Coyote Blog

Remember the whole VA thing?  It has mostly been forgotten, though we will all remember it again, or more accurately get to experience it ourselves, once the Democrats manage to get single payer passed.

People talk about government employees being motivated by "public service" but in fact very few government agencies have any tangible performance metrics linked to public service, and when they do (as in the case of the VA wait times) they just game them.   At the end of the day, nothing enforces fidelity to the public good like competition and consumer choice, two things no government agency allows.

I will admit that government employees in agencies may have some interest in public welfare, but in the hierarchy of needs, the following three things dominate above any concerns for the public:

• Keeping the agency in existence
• Maintaining employment levels, and if that is achieved, increasing employment levels
• Getting more budget

But look at the VA response in this context:

• The agency remains in existence and most proposals to privatize certain parts were beaten back
• No one was fired and employment levels remain the same
• The agency was rewarded with a big bump in its budget

The VA won!  Whereas a private company with that kind of negative publicity about how customers were treated would have as a minimum seen a huge revenue and market share loss, and might have faced bankruptcy, the VA was given more money.

Murry Rothbard via Bryan Caplan:

On the free market, in short, the consumer is king, and any business firm that wants to make profits and avoid losses tries its best to serve the consumer as efficiently and at as low a cost as possible. In a government operation, in contrast, everything changes. Inherent in all government operation is a grave and fatal split between service and payment, between the providing of a service and the payment for receiving it. The government bureau does not get its income as does the private firm, from serving the consumer well or from consumer purchases of its products exceeding its costs of operation. No, the government bureau acquires its income from mulcting the long-suffering taxpayer. Its operations therefore become inefficient, and costs zoom, since government bureaus need not worry about losses or bankruptcy; they can make up their losses by additional extractions from the public till. Furthermore, the consumer, instead of being courted and wooed for his favor, becomes a mere annoyance to the government someone who is "wasting" the government's scarce resources. In government operations, the consumer is treated like an unwelcome intruder, an interference in the quiet enjoyment by the bureaucrat of his steady income.

This is a re-post of an article I wrote in 2012.  I am re-posting it to demonstrate that recent stories about doctor shortages and wait times are absolutely inevitable results of government interventions in the health care economy.

My son is in Freshman econ 101, and so I have been posting him some supply and demand curve examples.  Here is one for health care.  The question at hand:  Does government regulation including Obamacare increase access to health care?  Certainly it increases access to health care insurance, but does it increase access to actual doctors?   We will look at three major interventions.

The first and oldest is the imposition of strong, time-consuming, and costly professional licensing requirements for doctors.  At this point we are not arguing whether this is a good or bad thing, just portraying its inevitable effects on the supply and demand for doctors.

I don't think this requires much discussion. For any given price for doctor services, the quantity of doctor hours available is certainly going to increase as the barriers to entry to the profession are raised.

The second intervention is actually a set of interventions, the range of interventions that have encouraged single-payer low-deductible health insurance and have provided subsidies for this insurance.  These interventions include historic tax preferences for employer-paid employee health insurance, Medicare, Medicaid, the subsidies in Obamacare as well as the rules in Obamacare that discourage high-deductible policies and require that everyone buy insurance rather than pay as they go.  The result is a shift in the demand curve to the right, along with a shift to a more vertical demand curve (meaning people are more price-insensitive, since a third-party is paying).

The result is a substantial rise in prices, as we have seen over the last 30 years as health care prices have risen far faster than inflation

As the government pays more and more of the health care bills, this price rise leads to unsustainably high spending levels, so the government institutes price controls.  Medicare has price controls (the famous "doc fix" is related to these) and Obamacare promises many more.  This leads to huge doctor shortages, queues, waiting lists, etc.  Exactly what we see in other state-run health care systems.  The graph below posits a price cap that forces prices back to the free market rate.

So, is this better access to health care?

I know that Obamacare proponents claim that top-down government operation is going to reap all kinds of savings, thus shifting the supply curve to the right.  Since this has pretty much never happened in the whole history of government operations, I discount the claim.  When pressed for specifics, the ideas typically boil down to price or demand controls.  Price controls we discussed.  Demand controls are of the sort like "you can't get a transplant if you are over 70" or "we won't approve cancer treatments that only promise a year more life."

Most of these do not affect the chart above, since it is for doctor services and most of these cost control ideas are usually doctor intensive - more doctor time to have fewer tests, operations, drugs.  But even if we expanded the viewpoint to be for all health care, it is yet to be demonstrated that the American public will even accept these restrictions.  The very first one out of the box, a proposal to have fewer mamographies for women under a certain age, was abandoned in a firestorm of opposition from women's groups.  In all likelihood, there will be some mish-mash of demand restrictions, determined less by science and by who (users and providers) have the best lobbying organizations.

My longer series of three Forbes articles on this and other economic issues with Obamacare begin here:  Part 1 Information, Part 2 Incentives, Part 3 Rent-Seeking

Update:  Pondering on this, it may be that professional licensing also makes the supply curve steeper.  It depends on how doctors think about sunk cost.

My son is in Freshman econ 101, and so I have been posting him some supply and demand curve examples.  Here is one for health care.  The question at hand:  Does government regulation including Obamacare increase access to health care?  Certainly it increases access to health care insurance, but does it increase access to actual doctors?   We will look at three major interventions.

The first and oldest is the imposition of strong, time-consuming, and costly professional licensing requirements for doctors.  At this point we are not arguing whether this is a good or bad thing, just portraying its inevitable effects on the supply and demand for doctors.

