The NFL season is now in full swing, with TV screens ablaze in households across the nation, eyes glued to an elliptically-shaped ball being thrown and kicked far distances. This reminds me of an incredibly rare case that happened to a male patient I saw in the ER many years ago, whose right testicle had jumped into his abdomen after he lost control of his motorcycle on the highway. My 43-year-old patient, whom I’ll call Richard, was in otherwise healthy condition and was not experiencing significant pain but knew he had a newly empty right scrotum after the accident. He was sure – despite my persistent questioning – that this was not the case before the motorcycle crashed. Fortunately, his testicle was still intact and only needed to be put in the proper place.
Working as an attending physician in the emergency department and trauma center at San Francisco General Hospital, I often see patients who encounter unexpected medical situations and seek care during desperate times. The ER is the only place in our health care system where all patients are seen regardless of their ability to pay, and as an ER physician, I am acutely aware of many of the major gaps in this system.
One of the biggest gaps is our willingness to accept the fact that health care is not a true market good. As Americans, we are wedded to the idea that “the market” can provide all of our needs, and thus you hear phrases that patients should be “empowered consumers” and “shop around” for health care. While there is certainly a role for the market, health care does not act like most industries, and this is because of what economists call “information asymmetry” – when all parties involved in a transaction do not have relevant knowledge.
In Richard’s case, he had no idea where his testicle went. In fact, neither did I as his physician. Even the radiologist looking at the CT of his abdomen and pelvis couldn’t identify the “unidentified heterogeneous structure in the right lower quadrant of the abdominal cavity.” Furthermore, Richard had no way of predicting he would be in need of medical services that day, and even if he had been able to predict it beforehand, he would not know how to shop for the specific services he needed. More than that, even if he had been able to diagnose himself and knew the name of the procedure he required – “manual closed reduction of unilateral testicular dislocation” – it would have been impossible for him to “shop around” for either the price or quality of the procedure to be performed. Try googling the procedure along with the word “price” and you will find not a single match for any sort of document on the entire world wide web. Finally, even if Richard were able to determine the best person to put his testicle back into place at the best price, he did not have any information on whether that procedure was absolutely critical or if it could be delayed or would resolve on its own.
Now let’s think about something markets do work well for – take, a laptop computer, for example. For a particular laptop model, I can find out what specifications it has, how much it costs, and where to buy it. I know or can find enough information about the quality and shop around. And, perhaps most importantly, I know a critical reproductive organ is not at risk if I choose not to buy it right now.
What is the solution, then? It might be easy to think that hospital price transparency – where hospitals are required to publish their prices – would be a quick fix. But this was mandated by the government in 2021 and little has changed. In the case of Richard, without knowing where his testicle went or what procedure was required, he would never have known what to Google. And in any urgent situation, patients aren’t really able to “shop” for services anyway.
If we decide as a society that we want a more equitable, functional health care system, do we need to go back to thinking about the single-payer system that so many health care researchers and experts have long championed? Sadly, the past few decades have shown us that our society does not seem to have the political will or appetite (or enough to counteract the prevailing market forces) to fundamentally rehaul the way we finance and pay for health care. In 2013, Senator Bernie Sanders’ staffers reached out to me to start a conversation on how to increase access to care by developing a single-payer system, with a valiant effort to do so in Vermont. That effort is still happening across the United States; in New York’s A4738A Colorado’s HB23-
A more politically palatable pathway would be a public option, a publicly sponsored plan. Americans could either choose to continue with their current private health insurance plan or select this government plan that could compete with private plans. In other words, no one would be forced to join this plan and it would exist alongside all current private plans. While federal public options have been proposed, state-based plans may be more feasible.
To be sure, the simple existence of market failure does not mean that the government will succeed. But the contrapositive is also true: government failure does not imply markets will succeed. Debates in health care are inevitably emotionally charged and, in fact, should be, since health care is a deeply personal issue. (For those curious about Richard, we maneuvered his testicle back into his scrotum, and he recovered well.)
We all agree that emergency care should be provided – now we need to focus on the how. In too many cases, the market is simply not equipped to determine what care costs and when and to whom it should be provided. The good news about market failure in health care is that we have a clear opportunity to improve how we deliver care.
It’s time to stop fumbling the ball and get it in the end zone.
Renee Hsia is an emergency physician.