The Problem With Talking About Health Care

This comment to my last post is so central to the debate about health care issue that I had to share it:

I'm not sure I wholly understand the argument here.

The idea is that were the government to make some cost-benefit analysis and decide this drug didn't give enough of a benefit to be worth paying for, that would be a bad outcome, yes? How would this differ from a private insurance company making the same choice?

In both cases individuals able to raise the money through outside means would be able to purchase the drug anyway.

No offense to the commenter who I'm sure is a fine and clever human being.  But: huh?  I write a post on why superficially bad sounding tradeoffs--$3,500 a month for an extra 12 days of life--might actually be good uses of money.  I tried, and I thought succeeded, in keeping the debate entirely on the terms that progressives looking to build a CER agency with some power would be interested in.  And I nowhere mention whether this would be better or worse if a private entity were doing it.  

I mean, I think that, to a much greater extent than most liberals think, insurance companies have largely dealt with this problem by throwing up their hands and erring on the side of approval, which is why health care costs are going up so fast.  But one could certainly argue that private insurers are going to have to crack down harder on this stuff soon.  Or turn it around and say that the public insurer is not going to bother, no matter how much Peter Orszag devoutly hopes otherwise, so that this is moot--an argument I actually find rather compelling.  But I did not comment on the relative awesomeness of private versus public, because regardless of their comparative fabulosity, a public agency is probably a more useful thought experiment to discuss the question Julian asked, which is the limits of the treatments that we think people have a reasonable right to.

It seems almost impossible to get anyone to engage in this kind of discussion.  As I replied to him, you have to try to enter an imaginary thought world where not all discussions are instrumental in some larger argument about the level of government intervention in the economy.  Where it is possible that I am not simply attempting to subtly maneuver my opponent into accidentally embracing my position so that I can jump out from behind a tree and scream gotcha!  Where one might simply hear Julian Sanchez ask whether we really want to guarantee access to an expensive cancer drug that buys a modest increase in lifespan, and want to explore the reasons that you might answer, "Yeah, maybe." 

But I wasn't concern trolling, or trying to set up a gotcha.  I'd be genuinely interested to know how Ezra thinks those questions should be addressed, and not because I think that his answers will be stupid, or provide some launching platform from which I can attack the left.  I simply think Ezra's answer is likely to be smart, nuanced, and interesting. 

Personally, I'm not that interested in addressing them as a policy matter, because I am one of the few commentators who just doesn't think that cost growth is all that important--it may be a political problem, but it is simply not true that the economy cannot handle vastly greater expenditures on health care, provided that our incomes continue to grow.

But if we are going to address cost control as a major policy issue at either the public or private level--and given that I'm in a minority, this seems like an eventuality we should prepare for--then I'm certainly interested in how we go about it.  So I thought it was worth exploring why days of life is not the simple metric it sounds like when you're reading a New York Times article, rather than talking to a patient about their very short future.  That's all.  Sometimes a blog post on cost-benefit analysis is just a blog post on cost-benefit analysis.