I don't think this requires much discussion. For any given price for doctor services, the quantity of doctor hours available is certainly going to increase as the barriers to entry to the profession are raised.

The second intervention is actually a set of interventions, the range of interventions that have encouraged single-payer low-deductible health insurance and have provided subsidies for this insurance.  These interventions include historic tax preferences for employer-paid employee health insurance, Medicare, Medicaid, the subsidies in Obamacare as well as the rules in Obamacare that discourage high-deductible policies and require that everyone buy insurance rather than pay as they go.  The result is a shift in the demand curve to the right, along with a shift to a more vertical demand curve (meaning people are more price-insensitive, since a third-party is paying).

The result is a substantial rise in prices, as we have seen over the last 30 years as health care prices have risen far faster than inflation

As the government pays more and more of the health care bills, this price rise leads to unsustainably high spending levels, so the government institutes price controls.  Medicare has price controls (the famous "doc fix" is related to these) and Obamacare promises many more.  This leads to huge doctor shortages, queues, waiting lists, etc.  Exactly what we see in other state-run health care systems,  The graph below posits a price cap that forces prices back to the free market rate.

So, is this better access to health care?

I know that Obamacare proponents claim that top-down government operation is going to reap all kinds of savings, thus shifting the supply curve to the right.  Since this has pretty much never happened in the whole history of government operations, I discount the claim.  When pressed for specifics, the ideas typically boil down to price or demand controls.  Price controls we discussed.  Demand controls are of the sort like "you can't get a transplant if you are over 70" or "we won't approve cancer treatments that only promise a year more life."

Most of these do not affect the chart above, since it is for doctor services and most of these cost control ideas are usually doctor intensive - more doctor time to have fewer tests, operations, drugs.  But even if we expanded the viewpoint to be for all health care, it is yet to be demonstrated that the American public will even accept these restrictions.  The very first one out of the box, a proposal to have fewer mamographies for women under a certain age, was abandoned in a firestorm of opposition from women's groups.  In all likelihood, there will be some mish-mash of demand restrictions, determined less by science and by who (users and providers) have the best lobbying organizations.

My longer series of three Forbes articles on this and other economic issues with Obamacare begin here:  Part 1 Information, Part 2 Incentives, Part 3 Rent-Seeking

Update:  Pondering on this, it may be that professional licensing also makes the supply curve steeper.  It depends on how doctors think about sunk cost.

It is a really weird mental block we have against paying out of pocket for medical bills, particularly since this is probably the most, not the least, important thing we can spend our money on.  Having a high-deductible health insurance plan has been a real eye-opener for me.  As in this post from Maggie's Farm, I too have found doctors will very often give a discount for cash.  My son has a great sports medicine guy (he plays 3 varsity sports so we seem to be at the doctor a lot for one injury or another) who gives us a $40 cash rate for a visit.  Further, when he needs X-rays, the radiology place downstairs usually does 2-3 films of the injured appendage du jour for around $35.  The X-ray place has a special cash price book they pull out when I show up.  I shudder to think what rate they charge insurance companies.  And t just think of the piles of infrastructure from my doctors office to the insurance company to Washington DC that would have had to come into play had I sought 3rd party payments for these bills.

And when it comes to the expensive things, it is amazing what price cuts you can find with just a little shopping.  Previously, I had spent less time in my whole life shopping medical care prices than I had price-shopping my last hard drive.  But when my son had to get a CT scan on his head (yes, another sports injury) we saved hundreds of dollars just calling a second place for a quote.  In fact, even mentioning that we were going to price shop the first quote got a few hundred dollars knocked off.  The lack of any rigor in health care pricing is just appalling, and will only get worse as government / single payer solutions crowd out approaches like mine under Obamacare.

Ezra Klein writes:

For a long time, I took questions about stifling innovation very seriously. So did a lot of liberals. But then I realized that the people making those arguments wanted to do things like means-test Medicare, or increase cost-sharing across the system, and generally reduce costs in this or that way, which would cut innovation in exactly the same way that single-payer would hypothetically cut innovation: by reducing profits.

I also found that I couldn't get an answer to a very simple question: What level of spending on health care was optimal for innovation? Should we double spending? Triple it? Cut it by 10 percent? Simply give a larger portion of it to drug and device manufacturers? I'd be interested in a proposal meant to maximize medical innovation. I've not yet seen one.

The reason he could not get an answer to this very simple question is that it is stupid.  It is a non-sequitur.  It is, as Ayn Rand used to warn, a statist trying to force the argument to conform to his statist assumptions.

Let's take a different example, because medicine is so screwed up by government intervention that it can be confusing.  Let's imagine ourselves in the computer market in 1974.  The market is dominated by IBM mainframes, and innovation at the time was considered to be the penetration of mini computers (not to be confused with PCs, these were really just smaller mainframes) by DEC and HP.

Let's say that for some reason the US government decides it is fed up with the IBM "monopoly" and the high cost of mainframe computing and it wants to take over.  It feels like there is a lot of waste in mainframes as some people are using them for frivolous reasons while other companies who really need them can't afford them.  They might have created review boards to make sure that they thought each dollar spent on computing hardware and software was "worth it."

