Free Markets, Free People
In this podcast, Bruce and Dale discuss the top stories of the past week.
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We need to face a few facts about health care reform. Our current system of health care funding is broken. It’s not broken because we have a free market in health care. It’s broken because we don’t.
Spending in the US health care system is essentially out of control. The US spends almost 16% of GDP on health care. Canada, our nearest neighbor, spends a bit more than 10%. In western Europe, the figure is generally between 7% and 9% of GDP. It’s something I addressed in my book a few years ago:
Why is spending so much higher in the US, with its supposedly free-market system? Why is it, with all that spending, that regular medical coverage doesn’t exist for 40 million Americans, when, in the rest of the industrialized world, there is 100% health coverage?
Something is deeply wrong with the financing of the US health-care system.
Part of the problem is that we really don’t have a free market in health care. Individuals, by and large, don’t buy health care policies. Health insurance is employer-provided. In effect, however, this is underwritten by the US government by making health care premiums deductible for businesses, which results in billions of dollars in lost tax revenues. And then, of course, you have to throw in the $300 billion or so that the state and federal governments spend outright to provide health care. And, of course, once you hit 65, you’re on the government’s health care gravy train, because you’ve got your Medicare, which also covers prescription drugs, now.
Why do we spend too much for health care in the US? The Heartland Institute, a public policy think-tank, has listed several reasons:
1) Government subsidies to health care increases demand by artificially lowering costs.
2) Favorable tax treatment of employer-provided health care has the same effect.
3) Lower-income people without health care must rely on emergency room health care delivery at substantially higher cost.
4) Health care buyers and sellers meet in a “market” that is heavily regulated by the government.
5) State governments increase health care costs by mandating benefit coverages.
6) State governments artificially reduce the supply of health care by requiring Certificates of Need before health care providers can expand services.
7) States interfere with the creation and operation of PPOs by fixing prices or the range of services they can offer.
So, really, we have what is, in many ways, the worst of both worlds. We have a market-based system, but one in which market incentives are minimized through regulation and subsidies. In effect, government policy bids up health care prices, while at the same time interfering with the market forces that keep a lid on prices.
It’s no wonder that more and more people are looking at single-payer, government-provided health care as an alternative to what we already have. At the very least, a single payer system would end the inefficient and fragmented ways by which health care is currently purchased.
This is not a situation we can afford to ignore for long.
We have ignored it, though–although that appears to have come to a screeching halt.
Because of various government intereferences, more than 1/3 of all health care spending is purely administrative. By contrast, Canada’s administrative burden on health care funding is about 1%. If we were to switch over to a single payer system, there is an excellent chance that we would, in fact, spend less money on health care than we currently do.
Are there horror stories about health care in Canada or the UK? Sure. There are horror stories about our system, too. For instance, you can find stories of families that were denied coverage, and were forced in to financial disaster all the time.
Canada, of course, has the rather unique problem of being a country with 1/10 of our population being spread over an equal amount of real estate. In that situation, if you don’t live near a major metropolitan center–and Canada only has about 10 of them, there’s a shortage of available services. In Britain, there are terrible NHS hospitals, but there are also excellent ones. But the same it true in the US. If you live in, say, Houston, Ben Taub Hospital probably wouldn’t be your first choice for treatment. M.D. Anderson, however, would.
The bottom line, however, is that a single payer system would, in fact, deliver an equal or better level of health care as we currently receive, and probably do so at a lower cost.
But there is a fundamental problem with our current debate. We are arguing over whether we should keep the system we have, or move to a system that sets us on the path to a single-payer system. But those aren’t the only alternatives. There is another option that is being lost in this debate. The democrats don’t want to mention it for ideological reasons. The Republicans don’t mention it because of…well…incompetent buffoonery, I guess.
