The Price We Pay

What Broke American Health Care--and How to Fix It

[Amazon Link]

I was tempted into getting this book via the author's appearance on Russ Roberts' EconTalk podcast back in Februrary. (I would have gotten to it before now, except for the Portsmouth Public Library's extended Covid-19 shutdown.)

Marty Makary, a doctor affiliated with Johns Hopkins, describes various ways that "we" (as taxpayers, health insurance customers, and/or patients) are being gouged by the health care system.

  • Some hospitals have "list prices" for their services that are stratospherically higher than normal; not only do they gouge, they go after slow-payers aggressively with collection agencies and garnishments.
  • "Health Fairs" that are setups to steer unwary attendees toward expensive and unnecessary services.
  • Surprise billing for participants in your care who are "out-of-network".
  • Ground and air ambulance services are notorious overchargers.
  • Some OB-GYNs aggressively seek out women in labor and persuade them to get unnecessary (but lucrative) cesareans.
  • Doctors (through greed or ignorance) gravitate toward more expensive procedures, out of whack with prevailing practices in their fields.
  • Doctors overprescribe, especially opioids. Probably that's less of a problem these days. But Makary admits do doing it himself, out of ignorance.
  • Middlemen, like pharmacy benefit managers (PBMs) and "group purchasing organizations" (GPOs) can skim, and sometimes a lot more than "skim".

And I got tired of typing, so I'll stop there.

Makary's style is informal, first person, often reporting in detail about his research interviews ("I landed at the Omaha airport and immediately saw a big Omaha Steaks shop in the airport terminal.") Hence, the book is largely anecdotal. That has pluses and minuses. Plus: the stories are grabby and rage-inducing. Minus: there's not a lot of quantitative data. For example, he (sensibly) thinks kickbacks from pharmaceutical manufacturers to PBMs should be banned; but how much would that save? Big problem, medium, or tiny?

Markary is also kind of weak (imho) on the promise made in his subtitle: how to fix it. The basic problem (to which he alludes over and over) is that health care doesn't work like a market. To a first approximation, the reason is pretty simple: someone else is paying, not the consumer. Consumers are insulated from the gory details, and so why should they care about the vast sums flying around that they never see?

Of course, they're paying. Sort of. Through paycheck deductions, mostly. But they have little control over that.

But Markary doesn't go so far as to advocate radical free-market reforms. And I don't think he even touches the over-regulation and over-licensing in the field.

My deep thought about why market reforms aren't coming to health care: we don't want them.

Markets are wondrous mechanisms, but there's one nasty fact: they will provide some things you can't afford.

We don't worry about that in most areas. Can't afford filet mignon? Fine, I'll grab the sirloin on sale. Can't get a Tesla? Honda Civic, baby. No problem.

But with health care, we want the best. We are entitled to the best. And if we can't have the best, then our inner egalitarian takes over: if I can't have it, then nobody else should have it either.

That's ugly, but very understandable. And that's why we can't have nice things.

ADDED slightly later: Markary blames doctor overprescription for the increase in opioid overdose deaths. I don't buy that. See, for example here.


Last Modified 2020-07-08 10:57 AM EDT