So, how much spending is needed to maintain innovation?  We know in hindsight that the PC revolution is looming in the next few years.  And in that context, Klein's question is absurd.  The answer is that spending per se, and even profits, in the mainframe computing market were irrelevant to the coming series of innovations.    The necessary preconditions were that entrepreneurs saw that new technology provided potential new value to consumers, and were allowed the freedom to launch these new products in hopes that the value these new products provided would be sufficiently high that consumers would pay enough for them to return their cost of manufacture and development and return them a profit.  Some succeeded, and some failed, but entrepreneurs were allowed to try, despite most "experts" predicting the PC was a silly toy.

Note that computer innovators were not required to trundle into some government computing board to justify the PC and its price, to justify how much, as Klein would say, needed to be spent on PC's.   If in fact they were forced to do so, if Jobs and Wozniak had to fly to Washington to justify the Apple I to the Computing Spending Decisions Board, they would have almost certainly been shot down.  Or told they could sell it but only for $200 and not their initial price of $2000.  We would have never had a PC revolution in a government single payer computing world, no matter how much, as Klein asks, was "spent" by the government.   It is possible that the government might eventually have greenlighted a PC (years later) just as the increasingly bureaucratic IBM did, but can you imagine how frail the PC revolution would would be if only IBM had ever sold PCs, without the slew of competitors that emerged, and if every innovation had to pass the scrutiny of a government review board before it could be launched?   Only a tiny percentage of PC innovation and of what we think of as a PC today, mostly in the basic architecture, ever came from IBM.

The very problem is that when government runs computers or health care, innovation is seen as a cost.  Klein, by asking the question in this way, is betraying exactly what is fundamentally wrong with a single-payer system.  The single-payer tends to think in terms of trying to deliver the current value proposition (ie the 2009 level of health care technology) as cheaply as possible.  The problem is that in 2039, it will still be focused on delivering the 2009 level of health care technology.  For the government -- a new drug, a new procedure, a new test -- these are all incremental costs, to be avoided.  Klein just wants a number he can plug into budget projections to say, "see, innovation is covered."  Its like Wesley Mouch asking John Galt near the end of Atlas Shrugged to tell him what orders to give.

I wrote about it just the other day.  You can see it in everything the Left writes -- increased spending is equated with increased costs which are therefore bad.  They all say that America's health care spending is rising and our per capita spending is higher than other nations and that this rising spending is somehow a problem to be fixed.  But there is a value side of the equation.  What are we getting from the spending?  When you leave out things the health care system can't do anything about (homicides and fatal accidents) Americans have the longest life expectancy in the world.  We are getting something for that extra money.  It is not just "cost" to be contained.  Is a year of life worth an extra $100,000 spending?  Everyone has a different answer, which is why we typically let each individual make these tradeoffs, and why people are uncomfortable having someone in the Post Office make the tradeoff for them.

But, the left will say, we will put really smart people on this board, who are angels of public service, who will make perfect decisions on the price-value tradeoffs of innovation (have you noticed that all their programs seem dependent on this assumption?)  Back to our computer example, these guys, they would argue, would have been smart enough to have given Jobs and Wozniak the green light.  This is a fantasy.  It never happens.  No matter how good the people, every such government entity is driven by its incentives, and this group's incentives will be to cut spending.  Innovations that result in a net total increase in spending are not going to be well-received.

Further, these boards get politicized, always.  Companies will quickly learn they have a better chance, say, of getting a new breast cancer treatment rather than a new prostrate cancer treatment past the board because the current administration is closely tied to women's groups.  Just look at current government R&D spending, this already happens.  AIDS was under-funded given its mortality because Conservative administrations thought it a disease mainly of groups it found distasteful; today, women's cancers get far more funding than men's due to the strong political activism of women's groups and the success of the pink ribbon campaign.  Drug companies will learn that the quickest way to board approval may not be winning over the board, but getting certain interest groups to lobby the board, or maybe lobby Congress to override the board.  Just look at the promise not to politicize ownership of GM -- that lasted about 2 days before Congress was passing legislation reversing internal GM decisions and GM was making plant closures based on political rather than economic concerns.

But even beyond these problems, there are Hayekian ones as well.  In the mid-seventies, there might have been only a few thousand people who were excited enough to buy an early microcomputer and see its potential.  What are the odds that one of those folks would be on the government review board, particularly since few of them were in the mainstream establishment of the computing field (heck, few of them were over 19 years old).  And even if one were on the board, would they have approved a technology with only a few initial adherents?  The fact is innovation often requires adoption of bleeding edge risk-takers who are willing to try a new technology and iron out its kinks before the mainstream catches on.   The iPod was not the first music player -- a few of us struggled for years before the iPod with large and sometimes hard to use early mp3 players  -- but if these early MP3 players had not existed, the iPod would not exist.

Perhaps most importantly, everyone makes different tradeoffs.  It may make perfect sense for some person in Washington that a biopsy is not required for certain kind of positive cancer test results.  This may make perfect price-value sense to the beauracrat, but I know a number of people who would lose months or years of their life to worry -- worry that could be short-circuited with an inexpensive biopsy.   Or consider a new cancer treatment -- is a year of life worth an extra $100,000 spending?  Would I prefer to extend my life through chemo or increase the quality of life of the time I have left by avoiding chemo?   Everyone has a different answer, which is why we typically let each individual make these tradeoffs, and why people are uncomfortable having someone in the Post Office make the decision for them.

One could say that all of this does not answer Klein's question.  That is because his question, built on the wrong premise, is unanswerable.  I suspect he knows this and is, as Brad Warbiany posited in the link above, just setting up a straw man.  All I can do is try to give a feel what what innovation does require, and help folks to understand that it has little if anything to do with Klein's question.

