20 Questions: John Hunt, MD

[CaffeinatedSquirrel]

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[Sickness (Not) Unto Death]

First off, this has to be the most interesting as well as inspiring interview I've read on SDN. Especially because I am envisioning a similar sort of dynamic and diverse career as Dr. Hunt.

His comments on the deteriorating health care system, however, compels me to raise some objections. In nationalized health care systems elsewhere in the world (Western Europe, Japan, and of course, Canada) both patients and doctors are reasonably happy with the services. Indeed, their efficiency is indeed demonstrated by much health outcomes in those countries. I do acknowledge that they're by no means perfect (lower physician income, longer waiting time for procedures, etc.) but the numerous evidences are definitely against Dr. Hunt's remark that health insurance itself is the source of the problem. He had a good point on capitalist cronyism in Obamacare, but I still believe that the major flaw with it is in the means employed by the current government, rather than the principle of providing better health care for the population by expanding the insurance pool.

But then again, nationalized health insurance is completely off the table in the U.S. due to political pressures, and that's what (at least partially, indirectly) forced the administration to commit to the second best alternative. Rising health care cost is definitely unsustainable in longer term but there seems to be no clear solution in sight that's politically acceptable AND economically feasible, at least as of yet. So at the end of the day, I do think it is crucial to keep the balance on issues by informing ourselves as well as remaining open to the rationales of the other side. Even more important for those on the formative track, like us.

 

[breakintheroof]

Like you, @Sickness (Not) Unto Death, I found this fascinating. Also like you, what jumps out to me is Dr. Hunt's fiercely libertarian perspective.

"The Moral Hazard of health insurance is the cause of so many of the challenges in health care. Health insurance is the problem, not the solution. Health insurance is the disease that causes health care to be so unaffordable."

I'm curious about this. How would sick, poor people gain access to care without health insurance? Dr. Hunt suggests in the linked post that the replacement should be private charity. There are issues about whether this would be an appropriate replacement, of course, but also, wouldn't that be effectively a third-party payer, and therefore prone to moral hazard as well? This would still be a problem even if prices fell as much as Dr. Hunt believes, as they would never fall enough for the poor to afford necessary treatment. I am not sure this system would be worse than our current one, but I am curious as to how a libertarian addresses this issue.

 

[Lya]

I'm curious about this. How would sick, poor people gain access to care without health insurance? Dr. Hunt suggests in the linked post that the replacement should be private charity. There are issues about whether this would be an appropriate replacement, of course, but also, wouldn't that be effectively a third-party payer, and therefore prone to moral hazard as well? This would still be a problem even if prices fell as much as Dr. Hunt believes, as they would never fall enough for the poor to afford necessary treatment. I am not sure this system would be worse than our current one, but I am curious as to how a libertarian addresses this issue.

I don't think that the health insurance itself is a problem, but rather an inevitable compromise in medicine. People are able to opt for not having computers, while they cannot opt out of healthcare, at least emergency care or even preventive care. No matter how much the price tags are, people will have to use medical services and face with medical bills sooner or later. Any healthcare organizations, let alone health insurance companies, have no incentive to minimize the cost, for they are guaranteed to have some customers no matter what. Given a wide range of socioeconomic status, some people will be simply unable to afford the healthcare. Thus, we need something like health insurance to distribute and spread out the burden of medical costs among patients. (Divide this medical cost into monthly bills, and these are typical health insurance premiums.)

If the health insurance system remains as nonprofit under the heavy regulation for price control and transparency, the consequence of moral hazard might not be as severe as it seems. But our current health insurance model is far from it, and I understand where Dr. Hunt is coming from. It's just that comments like getting rid of moral hazard will probably remain as a theoretical concept, rather than a practical solution.

 

[breakintheroof]

Any healthcare organizations, let alone health insurance companies, have no incentive to minimize the cost, for they are guaranteed to have some customers no matter what.

This seems to get to the heart of Dr. Hunt's argument. In considering moral hazard's effects, he focuses on prices rather than volume of services.

