Monday, June 29, 2009

If We Fixed Cars In the U. S. the Way We Fix People

You would typically get auto insurance (including insurance for major repairs) as an employment benefit, and you'd never see the money. If you lost your job, you'd either have to buy very expensive insurance on the open market, or just hope your car didn't break down before you got another job.

If you had insurance, all you'd have to pay at the repair shop would be a small copayment of twenty or thirty dollars. The insurance would cover the rest.

Many people with a car problem would first have to take their car to their primary care mechanic (PCM), no matter what was wrong. If it was the brakes, your PCM would have to write you a referral to a brake specialist before you could get your brakes fixed. Of course, you could just pay for the repair yourself, but that would cost many thousands of dollars.

You could do minor repairs yourself, but for something major like a new starter, you couldn't just walk into the parts store and buy a new one. You'd first have to get a handwritten note from your PCM. Then you'd take the note to a special parts store that has college-trained salespeople licensed to sell the higher grades of auto parts, and buy the part from one of them.

Every auto repair shop would have huge filing cabinets with multicolored file tabs sticking out of them, one file for each car. All the important records on your car would be written by hand.

Minor repairs would be made in small shops, but major repairs would take place in a few giant facilities in each metropolitan area, where hundreds of cars would be collected together for repairs. Getting an estimate for repairs at one of these mega-shops would be next to impossible. Instead, you just take your car in, wait till they fix it, and hope your insurance will pay for it.

Reading a repair bill would be an exercise in mystification. Even professional accountants couldn't explain why the repair shop would charge $674.92 for replacing a U-joint, the auto insurance would pay $407.17, and you would end up owing $103.37.

Mechanics would check for the most unlikely problems even when the issue was a simple one. You might take your car in because the wiper blades needed replacing, and the mechanic might do a stress test on the windshield and charge the insurance company $400.00 for it. But you could rest assured that your windshield wasn't about to shatter spontaneously, which happens maybe once in every 30 million passenger miles.

Auto mechanics would have to go to school for six to eight years after their BS degree and pay back hundreds of thousands of dollars in school loans before getting their license to fix cars. But they would earn almost as much as lawyers do, if they could keep ahead of their own soaring insurance premiums. If you didn't have a government-sanctioned auto repair license and you tried to fix anybody else's car, you could go to jail.

Gasoline additives would be a multi-billion-dollar business, funded with a combination of government support and private money. Universities would have special auto-repair branches and auto-repair research departments to develop new additives and repair techniques.

Mechanics could be hauled into court and made to pay millions for faulty repairs. Mechanical malpractice law would be a lucrative branch of the legal business.

Eventually, things would get so screwed up that the U. S. government would wade into the mess and take over large portions of it, promising to manage things better than the former private owners did. Of course, that's exactly what has happened with the U. S. auto industry already—so maybe it's time to wind up this little fantasy. . . .

Health care in the U. S. is a complex system that can be viewed as a technology. And it is fraught inside and out with ethical implications, so I think the current debate over what should be done about health care is fair game for an engineering ethics blog, broadly defined.

Of course, people aren't cars, and the analogy between car repair and health care breaks down if you examine it seriously. But sometimes casting a familiar situation in a new light will reveal problems in a way that more people can understand. For example, it is a fact that most people don't know they pay an average of $400 a month for health care—either as a deduction from their paycheck, or a contribution from their employer, or typically both. If you had to write a health-insurance check for $400 from your own pocket every month (as some self-employed people do), that single change would bring the reality of health-care costs home in a way that no number of TV ads will do. Most people do pay for their car repairs out of their own pocket. If we had the direct price information that would let us pay attention to the quality and price of health care in the same way we evaluate an auto mechanic's services, it would do a lot to reduce needless health-care expenses.

Eliminating the employer tax deduction for health-care costs, if done the right way, will be a step in this direction. But not if it is done just as a way to raise revenue and make a government-funded public insurance option more attractive.

As the debate develops, it seems to be coming down to a single question: Who can exert more effective discipline on the health-services sector: a set of government bureaucracies that will ration and regulate the system, or an enlightened public which is allowed to see the costs of health care directly and make their own judgments as to which insurance plan and caregiver is best for them? The latter option still has a role for government, possibly as the provider of last resort for insurance or services for those who can't afford them, and as a check on rampantly malicious behavior on the part of powerful institutions.

Either there will be major changes in the way health care is delivered in this country by later this fall, or there won't be. Sometimes no change is better than a bad change. After all, we could be worse off. Surveys indicate that most people are reasonably contented with their present state of health care. The trick will be to help the groups who are under-served without worsening the status of those who like what they have already—and not do something else awful like run the government into bankruptcy in the meantime.

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