So, if I had to come up with a pithy one sentence answer, here it would be:

Klein:  What level of spending on health care is optimal for innovation?

Me:  The very fact that you intend to control spending centrally, at any level high or low, is what kills innovation.

Postscript: For a totally different reason, I was reading this article on the Russian T-34 tank, probably the best all-around tank for its time ever made when considering its production volume (the Panther was theoretically a better tank but volume production of the scale of the T-34, not to mention mechanical reliability, eluded the Germans).  Apropos of government boards and innovation was this:

The L-11 gun did not live up to expectations, so the Grabin design bureau at Gorky Factory No. 92 designed a superior F-34 76.2 mm gun. No bureaucrat would approve production, but Gorky and KhPZ started producing the gun anyway; official permission only came from Stalin's State Defense Committee after troops in the field sent back praise for the gun's performance.

Kevin Drum presents this chart:

Look at the top and the bottom of the chart.  The top says "growth of health care costs" while the bottom says "average annual percentage change in total health expenditures."  Drum goes on in his post to use rising expenditures and rising costs interchangeably.  I responded in the comments:

The disconnect between the person purchasing and paying for the service and the person receiving the service.  This causes the most friction that piss people off (either against their insurance company or the government for not paying for something or limiting their flexibility).  But is also tends to drive costs up, as people who are ultimately driving most of the health care choices have zero interest in how much it costs.  Via John Stossel (and the Goldwater Institute)

I wrote more on this issue here.

Greg Mankiw writes about a Paul Krugman article on "the public option," a plan in Congress to provide a federal health insurance plan to compete with private plans and "keep them honest"**

It seems to me that [Krugman] leaves out the answer to the key question: Would the public plan have access to taxpayer funds unavailable to private plans?

If the answer is yes, then the public plan would not offer honest competition to private plans. The taxpayer subsidies would tilt the playing field in favor of the public plan. In this case, the whole idea of a public option seems to be a disingenuous route toward a single-payer system, which many on the left favor but recognize is a political nonstarter.

If the answer is no, then the public plan would need to stand on its own financially and, in essence, would be a private nonprofit plan. But then what's the point? If advocates of a public plan want to start a nonprofit company offering health insurance on better terms than existing insurance companies, nothing is stopping them from doing so right now. There is free entry into the market for health insurance. If a public plan without taxpayer support would succeed, so would a nonprofit insurance company. The fundamental viability of the enterprise does not depend on whether the employees are called "nonprofit administrators" or "civil servants."  (via Q&O)

But I think we already know the answer to this question.   If Obama and the Democratic Congress is willing to pour a hundred billion dollars or more down the Chrysler and GM rat holes, they certainly are going to pony up far more to support a program so near and dear to their heart for so many years.

There is simply not some magic, easy to access pool of savings in health care available to government managers that will reduce costs 30% or pay for increases in benefits.  If there were, Medicare should have already captured them.

** This is always hilarious to see, as if health insurers make some kind of inordinate profits.  As shown before, the typical after-tax profit at health care companies and insurers is something like 3-4% of revenues.

Virginia Postrel has what seems to be a perfectly reasonable suggestion:

Think about this for a moment. Medicare is a huge, single-payer, government-run program. It ought to provide the perfect environment for experimentation. If more-efficient government management can slash health-care costs by addressing all these problems, why not start with Medicare? Let's see what "better management" looks like applied to Medicare before we roll it out to the rest of the country.

This is not a completely cynical suggestion. Medicare is, for instance, a logical place to start to design better electronic records systems and the incentives to use them. But you do have to wonder why a report that claims that Medicare is wasting 30 percent of its spending thinks it's making a case for making the rest of the health care system more like Medicare.

Of course, I think both Obama and Congress know that either 1) such savings are impossible and/or 2) such savings would require steps painful enough to have millions of users squealing.

OK, maybe not all, but there is really one critical issue at the heart of almost all the issues in health care.  It drives whatever cost problems might exist in the system, drives many of the quality problems, and is a source of much of the current dissatisfaction (at least from the middle class) with the current health care system.

For every proposal, you should make sure you understand 1) Who is choosing the amount and quality of the care and 2) who is paying the bills and is therefore trying to pay attention to the cost of care.

What the hell does that have to do with anything, Coyote?  What are you getting at?  Well, perhaps I can begin my explanation by talking about something, practically anything, other than health care.

Take purchasing a car.  When I need a new car, who determines what car I end up with?   Why, I do.  And who pays for the car and shops around for a price that makes sense in the context of the perceived value of the car?  Why, I do again.  The person who uses the car, the person who chooses the type and quality of the car, and the person who pays for the car are all the same person.

This clever procurement model of integrating the payer, the shopper, and the user all into a single individual is one we use for, well, just about every product and service we buy.  Milk, Internet service, DVD's, house painting, airline tickets -- all the same model.

OK, lets consider a model that does not work this way.  Let's say someone just rear-ended your car and, miracle of miracles, they actually have a good, solid insurance policy that owes you for your car repairs.  In this case, you will be consuming the repair services, and have the incentive to find the absolute best, cost-no-object body shop you can find to do the best, most fabulous job fixing your car, because someone else (ie the insurance company) is paying.  The insurance company has a different incentive.  They want to get off with as small a loss as possible, to protect their profitability as well as keeping prices low for future policy-holders.  They are going to want you car fixed cheap, particularly since you are probably not even their customer.  They are going to try to deliver the minimum.