If the health insurance system remains as nonprofit under the heavy regulation for price control and transparency, the consequence of moral hazard might not be as severe as it seems.

Price controls seem like the answer to ever-rising costs, given the necessity of at least some moral hazard. But Dr. Hunt writes (in the piece he links to from his blog):

"To address the price inflation caused by moral hazard, government mandates price controls, which always and absolutely lead to shortages and misallocation of resources and are uniformly and always proven to fail."

This statement seems ideological. I would like to see it fleshed out and applied to health care. Can't shortages and misallocation of resources happen in a "free-market" system too? How does he define "failure" of price controls?

 

[Optimus-Prime]

Awesome interview, though strange to hear someone without a liberal bias

 

[Eddie Marcus]

Price controls seem like the answer to ever-rising costs, given the necessity of at least some moral hazard. But Dr. Hunt writes (in the piece he links to from his blog): "To address the price inflation caused by moral hazard, government mandates price controls, which always and absolutely lead to shortages and misallocation of resources and are uniformly and always proven to fail." This statement seems ideological. I would like to see it fleshed out and applied to health care. Can't shortages and misallocation of resources happen in a "free-market" system too? How does he define "failure" of price controls?

Hi Breakintheroof... I appreciate your thoughtful comments. My username is Eddie Marcus, but I am John Hunt (the interviewee). For what my thoughts are worth, here they are. Price controls have to be compelled on unwilling parties. The use of force against an innocent person in my libertarian ideology is a wrong. Who is doing the forcing? Politicians and bureaucrats: the first (as a group) tend to be more untrustworthy, more narcissistic, and more incompetent than private citizens; the second, well, the second as a group are bureaucrats. What gives either politicians or bureaucrats the knowledge to know what price to set? Prices are supposed to be signals to trigger increasing or decreasing supply. When prices are controlled, the signal disappears, and it matters not in what sector of the economy. It leads to loss of supply/demand balance. The government then tries to make up for lost price signals by subsidization here and taxation there, stressing their government experts beyond any reason as they try desperately to meet the needs and desires of a constantly changing population through various manipulations. Supporters of price controls need to assume that government experts know more than the market (a false assumption) and have our best interests at heart (as opposed to crony interests)--a questionable assumption indeed.

I can see how price controls might make sense to some, in some settings, for example when the government has screwed up a market so badly as they have screwed up the health care marketplace. When the system has become crony, as the health care system is, and the cronies are making crony money through political influence peddling and rent-seeking, then there is no free market.. When there is no free market, the prices signals are lies, and those lies misdirect both supply and demand.. Then the government tries to come in with smarter prices than result from the crony system they created. Thus the government response is forced price controls to compensate for their crony policies. Two wrongs trying to make a right. That was the failed soviet model of course.

In a truly free market (of which there is very little in the health care sector), of course shortages can occur, quite regularly, but the prices then shoot upward to incite increased supply of the shorted good. Trade restrictions and price controls and regulations and impediments to the entrance of new suppliers all inhibit this supply rebalance..And we should be careful of those, because the supply rebalance is already slowed by the time it takes to create physical and intellectual capital, to build equipment and train people. A great way to fill shortages as efficiently as possible is to let the market allocate resources. Another advantage of this is that it doesn't expand the power of the politicians to feed the pork bellies of their crony friends.

That's my take on things. Ideological? YES! A carefully considered and tested ideology provides a great foundation to test ideas. Mine teaches me that force and fraud initiated against innocents is wrong, regardless of the end sought. Persuasion is how we should be synergizing and cooperating. Compulsion by government is just "work-camp lite" and is in my mind wrong even if the politicians think that their goal is worthy. Worthy goals can be accomplished without force through the loving cooperation of caring people. If people stop relying on the government politicians to fix problems (which the government attempts through compulsion), then they would start fixing problems themselves (through generosity and charity and market activity). Neither is necessarilyy easy. Problems are problems because they are hard. But one path is immoral and pessimistic. The other is moral and optimistic. I vote for the moral and optimistic!

