What can basketball teach us about health policy?

Basketball imposed my first patient experience in the American health care system. A loose ball and flying elbow saw me to an x-ray machine and a consult with a respected surgeon in New York City. The wait at the hospital was long. CNN blazed through the speakers and the only reading material was a sea of People magazine. For hours, I found myself in a blinking contest between Blitzer or Kardashian.

Once in the examining room, the surgeon was glad to know that I had insurance through the university. He enjoyed the fact that I stayed in a meaningless game with a broken nose and took pride in the scrappy win. He was affable, honest and decided against an operation. We laughed when he told me that he just returned to work after nursing a fractured foot from a pickup game at the local YMCA.

He had a love for the game he believed department chairs would never understand. I didn’t find things as amusing when his assistant informed me that I owed a couple hundred bucks upon leaving. My insurance plan would only cover the first $35 of the visit to a teaching hospital. Evidently, my choice came with a cost.

On a recent hopscotch of hospitals through the United States, I found myself back on a blacktop court in Boston. I always try to join a pickup game in whichever city I visit. There’s this belief that you’ll see the true psyche of a city from the ball court. Parisians foul much more than you’d believe, and New Yorkers have a knack for exploiting that one thing that gets to you in a matter of seconds. There’s got to be some truth to the correlation of the way you play the game and one’s character. I mean, didn’t Michelle Obama’s brother take Barack out for a game of one-on-one to see if the young punk was the real deal?

Playing on the mandate’s home court in Massachussetts, I pretty much assumed my team would be in heavy favour of Obamacare (a loaded misnomer) and its recent Supreme Court ruling. I was wrong.

After a tough loss, we were left to the sideline with time to bemoan every bad call, talk trash and talk of the election. Our best defender laid down a strong and straightforward rejection of the Affordable Care Act:

I’ll vote Obama but the bill is going to tank the economy even more. You can’t control prices and messing with a free market is where it runs amok. That’s why it works here. We have no refs, the calls even out and you have to hold your own. We don’t need a nanny when the ball doesn’t lie, right?

The following week on my way home, I was still sore about not having much of a response. Missing three open jumpers didn’t put me in the best position to speak against the mercy of the basketball gods or the virtues of markets. While at the airport, I was tweeted an article written by Michael Sandel on the crowding out of morals by markets. It all sounded quite nice, but it got me asking where the moralist’s argument meets my teammate’s take on health care?

No further than a game of pickup.

Woody Allen once said that basketball transports us to a primitive place for higher learning. The loose arrangement of strangers balling on public pavement illustrates many of the ivory tower’s arguments surrounding health insurance. We can try breaking it down like this:

Regulation. There may be no refs, whistles or commissioners, but the pickup system is exquisitely self-regulated. Every court has its own set of customs and conventions. You call your own fouls, and both sides feel out the going rate over the course of the game.

Just try calling a touch foul on an off-balanced jumpshot and witness the intense pressures from both sides to never do that again. There is little evidence that private insurers follow the same signals in an unfettered market. One of the most widely agreed upon provisions in the President’s reform establishes a floor for industry medical loss ratios (a number that basically measures how much of your dollar paid towards a premium is actually used for medical purposes in relation to a company’s overhead). The U.S. long trialed a system with few regulations, and smaller insurers dished out a lion’s share to shareholders instead of patients.

Administrative complexity. Every ball player hates waiting around for the game to get going. Now imagine you had to sign up at different booths just to figure out your eligible playing time. More providers may not clutter out morals, but they can make the market place more complex. This is believed to account for U.S. providers spending four times as much in interacting with providers than in Canada, and anincredible spread in prices for the same procedure or delivery.

Moral hazard. If you’re insulated from your own team’s cold looks or any other direct costs, the economist’s view is that you’ll choose to shoot the ball with no remorse and that’s their perceived transgression. The hazard herein lies in taking more than you need. While this may hold true for goods you want more of, I have a tough time believing that colonoscopies are like lay-ups. If there’s reason to believe that undue tests are taking place in the health care equation, it’s more likely to be happening on the supply side of medicine.

Adverse selection. At most parks, even if you show up wearing a Chris Bosh jersey, you get a shot to play. You get picked up by the next squad that needs a fifth and form a band of brothers/sisters on the spot. The thinking is that if you left it to insurers as to who to take on, they would cream skim and have nobody under 6 feet tall. Or pass over the guy with the knee brace. When it’s community based, you don’t end up with a yearning crowd on the sideline.

Solidarity. One of the beauties of pickup is that everybody comes together for the love of the game, no matter your trade. Is a democracy healthier even when there’s forced solidarity? In the wait to play, those that leave to play on another hoop are removed from the cue. Should the young, strong and quick be given the stark choice of opting out and playing at another court altogether?

Efficiency. We can almost all agree that any operation would be better off without waste. The challenge around its removal is in the pudding: a system’s generation of waste can be one sector’s income. It is definitely more efficient to score on your own basket, but that’s not the point of the game. We as a society have to figure out what exactly it is we value.

To be sure, I believe Canadians will be better served in demanding higher performance from their health systems and federal leadership. I’m also confident that Canada will step up. I just think it’s important to remember that we play a decent game.

Andrew Boozary is a public policy expert and a medical student in Canada. He can be followed on Twitter @andrewboozary.

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  • Janelle Wiley

    or one could consider that it’s the regulative burden which has created the administrative complexity. The American Medical Association considers this to be the case. The problem with directly comparing US and Canada is that different items are considered regulatory. If one compares the actual items, it seems Canada’s costs would be a bit higher (AMA’s report).

    Plus, we have regulatory burden which could be simplified by changing to a more free-market system than what we have now (we do not now have a free market system; differing State regulations, federal regulations, the tie to employment, etc., are all constraining the market forces which could otherwise be promoting innovation in a way that reduces the actual costs of delivering care, and improving customer service). We could do this while still insisting on necessary regulations such as not allowing people to become permanently uninsurable due to pre-existing conditions (see, for example, Washington State’s reforms which were enacted some years ago). Again, see the AMA’s (2010?) proposal for detailed explanations about how such a system would work.