No surprisingly, people tend to get ticked off in these situations, as they grind against the opposing incentives of the insurance company.  It's one reason that the insurance field is highly regulated (because nowadays people complain to their Congressman whenever they get irritated).  It's also a measure of how ineffective regulation is in really managing this friction, since despite zillions of government rules people still get pissed off.  The reason is that there is simply no good solution.   Both parties want a solution at the extreme end of a cost-value scale, neither have much of an incentive to compromise, and neither will be happy with a solution in the middle of these extreme incentives, and no amount of government fiddling with the tradeoff point is going to change this.

OK, but in this example, at the end of the day, it is just a car, and probably this is a once-in-a-lifetime event.  What if we replace "car" with "baby daughter" or "grandmother" or "your life?"  Now, as Bill Murray says, the kidding around is pretty much over.  It is a recipe for an incendiary disaster.  Which is exactly what we have in health care.

If we take these three roles - user, service quality specifyer, and payer/price shopper - there are very few places in medicine today where these three roles are united.  Further, despite the fact that the vast majority of the problems in US health care are demonstrably from this role separation, none of the plans currently being considered by Obama or Congress unify these three parties.

With my high deductible medical policy, I am actually one of the few middle/upper class folks who actually shops for health care.  And I can tell I am in the minority by the reaction I get from doctors and medical services companies, that look at me like I am from Mars when I ask for detailed pricing, or when I order less than the full and complete battery of potential tests and services based on my own judgment and price/value trade offs.  Folks in the medical profession are used to people saying "whatever, the insurance company is paying for it."

We all know the straights that the auto industry is in, but can you imagine how bad their price and product would be if everyone had some sort of policy that purchased just about any car they wanted for them whenever they wanted it?  What do you think would happen to the prices at your grocery store or at BestBuy if the proprietors of those stores knew, absolutely knew, that you were not even going to look at a price tag before you bought what you wanted?  So why do we expect anything but inflated pricing in the health care field?

Devon Harrick via Carpe Diem writes

The market for medical care does not work like other markets. Providers typically do not disclose prices prior to treatment because they do not compete for patients based on price. Payments are usually not made by patients themselves but by third parties "” employers, insurance companies or government (only 12% of medical costs are paid directly by patients, see chart [below]). And the amounts paid are not really market-clearing prices; they are "reimbursement" rates negotiated with bureaucratic institutions and networks. Furthermore, when providers do not compete on price, they usually do not compete on quality either. In fact, in a very real sense, doctors and hospitals are not competing for patients at all "” at least not in the way normal businesses compete in markets.

The author above has an interesting analysis.  The one exception to the separation of roles in medicine is cosmetic surgery.  Not covered except in special circumstances by most insurance, cosmetic surgery is something the individual must pay for and thus has a tendency to shop for.  The results in prices are clear.

This pricing differential is all the more compelling because itis probably opposite what most people would initially assume.  As cosmetic surgery tends to be a luxury good, one might expect it to have the higher-than-average inflation rate that many luxury goods have had over the past 10 years.

The flip side of the pricing situation is the incredible dissatisfaction that seems to permeate health care customers.  Because the users aren't paying the bills, health care providers have little incentive to provide good service, as even with bad service the value they provide will be able to exceed the user's price of zero, or close to zero.

But, like with the body shop in the collision, someone is indeed paying the bills.  And that someone faces a choice -- either let customers run amuck and buy absolutely as much health care as they want, or try to ration or restrain the care users receive in some way.  So, when Joe and Mary want the 9th sonogram performed just to make sure their fetus is still doing great, the insurance balks at the cost as unnecessary.  The insurance company is upset, because they feel like Joe, Mary, and their doctor are milking the insurance for unnecessary procedures.  Joe and Mary get upset, because they feel like the heartless insurance company doesn't care about their little darling baby.  Everyone calls their Congressman to tell him or her that they are unhappy and could the government please intervene to make them happier.

And so we get to current health care proposals.  Folks have, rightly, come to the conclusion that a system where the user benefits from the service and decides how much and of what quality should be consumed, while someone else pays, is not sustainable.  However, in response, no one in power is suggesting we end the split.  Instead, they are suggesting that the role of service determination and payment/price-shopping be performed by the government.  We as a consumer will just have to trust that the government will make this price-value tradeoff somehow close to how we would make it for ourselves.

But of course, this is absolutely freaking impossible.  First and foremost is the problem that the government can only choose one policy for everyone embodying a single point on the trade off curve.  But we have 300 million people with 300 million different preference functions.  No one is going to be happy.  Second, the government is a terrible shopper.  We all know this to be true.  So why do we think they are going to suddenly become wizards when it comes to health care?  Third, the government is a terrible administrator.  As a monopoly provider, they simply don't have the inventive to be either responsive of cost-effective.  Again, we all know this to be true, so why are we so willing to hope that things will suddenly change for health care?

The only thing that makes any sense at all to me is to try to give the user of health care some financial incentive to participate in the price value tradeoff and shopping process.  I know that I have simultaneously saved a ton of money as well as substantially increased my health care shopping IQ since our family adopted a high-deductible health insurance policy.  Incredibly, however, this is one solution that absolutely is off the table -- for example, the first step Massachusetts took in their single payer system was making it illegal for consumers to buy the kind of high-deductible insurance I have.  Illegal!

Megan McArdle makes a great point that should be absolutely uncontroversial:

government is much better as a price taker than a price maker.
Government procurement is all kinds of tedious and cluttered with red
tape, but in the end there's no gigantic problem with the government
pencil supply. Defense procurement, on the other hand, is pretty well
agreed to be godawful-expensive for what we get, the only excuse being
that we can't think of another way to buy fighter planes.

