Health Care, Education Through the Looking Glass

Transitions are exciting times, buzzing with possibility and new ideas. Task forces, academics, and bloggers seek attention and support for their reform proposals, dreaming things that never were and asking, “why not?”

Many people believe that American education and health care are overdue for reform. However, meaningful change is unlikely unless we recognize the irrational elements of both systems, flaws we may not even notice because we have become accustomed to them.

A thought experiment may be helpful: what if public education worked like our health care system?

First, children’s education would depend on where their parents worked. If the employer provided it as part of a benefits package, kids would receive an education. Some employers would offer high-quality educations to their employees’ kids, while others would offer stripped-down schooling that omitted whole subjects or stopped after sixth grade. Students would bring daily co-payments to school with their lunch money.

America would also have a program for poor children whose parents did not have jobs or had jobs without education benefits. However, the quality of education would vary widely depending on how much funding each state provided. One child in seven would have no education plan at all, although they could receive instruction on an emergency basis — for example, just before the SAT exams.

Teachers would be paid in piecework fashion, their compensation depending on how many lessons they taught each day. Much of the nation’s education budget would be spent determining whether students’ educational payment plans covered a particular subject, and on TV ads pushing new materials for teaching various subjects.

Of course, no one is proposing that public education emulate our health care system, and for good reason. It would strike most people as wrongheaded to tie the availability and quality of kids’ schooling to their parents’ jobs. We would quickly see that paying teachers by the lesson creates the wrong incentives. We wouldn’t stand for all the haggling, delay, and administrative cost of deciding whether a benefits plan covered a particular subject.

Yet we tolerate just such bizarre arrangements in our health care system. Tens of millions lack access to care. Doctors get paid to do procedures, not to get or keep people healthy. Insurance companies waste untold billions playing the ‘your plan doesn’t cover that’ game.

So, now imagine if American health care worked the way our education system does.

The three most important factors in the quality of your health care would be ‘location, location, location.’ Adjoining towns or counties would have dramatically different levels of care and health outcomes. Young couples would stretch their budgets and lengthen their commutes to live in communities with the best doctors and hospitals.

After doctors had practiced for three years, they would become tenured. But they would receive only modest salaries, and our most promising young people would choose different careers. Many doctors would not be able to pass exams in anatomy or physiology, but all would have taken the required course in theories of medicine in order to be certified.

This is not a world most of us would want to live in. Yet we do — it’s the world of American K-12 education. Access is universal, but quality varies widely and is often poor.

Both systems are deeply flawed, but their weaknesses and irrationalities can be hard to see simply because we are so used to them. Flip them, and it’s easier to recognize their problems.

In the real world, of course, health care and education have a few things in common. Both doctors and teachers resist being evaluated or paid based on the outcomes achieved by their patients and students, claiming that it is unfair or too complicated to sort out their own contributions to results. Poor people and people of color get disproportionately bad outcomes from both systems. And, of course, the wealthy can buy their way out of either, choosing ‘concierge medicine’ or elite private schools.

Reforming these critical sectors will not be easy. But our economic competitiveness, quality of life, and basic fairness all make change imperative.-

Jim Gomes is the director of the Mosakowski Institute for Public Enterprise at Clark University.