses is more fraught with complications than carving on the eye itself? Then what accounts for the difference? Absent 3rd Party payer, economic incentives on both the consumer and producer do.
The second example is to be found in disaster relief. In those places where "price gouging" is outlawed, commodities necessary to the recovery are delayed in getting to the places needed most. And with commodities, perforce, at the same price level as prior to the disaster, consumers do not need to weight their actual requirements against their resources; thus commodities are snapped up in short order leaving those a little further away with no supplies and no recourse. And suppliers, faced with the additional costs (such as airlift, road clearing, security forces, etc.) of reaching those needing the commodities being legally barred from recouping those costs and risks, there is a huge disincentive to providing those commodities. Thus, the recovery is delayed and people who did not have a prime position to take advantage of those early low-priced commodities are left without.
This is directly analogous to the type of rationing that will occur under a command and control type of medical system, except that the deciding factor will not be geographical proximity but political clout and connections.
And like the "remote investors and senior management [with their] large dividends, hefty bonuses and egregious salaries"3 those people risking their lives to supply these commodities while looking for compensation for their level of risk, will also be decried as "evil."
To address the question of choosing treatments based on efficacy versus cost; this is an attempt to disconnect cause and effect. And it is exacerbated by the structural problems outlined above, ie., that of 3rd Party payer, Fascistic government regulations, discouragement of innovation, and barriers to market entry.
But first, an anecdote. When IBM decided to offer their first PC for sale to compete with Apple, many in the technical community decried their decision to use the Intel 8088 processor. Why? Because while the 8088 had a 16 bit internal bus, it had only an 8 bit external bus and the techies were saying that that was just like a international mega-corp - screwing the consumer in order to make a profit.
When I was at the IBM Walnut Creek center, I had an opportunity to talk to a few guys around the original development team. I asked them about the infamous 8088 decision. I was surprised by how reasonable the answer was.
Certainly, a 16 bit external bus would have made for a faster machine. But given that there had not been, until recently, 16 bit processors, the ancillary chips required for such an external bus would have been about 3 times more expensive than the 8 bit chips which were in easy supply because of the previous success of the Z-80 chip. So even though the margins would have been higher in the 16 bit external bus, IBM opted to swap higher margin/lower volume for higher volume/lower margin. With the end result that PC were affordable for a much larger number of consumers.
So the more expensive treatment is not always the superior treatment when the full context is taken into account.
Generally speaking, innovative treatments ARE more expensive and their efficacy is not always clearly proven and they do not have a track record to draw on for clinical use. Insurance companies are conservative; this is not a criticism, but a question of identity. They have to be conservative to stay in business and provide the services contracted. The problem is not with the insurance companies as such (although there are laws exploited by insurance companies that are a problem) but in how our medical system uses them as a 3rd party payer system for normal expenses instead of a recourse at need for extraordinary expenses.
Now some will argue that medical costs are so high now that even "normal expenses" are prohibitively expensive and thus require insurance, and they are right - in today's malformed system. But let's figure out WHY that has come to pass.
Another series of anecdotes here as I don't know if anyone has done a statistical study on this and I would be grateful if any commenters could point me in that direction.
Prior to the enactment of medicare/medicaid in the 1960's, according to my parents, their circle of friends who were having babies, paid about $300.00 (appx $2100.00 today) for delivery and a 7 day hospital stay. When my younger brother was born, the year after medicare/medicaid, my parents paid $1000.00 (appx $6650.00 today) for delivery and a 3 day hospital stay. Same hospital, same doctor, same kind of delivery without complications. And a 3 fold (6 fold if you count the reduction in days) increase in price. Even early on, these programs were setting up perverse incentives and that was before the various regulatory concretions were put on, layer by layer, until we have what is seen today.
Secondly, although innovative therapies are usually not covered by insurance, they are paid for by those wealthy enough to make the resource expenditure/benefit received at that price workable for them. They also are the ones taking the higher risk of an unproved treatment in hopes that it will work where others have not. And if it is successful, they live. And provide the monetary means and incentives thereby for further innovations in improving the treatment in efficacy and safety.
But in a free market economy, this treatment will not stay the province of the rich. Why? Because, like the IBM PC, more money is to be made by low margins/high volume than the inverse. Look at the differences in historical success, in gross dollars, between Ford, who made cars that the working man could afford, and Bentley, who made cars only for the rich. And, analogously, take MRI and CAT and the various other imaging techniques. They have improved in quality and reduced in price to the point where, prior to Obamacare, some large medical practices were buying their own for their patients' convenience and the practice's own profit. And what is the first thing that seems to occur in gov't systems? The reduction in such capital expenditures. Compare the paucity of imaging resources in Canada versus the US. Can it be sincerely argued that such reductions serve the interests of the patient especially when non-emergency scans show diverging waiting times of 3 hours for the US vs 39 days for Canada?