That means that government procurement alongside a free market looks a lot
different from government procurement when the government is the only
buyer. Yes, the health care market is extremely screwed up, but the
prices in it do tell you something about demand for various services,
and provide some signals about cost/benefit. You may think that viagra
is a prime example of wasted pharmaceutical R&D spending (though if
you do, I am willing to bet that you are either under forty, or
female), but the fact that a lot of people are willing to pay a fair
amount of coin for it tells you that they probably feel it is improving
their lives in some significant way. Governments can estimate
cost-benefit when the benefit is limited to crude mortality
improvements, but they are pretty much at sea when it comes to
quality-of-life. America's price signals are wildly distorted by its
insurance markets--but they're almost certainly better than no signal
at all.

Europe's governments operate their health care systems in the
context of an existing US market that provides information about demand
for new treatments (and of course I would argue, also the new
treatments). They don't use that price information to set what they pay
for drugs, but it does filter through to their markets--for example,
more widespread use of Herceptin for breast cancer in the US is putting
pressure on the British government to provide it. I think an American
shift to single-payer would be more problematic than the European
example for a variety of reasons related to our government structure.
But one important reason is that if we did, we'd have no where left to
get prices from.

For a while, I have been trying to highlight that the real problem with health care is that consumers who receive the service do not have any incentive to shop for the best price or to make trade offs on marginal procedures based on price.  The only people who have any incentive to shop are 1) people without insurance and 2) people with high deductibles (like me).  Politicians are trying to eliminate the former group, even if they don't want insurance, and programs like Romney's in Massachusetts actually ban high deductible insurance.

Now, Obama is worried about anti-trust:

The consequences of lax enforcement for consumers are clear. Take
health care, for example. There have been over 400 health care mergers
in the last 10 years. The American Medical Association reports that 95%
of insurance markets in the United States are now highly concentrated
and the number of insurers has fallen by just under 20% since 2000.
These changes were supposed to make the industry more efficient, but
instead premiums have skyrocketed, increasing over 87 percent over the
past six years. As president, I will direct my administration to
reinvigorate antitrust enforcement. It will step up review of merger
activity and take effective action to stop or restructure those mergers
that are likely to harm consumer welfare, while quickly clearing those
that do not.

How can these mergers harm consumers when consumers don't shop for the service and don't care about price in the first place?  Candidates like Obama and Clinton are threatening to create single payer systems that use monopsony power combined presumably with the coercive power of government to hammer suppliers.  Is it any wonder that they are joining together to try to gain some sort of bargaining position for themselves?  In the context of what Obama wants to do with health care buying, this can be thought of more as unionizing than merging.

By the way, does anyone else note the irony of Obama, who wants to create a single supplier for health care (the US Government) lamenting concentration in the health care field?

Via Q&O:

Again, the grand claim of such a system is it will be more efficient
and less costly. Nary a one of the systems in existence today that I've
read about has lived up to the "efficiency" claim, if access and
waiting times are a measure of efficiency. Every one of them seems to
suffer from lack of access.

Secondly, the "less costly" claim
seems to be accomplished by limiting access and limiting treatment. A
rigid structure with prescribed treatments which disallow deviation.
Imagine the sort of cancer treatment forced on the Japanese attempted
here. Now imagine it with any other chronic disease you can name.

What's the premise at work in a system like that?

Commenting
on the WSJ article, Craig Cantoni, a columnist in Scottsdale, Ariz.,
writes: "Like nationalized health care in other countries, the Japanese
system is based on the premise that the state owns your body."
Therefore, "the state can dictate what medical care can be withheld
from you, either by policy or by making you wait so long for care that
you die in the mean time."

We see all sorts of bloviation
by the left about attacks on our liberty. Yet, for the most part, they
are supportive of the most insidious attack on our liberty you can
imagine with their call for some form of universal health care system
here. And make no mistake, all of the leading Presidential candidates
are talking about an eventual government-run system despite their
obvious spin.

I've said something similar for years.  As one example, I have pointed out that the National Organization of Women's strong support for national health care just demonstrates their utter intellectual bankruptcy, as I wrote here:

What this article really shows is that by going with a single-payer
government system, each of us would be ceding the decisions about our
health care, our bodies, and even lifestyle to the government.  So
surely women's groups, who were at the forefront of fighting against
government intrusion into our decisions about our bodies, is out there
leading the fight against government health care.  WRONG!
Their privacy arguments stand out today as sham libertarian arguments
that applied only narrowly to abortion.  It's clear that as long as
they can get full access to abortion, women's groups are A-OK with
government intrusion into people's decisions about their bodies.

Don't miss their web site, which has sales offers for "Keep your laws of my body" T-shirts right next to appeals to "demand health care for all now."

Reader Robert Hammond, who always sends me good stuff, pointed out this article from the Evening Standard about proposed new health care rules in England.  Frequent readers will know that I have long argued that nationalized or single-payer health care is a Trojan Horse for fascism (and much more here) in the form of micro-management of individual decisions.  If your personal choices that in the past only put yourself at risk now cost other taxpayers money, then those other taxpayers are going to try to redirect your choices.

Failing to follow a healthy lifestyle could lead to free NHS treatment being denied under the Tory plans. 

Patients would be handed "NHS Health Miles Cards" allowing them to earn
reward points for losing weight, giving up smoking, receiving
immunisations or attending regular health screenings.

