It’s been painful watching the ridiculous arguments and accusations in the current
First of all, many people are comparing health systems around the world and making unjustifiably strong claims, sometimes using questionable data or results. For example, the oft-cited WHO study ranking countries’ health care systems focuses almost entirely on the distribution of health care, rather than the level, and has error bars so large that the results are almost worthless. Rankings of life expectancy are also of questionable use when comparing countries’ health care systems, as life expectancy can vary for reasons unrelated to health care systems. For example, Americans tend to be more obese, get in more care accidents, and experience violent crime more often than people in other countries. These may be serious problems with American society, but they are not problems with the health care system. Another measure that has been used recently is a comparison of preventable deaths for people under 75 years of age. This suffers from a problem similar to life expectancy—Americans may be more prone toward particular kinds of health problems, and treatment of them may be less successful, for reasons unrelated to the health care system. A real study of the subject would need to control for more variables.
Similarly, one hears that around 50 million Americans do not have health insurance. While technically correct, this number is of dubious value. What fraction of those 50 million people qualify for government aid but have not used it? What fraction are wealthy but have opted not to buy health insurance? How many actually went for an extended period without health insurance, and how many went without for a short period only?
There are also questionable statements about health care in other countries. They are sometimes presented as utopian, and at other times as hellish, depending on the position taken by the discussant. Conservatives like to claim that wait times in
Do other countries do a better job controlling costs? David Goldhill argues that if they do, it’s not by much:
From 2000 to 2005, per capita health-care spending in Canada grew by 33 percent, in France by 37 percent, in the U.K. by 47 percent—all comparable to the 40 percent growth experienced by the U.S. in that period. Cost control by way of bureaucratic price controls has its limits.
Perhaps other systems get the level of costs down, but cannot control growth, meaning they will end up where the
None of this is to say that the
Students in any economics class learn that resources are limited, or scarce. We cannot all have as much of anything as we want. This is true of cars, gasoline, televisions, computers, clothing, leisure, and everything else people enjoy consuming. One can have more of something, but only at the cost of giving up something else. Over time, economic growth allows us to produce more goods and services with fewer resources going into each of them, but this is a slow process. Even with growth, getting more of something is not free.
This applies to health care just as much as it applies to everything else. From society’s point of view, providing more health care means providing less of something else. When people become doctors, nurses, medical device engineers, or other medical specialists, they cannot also be computer programmers, chefs, or produce other non-medical goods and services. No health care system—government run, purely free-market, or anywhere in between—can produce as much free health care as everyone wants. They can be more or less efficient, depending on the incentives of the system (which I will discuss later), but unlimited free health care is not an option, and anyone that tells you it is possible is lying to you.
Economists call the process by which things get allocated to people “rationing”. In a purely market-based system, economists say that the price acts as a “rationing mechanism”—people who are willing and able to pay enough for something get it, and people who are not willing or able to pay enough for something do not get it. In a purely government-run system (say, Soviet-style central planning) bureaucrats decide who gets what, and base it on a calculation of needs, political influence, or some other measure. There are possibilities in between the two extremes.
In any health care system (as in every part of an economic system), someone ultimately says “no”. There are entities that decide who will get care, and who will not. In the
One might object that doctors get to decide who gets what kind of care, if any, and to an extent that’s true—they (hopefully) will not treat a torn ACL with chemotherapy. Yet doctors are ultimately paid by someone, and if that someone (consumers, the government, insurance companies, charities, whoever) stops paying, they will eventually reduce the amount of care they provide.
In other countries the decision makers may be government officials. The NHS in the
Whether government decision makers do a better or worse job than private decision makers is an interesting question, and you might have gathered from the discussion of international comparisons above, it is a difficult question to answer. Nonetheless there is a consensus that the
There are two economic primary theories to explain why this would be the case: adverse selection and moral hazard (both having to do with the economics of insurance). Both can be expected to drive up the costs of health care, pricing many consumers out of the market.
The adverse selection argument goes like this: Suppose that there are two types of consumers, those who will get sick (the unhealthy) and those who won’t (the healthy). Suppose consumers know which type they are, but insurers do not. Then the healthy types, knowing that they do not get sick, will not buy health insurance. The unhealthy types, knowing that they will get sick, will try to buy health insurance. Should insurers sell to them?
They should not. If only the unhealthy types buy, then selling health insurance is a sure way to lose money. Each consumer is going to incur, say, $10,000 in average medical costs, which the insurer will have to pay, and then pay his workers and stockholders. But the consumer isn’t willing to pay more than $10,000 for the insurance policy, so there’s no way for the insurer to make a profit.
This is an extreme version of the adverse selection story, in which the insurance market completely disappears. A more realistic version would involve probabilities, rather than certainties, and when one creates such a model, an interesting result can emerge: If enough healthy consumers drop out of the market, health care can get sufficiently expensive that only the most risk-averse, wealthy consumers (of either healthy or unhealthy type) can afford to buy. That is, even if I am a healthy consumer, I might still want to buy insurance because I am particularly risk-averse—but I can’t, because it’s too expensive, because of adverse selection. If everyone could be forced to buy insurance, it would be cheaper for all. (Here is a clever related argument regarding car insurance, suggesting that cities that require all drivers have car insurance should experience lower rates.) Adverse selection is why health insurance companies try so hard to screen for preexisting conditions, smoking, and other factors that can increase the risk that a consumer will become ill; they are trying to sort out the good risks from the bad.
Does this argument help explain why health care is so expensive in the
Moral hazard is a simple response to incentives: Once insured, people have fewer incentives to take precautions to prevent future illness, because the medical costs will be paid for by a third party (the insurer or the government). This makes small medical problems into big medical problems, driving up the cost of treatment (and the cost of insurance). In fact, in the
When a large portion of consumers are no longer paying attention to costs, and no longer shopping around, competition stops functioning. Competition—the process that gave us the $20 DVD player, instead of the $900 DVD player we started with—is an important mechanism for disciplining producers, whether they are producing cars, newspapers, computers, or cancer treatments. Competition keeps producers on their toes, forcing them to find better, more efficient ways to do things. I find the moral hazard/lack of competition argument compelling. In health care, competition seems broken.
Robin Hanson has argued that overconsumption of medical services means we could cut health care spending in the U.S. in half (by simply denying care or refusing to undertake procedures or tests) with almost no effect on health care outcomes. If correct, is a pretty stunning result—if we can get people to consume more carefully, we can dramatically reduce costs.
What reforms should be enacted? It is possible that moving to something like
This brings me to a reform that I think would work. Bryan Caplan, Tim Harford, and others have praised
You can read Caplan’s account of
You can read Caplan’s account of
1) Mandatory medical savings accounts: Every person pays into a savings account that accumulates over time, and can even be passed on to one’s children. The money in the account can only be used for medical care. This gives consumers an incentive to shop around—they are spending their own money, after all. It may also give them an incentive to undertake preventative care, as doing so increases the amount in their account in the long run. This policy puts competition back in health care markets.
2) Mandatory published price lists: All hospitals and medical facilities must say what their procedures and tests cost. This allows consumers to shop around, and even establish reputations for low prices. Try calling a local hospital in the
3) Optional low-cost catastrophic coverage: When health care expenses go over a certain threshold, the government steps in and pays. Because catastrophic illness is uncommon, this coverage is relatively cheap to provide. Private insurance can also be purchased. This is sort of like the “public option” of the current health care reform proposal in the
There is one aspect of
I think such a system might be manageable in the
Realistically, however, I do not think we will get reforms that will make a significant difference, for better or worse.