6 Lessons in Healthcare Mythology
Exaggerations, Half-truths, Non Sequiturs, and Falsehoods in Policymaking
This month, I’m speaking to a group of healthcare policy fellows, and I’ve structured our time together as six mini-lessons. I thought I’d share their required and optional pre-readings with Bastiat’s Window readers, supplemented by a bit of narration. The required readings are short and easily readable for economists, medical personnel, or laypeople with no background in health or economics. Optional readings include short articles, longer articles, and academic papers. At the end, I recommend four excellent books for understanding contemporary healthcare policy issues. I suggest tackling the required readings first and then reading the optional stuff when you have time on your hands.
From 1999 to 2017, I taught the economics and ethics of healthcare at five different universities, and my overriding theme throughout those years was, “Always be skeptical.” Healthcare policy debates tend to be drenched through-and-through with myths, opinions, and politics—all masquerading about as scientific facts. As a result, we miss opportunities to work together constructively and to increase the quality and quantity of care available to society. The readings below identify six areas where mythology often drives policy debate in unproductive directions. The readings also offer alternative pathways to pursue.
[1] Healthcare isn’t all that “different.”
[REQUIRED] “Defying Gravity” (Robert Graboyes). “For over a century, we've regarded health care as qualitatively different from other goods and services—an analytical Oz, where the normal rules of economics don't apply. In doing so, we waste resources, keep prices artificially high, and delay life-saving and life-improving technologies.”
[OPTIONAL] “Uncertainty and the Welfare Economics of Medical Care” (Kenneth Arrow). Arrow’s 1963 paper argued that certain institutional features in healthcare (e.g., domination by nonprofits, insurers as intermediaries, consumer ignorance) make healthcare qualitatively different from other economic sectors. I argue that the differences Arrow described are artificial conditions created by 20th century laws and regulations.
[2] Healthcare policy debate is heavily driven by myths.
[REQUIRED] “The Din of Healthcare: Myths and Maybes” (Robert Graboyes). I wrote, “There are widely held propositions, perceived as truths, which are (or may be) exaggerations, half-truths, non sequiturs, or outright falsehoods. Many are accepted by the political left, right, and center, as well as by political agnostics. They lead policymakers into futile efforts to solve problems that don’t exist and to ignore problems that actually do.”
[OPTIONAL] “Who's Fooling Who” (Glen Whitman) and “The Worst Study Ever?” (Scott Atlas). Whitman and Atlas effectively debunk the World Health Organization’s World Health Report 2000, which famously claimed that the U.S. healthcare system ranked only #37 in the world—just below Costa Rica and just above Slovenia and Cuba. The report remains enormously influential, even though its methodology and execution were so abysmal that some of its top-ranked editors publicly refuted it. If you have time, “Fifty-Million-Dollar Baby” (Robert Graboyes) tells some ways in which health policy analysts should always retain an air of skepticism.
[3] Excellent writing & credentials do not imply truth.
[REQUIRED] “Another Side of Atul Gawande” (Greg Scandlen). Scandlen gently debunks a highly acclaimed, wildly popular article by Harvard’s Atul Gawande—focusing on healthcare prices in McAllen and El Paso, Texas. As Scandlen wrote, the paper purported to show that “physicians are greedy and need to be controlled by bureaucrats.” He argued that, despite excellent writing and impressive credentials, Gawande had produced “a poorly researched article” that relied solely on Medicare data and failed to account for unique conditions” in McAllen.
[OPTIONAL] “The Cost Conundrum” (Atul Gawande) is the article that Scandlen critiqued. I also recommend a second post,“Gawande’s Kitchen” (Greg Scandlen), which critiques another influential Gawande piece. (Note: Scandlen wrote “Gawande’s Kitchen,” though the website mistakenly lists John Goodman as the author.) I particularly enjoy Scandlen’s metaphor involving patients and slabs of meat on the griddle.
[4] Some healthcare trends don’t result from healthcare.
[REQUIRED] “From Strings to Sutures: What String Quartets Tell Us about Healthcare Prices” (Robert Graboyes). I write that, “American healthcare prices are high and rising, but a big part of that trend doesn’t have much to do with healthcare. Hence, governments commanding prices to head downward will likely enjoy as much success as Canute had commanding the tides to recede.”
[OPTIONAL] “The Price Is Right” (Peter Laakmann). Laakmann offers an eloquent explanation of the phenomenon I describe.
[5] Beware of “The Data.”
[REQUIRED] “How Is an Emergency Room Like a Monkey Wrench?” (Robert Graboyes & David Goldhill). Conventional wisdom says that the emergency room is the most expensive place to get care. David and I argue that you can posit just as plausibly that it’s the cheapest place to get care.
[OPTIONAL] “Experts with Statistics: Chimps with Machine Guns” (Robert Graboyes). Experts armed with statistics can be dangerous as hell. This article provides some examples to keep in mind. A couple of the examples ought to terrify you.
[6] Maybe we’re having the wrong debate.
[REQUIRED] “Fortress to Frontier” (Robert Graboyes). In this 4-minute video, I argued that the traditional left-versus-right argument in healthcare is misleading—that we ought to focus more on delivery systems and less on insurance particulars.
[OPTIONAL] Fortress and Frontier in American Health Care (Robert Graboyes). This is the monograph which the video summarized.
Lagniappe
Further Readings for the Truly Ambitious
For those who would like to take a deeper dive into healthcare policy, I’ll recommend the following books:
The Innovator’s Prescription: A Disruptive Solution for Health Care (2010). Clayton Christensen, Jerome Grossman, and Jason Hwang, wrote this pathbreaking book that introduced the concept of disruptive innovation into healthcare. (Christensen and his collaborators first formulated the concept of disruption around 1995). This book tells why we don’t get cost-cutting innovation in healthcare and how we can do so.
Catastrophic Care: How American Health Care Killed My Father—and How We Can Fix It (2013). David Goldhill, whose background is in business, wondered why his father needlessly died from a medical error in a highly rated hospital. He set out to find the answers and, in doing so, produced an intimate and penetrating analysis of where American healthcare goes awry and how it can be improved.
Priceless: Curing the Healthcare Crisis (2012). John Goodman asked where conventional healthcare analysis goes wrong and how we can improve the healthcare system. While he writes for the more conservative end of the spectrum, his book received acclaim from observers across the political spectrum.
Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again (2019). Eric Topol explores the ways in which AI might improve the practice of healthcare—and also offers some caveats related to overconfidence in technology.
Robert F. Graboyes publishes Bastiat’s Window, a Substack journal of economics, science, and culture—with an emphasis on healthcare. He is a health economist, journalist, and musician in Alexandria, Virginia, and holds five degrees, including a PhD in economics from Columbia University. In 2014, he received the Reason Foundation’s Bastiat Prize for Journalism. His music compositions are at YouTube.com/@RFGraboyes/videos.
Are the articles referred to on this site? Do you have to go searching to find them?
Interesting matter.
Lola Murray
A cornucopia of useful information.
You sure rely heavily on that Graboyes fella, though.