The alternative, of course, is to make the case that our current system costs so much, and is so distorted, because of government interference. We have a mixed system of health care funding in which the government’s intervention imposes a wide range of unnecessary costs. So our choice is not to keep what we have, or eliminate the administrative overhead by turning it all over to the government. The third choice is to return to a free market in health care.
Eliminate state by state coverage mandates, which result in 50 different–and sometimes wildly so–regulatory regimes. Eliminate federal and state laws that prevent insurers from creating nationwide plans and risk pools. Eliminate employer health-care coverage, and personalize it, to make it personal and portable.
Here’s another idea: allow people to buy health insurance. That isn’t what we have now. We have pre-paid health care. The two things are wildly different. For example, look at how auto insurance works. Imagine how much your car insurance would cost if we expected our insurance to cover 80% of the cost of oil changes, tire rotation, wiper blades, new tires, regular service, etc. But that’s precisely what we expect medical insurance to do. And then we wonder why it costs so darn much.
We need to allow insurers to offer simple catastrophic care coverage, with varying deductibles. That way, you can pick up the tab for your own doctor’s visits, but you don’t have to worry about bankrupting yourself if some idiot runs a stop sign and knocks you off of your motorcycle. We need to allow anyone who wants to set up a medical savings account. Heck, if we really want “the government” to finance it, we could offer a 100% tax credit for health care expenditures.
We don’t need the government to rescue us from the unsatisfactory state health care is in. We can accomplish the same goals of universal coverage and lower cost, by getting the government out of health care as completely as possible. There are so many ways we could use free markets to relieve us of the distress the current system of funding is in, that they’re almost impossible to enumerate.
And best of all, doing so would comport with the country’s traditions of freedom, and individual choice.
And one final thing. With a real free market in health care, if there’s a problem, you’ll also get accountability. You’ll get access to courts where you can sue a private insurer who defrauds you, or someone who gives you substandard care. What you’ll get with a single-payer system is no recourse. If the government turns down your procedure, or you don’t get the health care you should, or if you keel over before your slot on the waiting list comes up, there’ll be nowhere to go, and no one accountable, any more than there is now if the public schools fail to adequately educate your children.
But free market reform doesn’t even seem to be on the table.
Ramesh Ponnuru writes one of the better op/eds discussing the push for “universal health care” I’ve seen.
The practical case is that uninsured people raise premiums for everyone else. But such cost shifting raises premiums by 1.7 percent at most, according to a 2008 study published in the journal Health Affairs. Reforms that increase the number of people with health insurance, while stopping short of universal coverage, would presumably make that small percentage even smaller.
The obvious way to take care of that is to directly insure that relatively small group instead of messing with the entire system.
What about portability and pre-existing conditions? As we’ve been saying here, for literally years, remove it from being employer based and you’ve taken care of both as long as a person keeps their payments current. And, to make it more affordable, remove state mandates. Ponnuru says precisely the same thing:
An alternative approach would be to make it easier for people to buy insurance that isn’t tied to their employment. The existing tax break for employer-provided insurance could be replaced with a tax credit that applies to insurance purchased either inside or outside the workplace. At the same time, state mandates that require insurers to cover certain conditions, which make it expensive to offer individual policies, could be removed.
More importantly, it is a free-market approach. As Ponnuru says:
These two reforms would address most people’s anxieties about the health care system. Insurance would be more affordable, especially for people who cannot get it through an employer, so the number of people with insurance would rise. Indeed, this would enable more than 20 million more Americans to get insurance, according to a model created by Steve Parente, a health economist at the University of Minnesota.
More important, people would own their insurance policies and thus be able to take them from job to job. They would no longer need to worry about losing their job and their insurance at the same time, or feel they need to stay with a job they dislike because they need the benefits.
There it is, the same solution we’ve been pushing at QandO pretty much since QandO has existed. It is a common sense solution which actually reduces government’s role, gives people choices and makes coverage more affordable for a larger number of people, portable and negates the concern for “pre-existing” conditions.
