Back in the 2008 Presidential election, defenders of earmarks pointed out that they make up a minute part of the federal budget, accounting for approximately $17 billion in annual spending.  Factcheck.org trashed McCain for claiming that there would be cost savings through elimination of earmarks; presumably, eliminating earmarks only eliminates the associated spending.

Back in the summer of 2008, the obvious response – that earmarks are used to persuade Senators to vote for bills (often, spending bills) that they otherwise would not vote for – was ignored.  Several months later, vindication came unexpectedly in the stimulus bill: $1 trillion in spending that is largely pork, inserted therein to buy votes from Congressmen.  In contrast, Bush’s much-derided stimulus cost approximately $150 billion, or one-sixth of the 2009 version.  Much as one cannot claim that the true effect of flipping a switch on a dam that releases a deluge of water is but the force exerted on that switch, one cannot claim that the true cost of earmarks is just the value of money being directed towards special interests: it must include the cost of other spending that would have, but for the earmarks, not have happened. 

This effect also plays out in medical malpractise.  Ezra Klein, among others, repeats the statistic that medical malpractise – attorney’s fees, court costs, insurance, settlments, and awards – accounts for approximately 1/2 of 1% of the cost of health care in America.  The math only makes sense if one assumes that the threat of a multi-million dollar jury verdict has no other effect upon doctors than to persuade them to purchase insurance and not be totally reckless with their patients.  Any doctor with a reasonable amount of forethought and awareness is going to spend a good deal of time (and money) doing his best to avoid lawsuits. 

Aside from ordering extra tests, defensive medicine has other costs for the medical industry and patients.  It is not by accident that approximately 1 in 3 American women give birth via C-section: as Dr. Faith Friedan said, “They’re never faulted for doing a C-section.”  Many insurance companies will not insure a physician who performs a vaginal delivery after a C-section;  this more than doubles the cost of labour and delivery (from approximately $5,500 to $11,300) and has many adverse effects on women.  (The costs, of course, are not insubstantial: if the C-section rate were reduced from 30% to 10%, American women would spend about $5 billion less on child birth than they do  now.)  That is but one procedure for one group of patients. 

Not only does this raise costs for people who have insurance, it makes it very difficult for those who are paying out-of-pocket or have high deductibles to access medical care.  Doctors may be unwilling, and certainly not used to, patients who are more than content to get a basic amount of care.  Even if the doctors were willing to forgo additional, redundant tests, or let a patient risk her health by attempting a VBAC, they are well aware that reasonable care is not a defence to a lawsuit: only an extraordinarily high standard of medical treatment may suffice for a jury. 

Until Congress and Obama understand that lay juries are, intentionally or not, dictating medical policy in America, they cannot improve access to care.  Insuring patients is not enough: those patients need to be treated by doctors who value their jobs, have invested a tremendous amount of time and money into their careers, and, like anyone else, ultimately need to retain those jobs and bring home a paycheck for their families.  “One half of one percent” is the force needed to create the chaos we have now; it is hardly a full measure of the cost of that chaos, no more than a few million in Stimulus 2009 represents the cost of that debacle.