These conversations are, in my mind, very worthwhile to have. Especially with open minded folk, so thanks for discussing... Best to all!

 

[fungusman]

"War is the health of the state and it is used to distract the population from the shenanigans of the politicians."

OMG, I will follow you to Mordor and back my anarcho-capatalist physician.

 

[TheWeeIceMan]

Definitely one of my favorite physician Q and A's. 👍

 

[Silo004]

The fact that this guy is railing against the FDA is kind of silly -- kids in Europe had tons of defects because thalidomide was used there for morning sickness. The FDA was careful in approving it and we saw far less of those birth defects state side. Granted there are problems, many problems, with the way that we do things here. But deregulation is not a panacea.

 

[TeethLikeGodsShoeshine]

I will admit that this is a far more interesting article than usual. He really seems to enjoy his work and that is a quite refreshing angle. I was completely on board until he started pulling out the Rand Paul act. I still am having difficulties seeing how a full scale charity healthcare system would work for the poor or those who cannot afford healthcare in this capitalist utopia.

 

[DermViser]

I will admit that this is a far more interesting article than usual. He really seems to enjoy his work and that is a quite refreshing angle. I was completely on board until he started pulling out the Rand Paul act. I still am having difficulties seeing how a full scale charity healthcare system would work for the poor or those who cannot afford healthcare in this capitalist utopia.

Thank you, utopian premed.

 

[TeethLikeGodsShoeshine]

Thank you, utopian premed.

Enlighten me. Is the idea that the costs would just be driven down to a point where healthcare would be affordable for the poor as well?

 

[DermViser]

Enlighten me. Is the idea that the costs would just be driven down to a point where healthcare would be affordable for the poor as well?

Costs will never be affordable for EVERYONE on anything no matter how much you subsidize something.

 

[Eddie Marcus]

Silo 044.. Excellent point. It should be noted that the thalidomide episode (1959) occurred before the change in regulations at FDA in the 1960's. Prior to these changes FDA was focused on safety, and drugs got to market without horrific delays and horrible expenses. Indeed Thalidomide was kept out of the US under the pre-1962 regs (where FDA was focused solely on safety). In the wake of thalidomide, FDA's powers were massively expanded: they then demanded proof of efficacy as well as safety, before allowing a drug to go to market. They got distracted from their safety mission. And things have been a major mess ever since. It is hard to say that protection against thalidomide was not a feather in the FDA's cap. It was a feather certainly in the cap of Dr. Kelsey. But the danger is in reflex responses. "No good crisis should go to waste" so said some political crony psycho. For example 9/11 led to Homeland Security and TSA and NSA's Utah data center, even though the horror was self correcting (within one week after 9/11 men and women throughout the country knew that if they were, in the future, on a plane taken over with knives they won't sit back and hope for the best, but will instead FIGHT!). Thalidomide crisis led to far reaching expansion of FDA powers likewise that were not needed anymore than the far-reaching excesses and wastes of TSA were needed.

Wins and saves from regulatory and legal and welfare interventions are actively noticed (such as the Thalidomide save). But it is wrong to forget the "Forgotten Man" who is injured by the FDA's regulations. It has been calculated (estimated, whatever) that 4.5 million people have lost their lives since 1962, from inability to access lifesaving medications that the new FDA regulations caused delayed approval of, but eventually indeed did get approved. We should not forget these 4.5 million adversely affected (killed?) by those regulations! (Which compares to an estimated 7500 or so lives saved by those regulations during the same period.) Don't forget the forgotten man! 4.5 million vs 7500... That is a poor ratio. Even saving us from thalidomide does not compensate for the injurious effects of FDA since then.

The government, in my opinion, needs to focus on 1) what it SHOULD be doing, and 2) what it can do well... It is currently distracted and overburdened by things that it should not be doing, has no authority to do, and that it does poorly. Perhaps we should all work to help government focus better. By focus, I mean LEAN and EFFICIENT and HUMBLE..... What I wouldn't give for a HUMBLE government.