Which is precisely why government will reject such a remedy.
According to Ezra Klein, the Obama administration intends to finagle universal health care coverage out of its budget proposal, including an individual mandate:
I’ve now been able to confirm with multiple senior administration sources that the health care proposal in Obama’s budget will have a mandate. Sort of.
Here’s how it will work, according to the officials I’ve spoken to. The budget’s health care section is not a detailed plan. Rather, it offers financing — though not all — and principles meant to guide the plan that Congress will author. The details will be decided by Congress in consultation with the administration.
One of those details is “universal” health care coverage.
Some of you may recall that Obama, while in campaign mode, consistently denied that he wanted to introduce mandates as part of his health care package. Paul Krugman cited that opposition as the major difference between Obama and Hillary Clinton:
Let’s talk about how the plans compare.
Both plans require that private insurers offer policies to everyone, regardless of medical history. Both also allow people to buy into government-offered insurance instead.
And both plans seek to make insurance affordable to lower-income Americans. The Clinton plan is, however, more explicit about affordability, promising to limit insurance costs as a percentage of family income. And it also seems to include more funds for subsidies.
But the big difference is mandates: the Clinton plan requires that everyone have insurance; the Obama plan doesn’t.
Mr. Obama claims that people will buy insurance if it becomes affordable. Unfortunately, the evidence says otherwise.
Now that he’s been elected it’s presto hope’n change-o, and voila! Mandates!
Ezra Klein notes that the difference between the pre- and post-election plans is based on one word in the budget — “universal”:
That word is important: The Obama campaign’s health care plan was not a universal health care plan. It was close to it. It subsidized coverage for millions of Americans and strengthened the employer-based system. The goal, as Obama described it, was to make coverage “affordable” and “available” to all Americans.
But it did not make coverage universal. Affordability can be achieved through subsidies. But without a mandate for individuals to purchase coverage or for the government to give it to them, there was no mechanism for universal coverage. It could get close, but estimates were that around 15 million Americans would remain uninsured. As Jon Cohn wrote at the time, “without a mandate, a substantial portion of Americans [will] remain uninsured.”
In essence, unless everyone is forced to buy insurance, there is no “universality,” and the benefits of large participation in the insurance pool cannot be realized. An even shorter version is, if healthier people opt out, then sicker people can’t sponge off them.
The budget — and I was cautioned that the wording “is changing hourly” — will direct Congress to “aim for universality.” That is a bolder goal than simple affordability, which can be achieved, at least in theory, through subsidies. Universality means everyone has coverage, not just the ability to access it. And that requires a mechanism to ensure that they seek it.
Administration officials have been very clear on what the inclusion of “universality” is meant to communicate to Congress. As one senior member of the health team said to me, “[The plan] will cover everybody. And I don’t see how you cover everybody without an individual mandate.” That language almost precisely echoes what Senate Finance Chairman Max Baucus said in an interview last summer. “I don’t see how you can get meaningful universal coverage without a mandate,” he told me. Last fall, he included an individual mandate in the first draft of his health care plan.
The administration’s strategy brings them into alignment with senators like Max Baucus. Though they’re not proposing an individual mandate in the budget, they are asking Congress to fulfill an objective that they expect will result in Congress proposing an individual mandate. And despite the controversy over the individual mandate in the campaign, they will support it. That, after all, is how you cover everybody.
So it looks like you better start scarfing down those cheeseburgers, eating transfats, smoking cigarettes, or whatever it is you do that’s not considered healthy, because once the federal government pays for health care (which is what individual mandates essentially works out to), then it also has the power to determine what “healthy” means. After all, since everyone will be pulling from the same health care pot, and since each claim on that pot diminishes what someone else can get, then each claim must be a legitimate one as weighed against all the competing interests. Because the viability of the system depends on healthy people making much fewer claims than sick people against the collective health care resources, the government now has a vested interest in making people healthier, whether they like it or not.