Like a
supermarket loyalty card, the points could be redeemed as discounts on
gym membership and fresh fruit and vegetables, or even give priority
for other public services - such as jumping the queue for council
housing.

But heavy smokers, the obese and binge drinkers who
were a drain on the NHS could be denied some routine treatments such as
hip replacements until they cleaned up their act.

Those who
abused the system - by calling an ambulance when a trip to the GP would
be sufficient, or telephoning out of hours with needless queries -
could also be penalised.

The report calls for a greater
emphasis on the "citizen's responsibility" to be healthy and says no
one should expect taxpayers to fund their unhealthy lifestyles.

Here is the real problem:  This is absolutely logical.  There is nothing at all incorrect about the last statement for example.  This is not an abuse or an excess.  This is a completely predictable result of single-payer health care.  Any single-payer is going to have these incentives, but when the single-payer is the government, they not only have the incentives but the full coercive power to do something about it.  I am exhausted with the statist defense against such outcomes that "well, its just the particular individuals in charge -- if we could get the right guys in there, it would work great."  No.  The right guys are never in there, despite technocrats' big dreams, in part because the incentives in place turn even the right guys into the wrong guys. 

One of the reasons we spend so much on health care today is because most of us can do so without any personal financial cost.  Few of us (I am an exception, with a very high deductible policy) actually have to make cost-benefit trade offs in each of our health care purchases like we do in contrast for ... absolutely everything else we buy except health care.   The results are predictable.  We get pissed off when our insurance company denies coverage on some procedure or cost, we is part of the base-level of discontent that health care "reformers" draw on.  But it is stunning to me that people who have discontent with their current insurer feel like things will be better with the government!

Hey, this sounds like a women's issue!

What this article really shows is that by going with a single-payer government system, each of us would be ceding the decisions about our health care, our bodies, and even lifestyle to the government.  So surely women's groups, who were at the forefront of fighting against government intrusion into our decisions about our bodies, is out there leading the fight against government health care.  WRONG!  Their privacy arguments stand out today as sham libertarian arguments that applied only narrowly to abortion.  It's clear that as long as they can get full access to abortion, women's groups are A-OK with government intrusion into people's decisions about their bodies.

So please, dedicated feminists are urged to comment.  How do I relate this T-shirt from the NOW web store:

With this button from the NOW home page:

And a bit of text from their site:

People need and deserve universal, continuous,
and accessible health coverage that is provided by a single payer and
does not require full-time employment and a beneficent employer.
Learn more with our action toolkit....

With the recent release of Michael Moore's new movie, "SiCKO", and the
introduction in Congress of a bill to provide health insurance to all
U.S. residents, the movement for universal single-payer health
insurance is gaining momentum. This toolkit is provided to help you
take action on this important issue....

Health care is a right, not a privilege.

I am always absolutely amazed when advocates of some form of national or single-payer health care argue that such a system would be more efficient.  For example, Kevin Drum argued:

A few days ago, during an email exchange with a
friend, I mentioned that I don't usually tout cost savings as a big
argument in favor of universal healthcare. It's true that a national
healthcare plan would almost certainly save money compared to our
current Rube Goldberg system, but I suspect the savings would be
modest. Rather, the real advantages of national healthcare are related
to things like access (getting everyone covered), efficiency (cutting down on useless -- or even deliberately counterproductive -- administrative bureaucracies), choice
(allowing people to choose and keep a family doctor instead of being
jerked around everytime their employer decides to switch health
providers), and social justice (providing decent, hassle-free healthcare for the poor).

I don't think any of these are true.  For example, let's take access.  Yes, everyone in a universal health care system would have a piece of paper that says they have health care, and the left seems really focused on that piece of paper.  But that paper has about as much value as my piece of paper that says I own a hundred shares of Enron.  Because someone has to redeem that piece of paper and actually provide the care, and there is the rub, is it not?  Canadian David Gratzer writes (vis Q&O):

My book's thesis was simple: to contain rising
costs, government-run health-care systems invariably restrict the
health-care supply. Thus, at a time when Canada's population was aging
and needed more care, not less, cost-crunching bureaucrats had reduced
the size of medical school classes, shuttered hospitals, and capped
physician fees, resulting in hundreds of thousands of patients waiting
for needed treatment"”patients who suffered and, in some cases, died
from the delays....

Nor were the problems I identified unique to
Canada"”they characterized all government-run health-care systems.
Consider the recent British controversy over a cancer patient who tried
to get an appointment with a specialist, only to have it canceled"”48
times. More than 1 million Britons must wait for some type of care,
with 200,000 in line for longer than six months. A while back, I toured
a public hospital in Washington, D.C., with Tim Evans, a senior fellow
at the Centre for the New Europe. The hospital was dark and dingy, but
Evans observed that it was cleaner than anything in his native England.
In France, the supply of doctors is so limited that during an August
2003 heat wave"”when many doctors were on vacation and hospitals were
stretched beyond capacity"”15,000 elderly citizens died. Across Europe,
state-of-the-art drugs aren't available. And so on.

I had forgotten about the heat wave.  Could you imagine backwards old America having 15,000 people die when the temperature got into the 90's?

As to efficiency, which Drum defines as "cutting down on useless -- or even deliberately counterproductive -- administrative bureaucracies," does anyone really ascribe these characteristics to the government?  Really?  Even European health care bureaucrats would not agree with this statement:

This privatizing trend is reaching Europe, too.
Britain's government-run health care dates back to the 1940s. Yet the
Labour Party"”which originally created the National Health Service and
used to bristle at the suggestion of private medicine, dismissing it as
"Americanization""”now openly favors privatization. Sir William Wells, a
senior British health official, recently said: "The big trouble with a
state monopoly is that it builds in massive inefficiencies and
inward-looking culture."

