Powerful prescription

Proponents of the Affordable Care Act (ACA, aka Obamacare) operated high on “the ladder of abstraction,” as some poor writers and preachers do. That’s why Nancy Pelosi and others said it wasn’t necessary to read the bill before voting for it: They were suite-level politicians voting for an abstract idea, not a program with counter-productive details at street level.

John Goodman in Priceless: Curing the Healthcare Crisis (Independent Institute, 2012) illuminates the abstract engineering ideal that animated ACA proponents. For example, Harvard medical school professor Atul Gawande argued that American medicine “can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance.”

When are government offices—think post offices and departments of motor vehicles—ever finely tuned? And when they try fine tuning, the result often is ludicrous. For example, Medicare does not let the market set prices, and instead tries to establish the precise value of every medical intervention. Medicare’s codebook, ICD-10, has 96 different codes for bites, including three different ones for being bitten by a squirrel (initial encounter, subsequent encounter, sequel), and six different codes for being bitten by a rat or mouse. It includes codes for injuries in art galleries, squash courts, nine locations in and around mobile homes. It has different codes for injuries on a merchant ship, passenger ship, fishing boat, sail boat, canoe, and inflatable boat.

Priceless repeatedly shows that what on paper seems well-engineered does not work out as planners had hoped. Medicaid coverage looks generous on paper but in practice limits access of the poor to medical care. (See “Medical care circus,” Feb. 25, 2012.) The healthcare regimes in Canada or Britain are also slow to provide care for those who aren’t rich. People sometimes pay less, but they pay far more in waiting time, and sometimes that wait is fatal.

Medicaid coverage looks generous on paper but in practice limits access of the poor to medical care.

Goodman contrasts that engineering approach with an “economic approach” that emphasizes individual decision-making. The operative word for Chapter 10, for example, is freedom: He writes of “freeing the doctor … the patient … the employee … the employer … the nontraditional workplace … the uninsured … the kids … the parents … the chronically ill … the retirees.”

Goodman has many insights: In this issue, you’ll see our recent interview with him. He’s right about the need to improve the supply of medical personnel by providing additional incentives, rather than smothering doctors in bureaucratic reporting that kills for many the reason they originally entered medicine: to help others.

That desire to help makes it possible to supplement Goodman’s economic analysis with an emphasis on charity for those who have lost out in the market economy but are still creatures made in God’s image. That’s why we should be looking to strengthen the more-than-1,000 independent charity clinics in the United States that WORLD reported on in our Sept. 22 issue. The next issue will have the second half of our report.

Bad calls

Another healthcare book, Marty Makary’s Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care (Bloomsbury, 2012), shows that hospitals can be dangerous places because of a medical corps that sometimes “leaves surgical sponges inside patients, amputates the wrong limbs, and overdoses children because of sloppy handwriting.”

If this level of detail leaves you depressed, I hope you enjoy the baseball playoffs and World Series. During commercials I’d suggest reading The Baseball Hall of Shame by Bruce Nash and Allan Zullo (Globe Pequot, 2012), which has 200 weird stories from more than 100 years of baseball. The book builds up to a chapter on “anger mismanagement” that describes pitcher Burleigh Grimes throwing a beanball at an on-deck hitter, Frank Lacorte being so distraught over a poor pitching performance that he set fire to his uniform, and fielders arguing with umpires as runner after runner scored. —M.O.