The Health Care Trilemma

Too often people throw themselves into the weeds of health care debates without stepping back to think through what the point of health care even is. Identifying effective policies requires understanding what it is people want when they consume "health care." They certainly don't just want health care. They want what they believe health care will give them. So far I can identify a few items people are looking for when consuming health care:

1) death prevention

2) improving quantity of life 

3) improving quality of life

Death prevention occurs when someone has a sudden onset of an illness that will kill them relatively quickly if not treated. Some examples are a heart attack, cancer, or the severing of an artery. If these are not treated quickly, the patient will die. Some cases are fairly easy to treat by an expert, while others involve probabilities. Some treatments may even hasten one's death if they do not work. However in situations in which it is clearly life or death people will try anything. 

One issue in death prevention is knowing when attempting to prevent death is not worth it. This is an emotional issue obviously, because most of us, all else being equal, would rather try something, even if the probability is very small, rather than just sit by and die (or watch a loved one die). The tricky part here is that the "all else being equal" is simply never the case. Often one's death can be made to be much more peaceful with palliative care, while actively (and often futilely) trying to save their life may incur more unnecessary suffering on the patient and the patient's family. 

Medicare is involved in a large percentage of death prevention (given that it essentially insures the entire American elderly population). One sinister aspect of Medicare, as noted by law professors David A. Hyman and Charles Silver in Overcharged: Why Americans Pay too Much for Health Care, is that Medicare will pay anything for the latest and greatest treatment, no matter how improbable, to try and save a life, while it will not pay out a single penny to help the patient die in a peaceful way with their family, avoiding the unnecessary pain and false hope that often results from such late stage interventions. 

Improving quantity of life occurs when someone goes to a health care professional to receive advice and potentially treatment to lower the probability of experiencing an episode requiring death prevention. Or in other words, its when we attempt to extend our life expectancy. This can come in the form of changing one's diet, or going on a prescription (say for statins) to lower the chance of incurring some sort of illness. As an example, statins lower cholesterol. People go on statins believing that lowering their cholesterol will reduce their probability of experiencing a heart attack.

This part of health care gets trickier. There is simply no limit on the things one can do to try and improve your life expectancy. Some things are obvious. An obese person will clearly gain a great deal in life expectancy if they slim down to a more normal weight. However, all possible changes in diet or in medications or lifestyle involve tradeoffs that may hurt quality of life.

Improving quality life occurs when someone goes to a health care professional to receive advice and potentially treatment to increase their quality of life. Mental health professionals are possibly the most obvious example of this, but I would argue plastic surgery can fall into this category as well, along with medications to treat chronic pain. As with improving the quantity of life, there is simply no limit on what one can do to improve your quality of life. Interestingly, some of these treatments contain a small risk of experiencing a life threatening episode (just listen to the warnings on any medication advertisement on tv). Most vividly, anti-depressants in some cases are associated with an increased probability of attempting suicide. 

The most interesting tradeoff here is between quality of life and life expectancy and the probability of experiencing a life-threatening episode. Certain policy interventions are often justified on the grounds that they will increase life expectancy. If we ban large sodas, people will drink less soda, and thereby live longer. If we ban fast-food, people will eat healthier, and thereby live longer. Lets assume these statements are true, which isn't obvious in themselves because we don't know what behavior people will substitute in (as an example, limiting oxycontin prescriptions likely drove many people to the black market, increasing deaths because people are using stronger, riskier substances). Ultimately, people have different preferences. Some may prefer to live a shorter life in return for greater happiness now. There is an unstated assumption in such policy proposals, and that is that people making such choices would be just as happy in a world in which their choices were constrained. This is a large claim, and not at all obviously true (or false). 

The other interesting tradeoff isn't quite as obvious. Its between all three, and it involves cost. Any intervention into any of these three involves costs and benefits. Some interventions may even pay for themselves (in a sense). As an example, vaccinations dramatically reduce the probability of premature deaths from various conditions such as Hepatitis, Polio, Tetanus, etc. These cost relatively little, and the saved lives can later contribute to the economy, and therefore are a huge net positive from a cost-benefit standpoint. One can argue of course that they diminish quality of life for the children, but to me anyway, thats fairly unconvincing given the massively reduced risk of premature death or life-long disability (such as in the case of polio). 

Other interventions may extend life expectancy, such as incentivizing the obese to eat healthier, and may even reduce their expenses in the short run. However in the long run these people may actually cost more exactly because they did not die prematurely. From a coldhearted public accounting standpoint, the ideal time for someone to die is just when they retire.

So when individuals are deciding to consumer health care, they are really deciding to consume services that may prevent death, reduce the probability of experiencing a life-threatening episode, or increase their quality of life. Lumping everything into one basket called "health care" can be misleading, and its important to understand the different tradeoffs involved in these different decisions, whether as an individual consumer, or as a policy analyst making recommendations as to what public health care expenditures should be spent on.