If you look at the health care policies favored by liberals and the health care policies favored by conservatives, here's the general difference: Conservatives believe the decision-maker in health care is the consumer. Liberals believe it's the doctor. And so conservative policies try to change consumer behavior. Liberal policies try to change doctor behavior.

That's why conservative policies tend to focus on how individuals pay for care: High deductible health care plans, for instance, make consumers spend more out of pocket, and so they're more price sensitive, and in theory, more careful. Single payer health care and other versions of the "global budget" theory change the way providers are compensated (overprescription means underpayments), and so, in theory, change the behavior of doctors. And a new Kaiser/NPR poll shows why this might be important:


You could argue that that question is flawed: Most people haven't been prescribed anything of any seriousness in the last two years. It's a bit like asking the population at large whether Microsoft Vista has crashed on them. The majority will say no, but then, the majority don't use Microsoft Vista. My sense, however, is that the poll is getting at another issue: Do you think your doctor would ever do such a thing? And most people don't. That matters. If my doctor prescribes a useless MRI, I have no way of knowing the MRI was useless. Patients can't easily check their doctor's work. Background skepticism is most all that matters. And very few patients want to be skeptical about their doctor. That's a worry they just don't need.

But that makes it hard to see how you control costs on the patient side. You can make it harder for them to afford care. But they're not going to know which care to skip. Which gets to the common liberal argument that we should change the payment structure that pays doctors more when they prescribe more care and also give doctors more evidence so they have a better idea of what care they should prescribe. But liberals shouldn't foll themselves. Neither solution is popular. For instance:


Honestly, I'm surprised patients even have an opinion on that. And it might be a very weak opinion. But for now, the public prefers that doctors get paid for each thing they do than on a salary basis. They prefer, in other words, that doctors have an incentive to do more rather than do less. Nor does it seem like the American people are particularly interested in implementing the findings that emerge from cost effectiveness studies:


This, I think, gets back to the need to change the behavior of doctors rather than consumers. Patients mainly know to ask for what their doctors tells them to ask for. That's a bit less true in the age of WebMD. But their underlying tendency is to want everything done, no matter the cost, no matter the evidence. A conservative would say that that's because they don't feel the cost. If they did, they'd be quicker to demand the evidence. A liberal would say that people don't worry about cost when they're dealing with their daughter's life. They largely offload decision-making to the doctor, and so the key is that the doctor has appropriate incentives and evidence to help them make wise decisions rather than to enable desperation.

Either way, one thing worth noting is the degree to which no one in the system currently has an incentive to control costs. Doctors and hospitals pass unlimited costs onto insurers. Insurers pass those costs onto employers. Employers take those costs out of wages. And individuals don't know their missing wage increases are a product of their health care costs. You're never going to control costs if you can't break some portion of this chain.

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