Pretty good post, but there are three subtle and intertwined mistakes in it that I think are worth commenting on. First, the claim that people aren't generally able to do a good job of being critically-engaged health care consumers is not well-described as a _philosophical_ matter. It is, rather, a straightforward _scientific_ one. There are some cognitive tasks that people are generally good at, and others that they aren't, and it is not up to the metaphysicians to determine which are which, but rather psychologists and economists. And the relevant science here is pretty overwhelmingly in Ezra's favor (as it is with SS, too, as the ample literature on hyperbolic discounting and the like indicates).

Next, it is a related mistake to frame these claims in terms of _stupidity_. Again, there are all sorts of cognitive tasks that we, as a species, are just not very good at, but it hardly follows that we're all stupid. Reasoning about uncertainties & probabilities is one of those areas that we're just not so strong in -- our developed mathematical frameworks for such reasoning is great, but unfortunately we just don't generally tend to reason in accord with those frameworks.

Finally, if we think of this as a scientific, not a philosophical, question, we can take a much better look at your interesting analogy with car repairs. I suspect that we would find that the criteria for evaluating car repairs are generally easier for drivers to pick up on, and so consumers are better able to tell after the fact whether they've had decent care; that it is generally much easier for consumers to comparison shop (by calling around to garages, or even driving around); that most consumers have in their circle of friends more people who possess substantial knowledge about cars than they do who possess such knowledge about medicine (so it is easier for people to get good guidance about these decisions); and, as you did note, the stakes are just radically lower (not only in terms of losing your life or your health, but even just in terms of the dollar expenditures involved). If we did a serious task analysis of car repair evaluation, that is, I would suggest that we'd find it is just an easier task overall for most people than health care evaluation is.

Honestly, is automobile care really the metaphor for decision making you want to refer to here?

Yes, there are some people who are perfectly able to decide what is the right thing to do to take care of their cars. But I think even the majority of Americans still don't take care of their cars even as well as is described by the owner's manual.

On one hand, you have the people who are off reccommending more service than you need (Oil change every 3000 miles!), and on the other hand, you have the average person who is going to want to put off whatever out-of-pocket expenses as long as is humanly possible, or cut those expenses wherever they can.

So you wind up with some mixture of unreliable mechanics who become notorious for overcharging people who don't understand everything their cars actually need, people who don't bring their cars in as often for service as they should and thus wind up with a higher percentage of car mechanical problems than there should be, and businesses who put out information that would help their businesses by convincing consumers to spend more money than necessary.

"They're qualified to evaluate whether the doctor was nice to them, whether he explained things clearly, whether the wait time was short and the experience pleasant."

As Jim Cramer once said, when he was managing other people's money, the game was not necessarily about making the most money for people, but rather treating people well.

You know what - the time waiting in the office and the "customer-service" orientation of the doctor ARE important. I would LIKE to be able to pay more to a doctor with a shorter office wait time, for instance, and I simply cannot DO that either under our current private insurance system OR socialized medicine.

Philosopher pretty much nailed it. You're entitled to your opinions, but not your facts, which overwhelmingly support Ezra's position. You can argue with the study on its own terms, but to frame this in terms of "the left" is just, well, stupid.

philospher and jpe seem to be missing the point. That people receive different standards of care than what they perceive is indeed a fact, as the WSJ article reports. But what the government should or should not do as a response is an opinion and philosophy, and the left's philosophy is markedly different than most libertarians. "jpe" misses the point entirely, as I never argued with the study on its own terms, and indeed never argued with anything. I did, however, note that the response highlights two very different philosophies. The left believes it is the government's responsibility to help us with our own stupidity, while consumer-driven advocates do not.

As for Balta's comment, it doesn't seem as though you read this sentence: "The obvious difference, of course, is that a shoddy car repair doesn't always end your life; poor health care can." The analogy isn't perfect, and I never claimed it was. That was part of the point of the post - consumer-driven advocates must come up with an acceptible answer, and it can't involve involve complex economic theory.

You're still making the exact same mistake, JC, of squooshing together the philosophical and scientific aspects of this question. I agree, and I'm sure everyone would agree, that the question "given whatever the cognitive capacities of people are, what sort of health care policy ought we have?" has a significant philosophical dimension to it. But that's not the question that you raised in the initial post! The question you raised in the initial post was the scientific one of "what are the cognitive capacities of people, vis-a-vis health care consumer?" (though you raised it in the more incendiary and inaccurate language of "are people stupid?").

You are surely right that if one is a certain kind of libertarian, the scientific questions is simply beside the point. If people are going to make bad decisions, well, they are still their decisions to make, as long as there's no dishonesty or fraud or compulsion involved. End of story. So, for this kind of libertarianism, there's only the philosophical question. But this kind of libertarianism is basically excluded from the policy debates, for the general reason that it has very little political support. People just don't want a pure health care market, and neither political party is looking to revert to a purely market system (which would make lots of essential care unavailable to a very large portion of the populace).

The debate about consumer-driven health care, then, involves a different type of libertarian, which we might call a utilitarian libertarian (as odd as that sounds): for this kind of libertarianism, the argument isn't based originally on rights, but on the idea that less government interference and more reliance on free markets just plain leads to better outcomes on the whole. As stated at a level of high generality, it's something that almost all liberals would agree with, too. There's room for some philosophical debate over what counts as better outcomes, but those aren't in play in this particular debate, either. Basically everyone in the debate agrees that we should do whatever will have the best outcome, and that this will very largely involve free markets. Where the left and right diverge in this area is mostly about what happens when you come down to specific cases, and in particular about whether & where are the cases in which markets _don't_ give better outcomes. In this instance, the evidence seems to indicate that the basic allocation of health care is just such an area where the market isn't going to get things right, because consumers aren't able to get things right in the first place. Markets work well under very special sorts of conditions (which is why one has to have a government that works hard to make those conditions happen, btw), and this includes the availability of information that, in this particular case, is simply not as easily available to the consumer as would be required for them to make the kinds of decisions that would allow the market to produce the best results.

To recap: if you're offering the kind of purist, damn-the-consequences libertarian view, then this study is just beside the point, and there's nothing to argue about except philosophy. But if the argument for the market in this case is that it will produce better, more efficient, more cost-restraining results, then there's really no philosophical questions in play; just scientific ones.

Is the premise for single payer health insurance/universal healthcare that the care would be better, or that the current uninsured people would have a healthcare safety net?

The study here doesn't seem to be applying a direct comparison between our current healthcare system, and a socialized medicine product. A proper and accurate study(one that wasn't an attempt to advocate a political solution), would compare the quality of care received under a universal or socialized mechanism and the care received through independent insurers. The study could have easily been conducted, by analyzing Medicare Recipients vs. managed care customers.

Aren't the researchers actually setting up a false dichotomy, by evaluating medical service quality based upon the insurer, instead of by the service provider? The real revelation in this study is concerning continuing education and medical license requirements concerning the continuing education of practicing physicians and medical first responders. By setting up the false dichotomy based upon medical service quality, the researchers are ignoring the current system of regulatory oversight that is available to remedy the problems pointed out in the study.

Eric, you're definitely right that this one study does not by itself determine which policy we should adopt. (Indeed, at the same time you were posting this, I was saying something similar on Zach's follow-up post!) But that's not a problem with the study, which anyway doesn't even begin to touch on the question of what types of provider give better care. I think you've just misread the study as trying to do something that it isn't at all trying to do. It's just trying to get at the question of how good people are (or aren't) at evaluating the quality of their care. This does have policy implications, but only as part of a broader picture.