I think I found this chapter as odd as Austin did. It’s entitled, “What Being Trapped Means to You.” I still don’t know the answer.
John begins with an attack on third party payers for trying to have restrictions on care. I was pleased to note that he acknowledged that restrictions come from all types of payers, private and public. I’m not pleased to note, however, that he seems to oppose them en masse. What’s the counter-argument? Should insurance companies be required to pay for anything? Note, even if you just believe that there should only be catastrophic health insurance, you must accept that it has limits, no?
But it’s the next section that was oddest. John really goes after guidelines. All of them. It’s a very strong attach against any types of guidelines. I found it wholly unpersuasive. The body of literature in support of standardizing care along an evidence base is enormous. In opposition stands the straw man of the patient who isn’t “average”. But there’s no one I know who doesn’t acknowledge that limitation. Guidelines are meant to be applied to a specific population. If you’re outside that population, the guideline doesn’t apply to you.
He also notes that some guidelines are written by people with conflicts of interest. True. We need to do a better job of that. But you don’t throw out the baby with the bathwater.
I do agree with him that wellness programs are often subtle ways to attract healthier employees.
I was somewhat mystified by the last few themes. I totally get that John does not like central planning. But insurance inevitably involves some level of it. We pool money. We spend it on some more than others. That’s always how it goes. It makes sense that someone make decisions as to how that will be spent. If you want to get rid of insurance entirely, that will avoind anyone else making decisions for you, but I don’t think he’s advocating for that.
As I worked through this, I had a thought. Are we “trapped” because many of us keep jobs we’d rather not because of health care? If that’s the case, and he’s advocating for uncoupling insurance from work, he’d be joined by many wonks on both sides of the political spectrum. I’d also point out that the ACA starts to take us in that direction by creating the exchanges. If that’s not what John meant by “trapped”, then I missed his point.
