[EAS] Health Care Costs -- What's Missing in the Debate

Peter J. Kindlmann pjk at design.eng.yale.edu
Sat May 30 15:31:15 EDT 2009

Dear Friends and Colleagues -

With shock I realize that it has been almost 
three months since my last mailing. A few of you 
have inquired after my health. All is fine, I'm 
glad to say.

I've been on a photographic project of the long 
abandoned Bigelow Boiler Co., on River St. in New 
Haven, CT, and also using this subject matter, so 
different from my usual landscape photography, to 
explore different aspects of printing. I'll tell 
you more about that soon.

While on the subject of health, let me recommend 
the finest article on health care costs I've read 
to date, by Atul Gawande, in the current New 


"Providing health care is like building a house. 
The task requires experts, expensive equipment 
and materials, and a huge amount of coördination. 
Imagine that, instead of paying a contractor to 
pull a team together and keep them on track, you 
paid an electrician for every outlet he 
recommends, a plumber for every faucet, and a 
carpenter for every cabinet. Would you be 
surprised if you got a house with a thousand 
outlets, faucets, and cabinets, at three times 
the cost you expected, and the whole thing fell 
apart a couple of years later? Getting the 
country's best electrician on the job (he trained 
at Harvard, somebody tells you) isn't going to 
solve this problem. Nor will changing the person 
who writes him the check.

This last point is vital. Activists and 
policymakers spend an inordinate amount of time 
arguing about whether the solution to high 
medical costs is to have government or private 
insurance companies write the checks. Here's how 
this whole debate goes. Advocates of a public 
option say government financing would save the 
most money by having leaner administrative costs 
and forcing doctors and hospitals to take lower 
payments than they get from private insurance. 
Opponents say doctors would skimp, quit, or game 
the system, and make us wait in line for our 
care; they maintain that private insurers are 
better at policing doctors. No, the skeptics say: 
all insurance companies do is reject applicants 
who need health care and stall on paying their 
bills. Then we have the economists who say that 
the people who should pay the doctors are the 
ones who use them. Have consumers pay with their 
own dollars, make sure that they have some "skin 
in the game," and then they'll get the care they 
deserve. These arguments miss the main issue. 
When it comes to making care better and cheaper, 
changing who pays the doctor will make no more 
difference than changing who pays the 
electrician. The lesson of the high-quality, 
low-cost communities is that someone has to be 
accountable for the totality of care. Otherwise, 
you get a system that has no brakes."

If the New Yorker URL has gone stale by the time you read this, email me.

All best,  --PJK

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