And given the fact that Obamacare and the Accountable Care Organizations4 will be introducing a direct conflict of interest for the government physician - that is, the physician's advancement and professional standing will turn on his meeting government mandated financial assessments and NOT on his care of the patient, it seems that the Marxist argument about money is turned on its head. How can "[Their] need to nurture a relationship of trust with their doctors on whom they must rely on for their well being and survival" possibly continue in the face of gov't disciplinary action taken against those physicians who do not meet cost cutting requirements imposed by that same gov't? For an example of the mindset that will follow generally in medical enforcement, look at the various prosecutions of pain doctors and patients undertaken by federal prosecutors looking to make their political bones.
I'm not saying that there aren't things to criticize in the American Health Care system pre-ObamaCare. They are legion. But the criticisms are targeting the wrong sector. It is Fascist regulation, transfer and entitlement programs, Rent-seeking by political "entrepreneurs" - including licensing requirements, FDA grants of monopoly on generic drugs5 and the like, and 3rd Party payer systems that had their root in the wage and price controls of World War II.
Now despite the enormous number of concretes that I have cited here, I am not making the practical argument against gov't health care to the exclusion of the moral argument. My purpose was two-fold; to address the specific arguments your quoted physician made and to let those concretes form the inductive basis for my evaluation of the causal chain that has led to the pre-ObamaCare health system. In particular, in footnote 5 I have quoted extensively from the controversy surrounding one instance of Rent-seeking. Look at the bolded portions and connect the causal actions and then look at the equivocations and evasions, the charges of price gouging and profiteering and see from what root cause they proceed. This is not an isolated case. This is happening across the pharmaceutical spectrum but it is "unseen" because most people have insurance that covers their prescriptions and those that don't - absent a popular political cause as is shown in the example - are essentially invisible6 in this public policy debate. And rest assured that, under ObamaCare, it is only the popular political causes that will get exceptions from the draconian approach required by the gov't control of health care.
For, at the root, the moral argument against collectivized health care comes down to these:
1 I say "apparent" because, like Rand, I don't think mistakes of this magnitude are made innocently.
2 “Now I will tell you the answer to my question. It is this. The Party seeks power entirely for its own sake. We are not interested in the good of others; we are interested solely in power, pure power. What pure power means you will understand presently. We are different from the oligarchies of the past in that we know what we are doing. All the others, even those who resembled ourselves, were cowards and hypocrites. The German Nazis and the Russian Communists came very close to us in their methods, but they never had the courage to recognize their own motives. They pretended, perhaps they even believed, that they had seized power unwillingly and for a limited time, and that just around the corner there lay a paradise where human beings would be free and equal. We are not like that. We know what no one ever seizes power with the intention of relinquishing it. Power is not a means; it is an end. One does not establish a dictatorship in order to safeguard a revolution; one makes the revolution in order to establish the dictatorship. The object of persecution is persecution. The object of torture is torture. The object of power is power. Now you begin to understand me.”
3 Yes, some of these "egregious salaries" are in fact egregious. But this comes, not from the operations of a free market, but from the dynamics of a 3rd party payer system and the restrictions on supply and innovation imposed by gov't regulation and the mandates of those same 3rd party payer programs. Notice, however, which economic sector is completely immune to the "egregious salaries" complaint even though the dynamics are much the same. My primary care physician works 14 hour days 6 days a week and makes about 600K per year. Compare that with the Billion Dollar Endowment Colleges and their Million Dollar Presidents. I'm not making the argument from envy here, but pointing out that the argument someone's salary is "egregious" seems to be employed in inverse proportion to political connection and in direct proportion to actual economic value.
4 Does anyone else remember Ted Kennedy railing against the evils of HMO's in the HillaryCare debate? And how the fact that Ted Kennedy authored the legislation that created those same evil HMO's was never mentioned?
The price of preventing preterm labor is about to go through the roof.
And now, the walk-back...
After numerous reports that KV Pharmaceuticals was planning a drastic price increase now that it had obtained sole rights to a drug designed to stop women from going into labor early, the Food and Drug Administration has announced it will not intervene if other companies make cheaper versions of the medicine.
From the Wall Street Journal:
On Wednesday the FDA said a letter sent by K-V Pharmaceuticals to pharmacists suggesting the agency was going to take action against them for making, or compounding, hydroxyprogesterone caproate “is not correct.”
6 As an example, I have chronic auto-immune disease for which I take two primary meds. A few years ago, one of them increased in price 10 fold and I switched to a less effective version that, starting in July 2011, increased 7 fold. The other drug, also in July 2011 increased 3 fold. All of these are generic drugs that have been on the market for decades - in one case for 50 years. Drug makers were handed monopoly rights by the FDA which [ironic voice] "doesn't dictate the prices of drugs they approve." No, they let the monopoly rights that they grant do that for them.