"Skin in the Game"

Here's a story that could be the basis for a class about the U.S. health care "system." My interlaced comments are in bold italics:

When Ben Schreiner, a 62-year-old retired Bank of America executive, found out last year he would need surgery for a double hernia, he started evaluating possible doctors and hospitals.

Ben's condition - a clearly diagnosed, non-urgent, standard surgical procedure - is well-suited to the "consumer" model of health care. The procedure is done at a limited number of facilities and data on experience, complication rates and cost is usually available.

But he didn’t look into the medical center in his hometown, Camden, S.C., or the bigger hospitals in nearby Columbia. Instead, his search led him to consider surgery in such far-flung places as Ireland, Thailand and Turkey.

For the procedure Ben needed, continuity of care was a relatively secondary consideration, so "shopping" far away from home was possible. Hernia surgery can reasonably be "outsourced." This would not be the case, however, for the majority of medical interventions.

Ultimately he decided on San José, Costa Rica, where just a week or so after the outpatient procedure and initial recovery, he and his wife were sightseeing throughout the country, then relaxing at a lush resort. He was home four weeks later, with no complications.

Mr. Schreiner is what’s known in the health care world as a “medical tourist.” No longer covered under his former employer’s insurance and too young to qualify for Medicare, Mr. Schreiner has a private health insurance policy with a steep $10,000 deductible.

Ben's demographic segment - no longer having employment-based insurance and too young for Medicare - will grow as the baby boomer's age. By taking a large deductible he lowered the cost of his insurance premiums, but in all likelihood those premiums were still quite high.

Not wanting to spend all of that on the $14,000 his operation would have cost stateside, he paid only $3,900 in hospital and doctor’s bills in Costa Rica. “I didn’t have to fork over my entire deductible,” Mr. Schreiner said. “What’s more, they bent over backwards there to take care of me — no waiting, a friendly staff, everyone spoke English.”

As a former bank executive Ben is presumably adept at running the numbers. The combination of Ben's skills with a non-urgent medical need for a procedure about which information is relatively available makes this kind of comparative "shopping" possible.

Ben Schreiner is a poster person for the market model of health care. His experience shows how market forces can potentially reshape health care in the U.S. If enough of Ben's neighbors in South Carolina go out of state and out of the country for hernia surgery, local surgeons and a local facility will ultimately figure out how to provide the surgery at a lower cost.

Ben's story appeals to two deeply held American values. First, he took responsibility for himself, by (a) choosing to take on substantial financial risk for his health care choices and (b) venturing to a far away "frontier" to find what he was looking for. And, he respected and used market forces, which our culture reveres much as we revere the six-gun carried by brave cowboys.

But extrapolating Ben's experience to a comprehensive proposal for how to govern the health system as is done by market hawks in the U.S. overlooks the fact that relatively simple elective procedures that require little or no continuity of care are the exception, not the rule. Individual responsibility and market forces will certainly play a major role in the forthcoming U.S. debate about health care reform, but they can't accomplish the task on their own.