 

[Lycian]

I liked this article a lot-Many good points were made, and more importantly, it was very authentic!
I think his assertion that private/government insurance plans raise health care costs is very true, and you can read the article he linked to on moral hazard, which highlights many of the pertinent points to make that case.
However, while I agree that moral hazards raise health care costs, I think overall the argument he is conveying is wrong.
In our political system, politicians are elected by the people, and they bare the (pseudo economic) burden of being voted out for the decisions they make. As a result, something very similar to a moral hazard intrinsically exists within the democratic structure.
I would argue with this being the case, it's essentially futile to try and address a moral hazard if it is being precipitated by a larger moral hazard. For instance, if the government magically stopped meddling in providing health care, and sick people were allowed to die to correct the market, the political system in turn would also be forcibly changed through broad swaths of unhappy voters that did not like being potentially denied the right to live by their political leadership.

I think the philosophical flaw being made is that you've created to constrained a system to work within. The fact that a moral hazard existing is causing prices to rise, does not mean the only way to address prices is to remove the moral hazard.
Truthfully, I don't think the moral hazard could be eliminated without eliminating democracy itself. This harkens back to a repeating political debate which generally culminates with Winston Churchill's quote "Democracy is the worst form of government except for everything else."

So what I would argue is "if your solution cannot be implemented, another solution must be searched for, no matter how inconceivable it initially appears to discover."

I did get the feeling from reading your post that you had other ideas to, but this was just the one you chose to emphasize.
Thanks for the article, thank you for reading this if you did, and thanks for being awesome/authentic in your prose.
I'm a bit tired, so this response not be perfectly composed!

 

[DoctorDozer]

Costs will never be affordable for EVERYONE on anything no matter how much you subsidize something.

So what do we do for the people who cannot pay? Relying on charity is great in theory, but in the current state of our nation (80% of the USA population only owns 15% of the total wealth, thanks cronies) there is such a large population that either cannot pay for anything or cannot pay for much of the necessary care. I consider myself an advocate of universal healthcare when done properly, efficiently, and with respect for free market innovation.

That said, I do not advocate for entirely free markets which have proven disastrous throughout history. Now, I know (I know...) the government seems to be the only force better at destroying markets and lives than the unhindered free will of man, but isn't it possible that a focused, efficient government could regulate markets in such a way to benefit the greater society? If I recall correctly, the current accreditation system for medical schools was put around 150 years ago (can't find source right now) in order to prevent hack doctors from practicing. Medical schools had become a sham accepting virtually all applicants and turning them out with hardly any training to practice their butchery and incompetence upon the unwitting patients who crossed their paths. Additionally, how can you support the unhindered marketing of "alternative" medical therapies such as homeopathy and cyanide (from apricot pits) being used to treat cancer (which allowed for the death of Steve McQueen). Also, Steve Jobs, not some fool, was even the victim of alternative treatment of his cancer that likely had a role in his death.

I loved the article and very much respect your opinions, John. Thanks for sharing and being able to create such an intelligent and practical dialogue. I very much see the path to medicine as a path to either indentured employment at the hands of bureaucrats or freedom to help people throughout the world--I find myself worrying.

 

[DoctorDozer]

This is another great article worth the quick read. Hospitals and doctors need to make true to the promise Obama couldn't: they must offer unprecedented transparency. If his xrays, cast, and follow up for my foot cost $600 and her xrays, cast, with no follow up included cost $750 I will be able to make an informed choice.

 

[WhippleWhileWeWork]

I will admit that this is a far more interesting article than usual. He really seems to enjoy his work and that is a quite refreshing angle. I was completely on board until he started pulling out the Rand Paul act. I still am having difficulties seeing how a full scale charity healthcare system would work for the poor or those who cannot afford healthcare in this capitalist utopia.

What's the "Rand Paul act"?

 

[mirabelle]

I love this part:

19. What information or advice do you wish you had received before beginning your medical studies?
I got good advice: Think of patients, not diseases. Think of patients, not grades. Think of patients, not papers or grants.