Another way to put it is that we will have entered a Pareto optimal world where no one can change their position for the better (i.e. receive more of the pooled benefits) without hurting someone else. Whereas in a competitive market system, each person can get at least as much health care as he or she wants to buy and can afford, in a Pareto optimal world, we are competing for the same scarce resources (health care dollars), and our claims are granted based on a a third party’s (the government’) determination of worthiness. No longer can we get what we can afford, we get a predetermined portion of what the government decides to pay for. That, of course, is why there are 6+ month waiting lists for routine health care in places like Canada and the UK.
Possibly the most depressing result of yoking America with universal health care, is that we can pretty much kiss medical and pharmaceutical innovation good bye.
Government run health centralizes the risks of exploring new technologies, medicines, techniques, etc. Centralized risk translates into (i) observing a very cautious approach to advances, and (ii) the politicization of research … From a purely capitalist point of view, opportunites that might have been pursued otherwise, are foregone since those who accept the risks of pursuing them do not get to maximize their reward, so instead those advances must come from the government. With government as the sole innovator, there are now two types of risk (1) the risk of failure (i.e. spending gobs of money on something that does not deliver as promised, or that costs significantly more than the benefit), and (2) the political risks (i.e. what politicians face for advocating spending on projects that either fail or that don’t disproportionately benefit favored voters). The result is that risk is increased overall, and fewer innovations are realized.
America is pretty much the last industrialized nation to still have a (semi) private health care system, which should be understood to include the pharmaceutical industry (as a supplier of that health care system). What would happen to the growth and advances we’ve realized over the past few decades if (when?) we adopt universal health care? Where will the innovation come from? Who will take the risks? Without the proper incentives, and indeed with some of the worst possible incentives as the only driving force to creation, I fear that the scientific and medical Atlas will shrug.
I don’t mean to say that there will be no breakthroughs ever again, but the pace will be slowed dramatically. That’s because, one the government is in charge of paying for health care, it will also be in charge of paying for medicines. As we’ve already seen around the world, drug companies will be forced to sell their wares for much less than the (legal) monopoly prices they charge now. The result, therefore, will be much less risky and expensive research into new drugs that may never come to market, and much more emphasis on improving old drugs so as to continue to pay for further research.
Surely the federal government will pony up money for research into some diseases. But then the government will be in charge of picking winners and losers when it comes to whose diseases will get cures and whose won’t. To imagine what this would look like, just think back to how AIDS and breast cancer research dollars were successfully lobbied for, despite neither affecting anywhere near as many people as other deadly diseases.
In the end we will be left with less individual freedom, worse health care, and fewer prospects for any improvement in either. That is not the change I was hoping for.
UPDATE: Tom Maguire helpfully reminds us of how the health care debate progressed during the Democratic primary season:
For folks whose memories have blessedly erased any recollection of the endless Democratic candidates debates, let me toss in a brief reminder. Obama claimed that he would offer health insurance subsidies so generous that most folks would volunteer to sign up. Hillary mocked that, insisting that the young and healthy would decline to subsidize the rest of us, especially since they could not subsequently be denied coverage on the basis of pre-existing conditions; her plan included a mandate obliging everyone to buy health insurance, like it or not (as in Massachusetts). Hillary then diligently ducked the “or else” question of what penalties she would inflict on the young, helathy and recalcitrant who would prefer to hold off on buying insurance until they were sick. As a nostalgia piece here is a link to a lefty wondering why his party was so committed to forcing young, healthy members of the working class to subsidize the rest of us on health care; that seems like a good question but I am long resigned to not being smart enough to be a lefty.
Aww, Tom. You’re plenty smart enough. Just not angry, bitter or jealous enough.
As for the “or else” question, Obama and the Congress won’t be able to duck that one. I can only imagine what sort of sword they intend to dangle of recalcitrant ,
comrades citizens who refuse to sign up for the program.