I won't get much into the last two, except to say that we actually have a ton of health care choice in the US today, far more than any other country.  And even if we did not, what does doctor choice mean if the best people are driven away from being doctors, as they are in socialized medicine.  And social justice?  Well, the poor get care in the US, the key is the "hassle-free" in his statement.  Would you immediately assume that a government-run service is going to involve less hassle than a private service?  Have you renewed your drivers license lately?  It may well be that the poorest 10% have such an awful health care experience that they will see things better.  But almost assuredly the other 90% are going to be worse off.

Remember this -- Universal health care is NOT a system in which the majority of us who are satisfied with our care can keep our current system, while the poor get a better one.  It is a system where all of us are thrown out of our current system and given the same care the poor get.  It is roughly equivalent to a Great Society housing program in which not just the homeless get housing, but everyone in the country are forced to give up their current house and live in public housing.

Postscript:  There is great improvement to be had in the health care system.  It revolves, though, around making the payer for health care the same person who receives the service, as it is for every other product and service we buy in this country.  We already have too much single-payer.  We need multi-payer.  I won't go there today, but I explained here.

Another Thought: A huge pillar of the women's movement was that the government should not make decisions for a woman and her body (e.g. by banning abortion).   All well and good.  But I have never understood how this was consistent with support, say, for the FDA, which tells women exactly what they can and can't put in their body.  And now women's groups are all for universal health care, where government will make all the medical decisions about what procedures one can and can't have, and when.  Consistency please?

The best answer, of course, as to why single-payer is bad is that the single-payer will not be me, and therefore will not make trade offs about my health, money, time, etc. in the same way I would.  One of the many problems with polling on issues like this is that someone asks a question like "Are you satisfied with your health care" and when XX% of people say "no", the person using the poll goes on to postulate that the people are dissatisfied for Y reason.  But people may be dissatisfied for many reasons.  For example, I know that many people's main source of dissatisfaction is that their current insurance company was callous in rejecting them for so-and-so procedure.  But do they really think the government is going to be less callous?

Unfortunately, this best answer does not seem to be getting anywhere, so I will offer another answer.  Single payer health care will almost certainly lead over time to single provider health care.  What is my evidence?  Well, that is what happened in K-12 education.  And note the very very strong opposition to migrating education from single-provider to single-payer by the exact same people who are the intellectual driving force for some kind of massive new federal intervention in health care.  Kevin Drum and Matthew Yglesias both argue that single payer is inherently unfair.  So get ready, Walter Reed and the Post Office may soon be teaming up to provide your medical care. 

Steven Pearlstein has a column on the American health care system based on a recent study by the McKinsey Global Institute.  As Mr. Pearlstein reads it, the problem with the American medical system is all about the profit - it's all about the doctor profit stacked on the drug profit stacked on the insurance profit.  If the government would just take over and get rid of all that profit, the system would run smoothly and be much cheaper.  I am flabbergasted that anyone at Cato would remark on such an article with approval.

First, while I worked at McKinsey & Co, I never worked for the global institute.  However, though I have not yet read the study, it would be unusual to the point of uniqueness if their recommendation for the industry was more government control and less profit motive, but I guess it is possible.  More likely, Mr. Pearlstein is reading the study through his own progressive lens.  Anyway, let me deal with a few parts of the article:

Even after adjusting for wealth, population mix and higher levels of
some diseases, McKinsey calculated that we spend $477 billion a year
more on health care than would be expected if the United States fit the
spending pattern of 13 other advanced countries. That staggering waste
of money works out to 3.6 percent of the nation's entire economic
output, or $1,645 per person, every year.

I will agree that for a variety of reasons, there is a lot of waste in the medical system.  We will get to "why" in a minute.  However, note that the author is taking a leap from "we spend more per capita than Europeans" to "staggering waste."  The US spends more per capita on a lot of things than the Europeans, in large part because we are wealthier (by a lot, and more every day).  One man's waste is another man's preference.  However, I would agree that health care is unique, in that it is the one industry where the decision maker(s) on whether to purchase a service is not the same person who is paying the bills.  I think we will find, though, that I and Mr. Pearlstein differ on who the person should be who should do both simultaneously (I say each person for himself, he says Nancy Pelosi and George Bush for everyone).

But let's get into all that money-grubbing.  Mr. Pearlstein reads the study as saying the problem is all that profit.  Because we have layers of profit in the distribution channel, our health care costs more than it does in Europe, where you have the efficiency [sic!] of government management.  Before we get into detail, I would observe that this fails a pretty basic smell test right off:  Nearly every single product and service we Americans buy, all of which are rife with layers of nasty profits in the supply chain, are cheaper than their counterpart services and products in Europe.  If this layering of profit without government management is a problem, why is it only a problem in health care but not a problem in thousands of other industries.  But anyway, to details:

Let's start with one the American Medical Association hopes no one
will notice, which is that American doctors make a lot more money than
doctors elsewhere -- roughly twice as much. The average incomes of
$274,000 for specialists and $173,000 for general practitioners are,
respectively, 6.6 and 4.2 times those of the average patient. The rate
in the other countries is 4 and 3.2.

According to McKinsey, the
difference works out to $58 billion a year. What drives it is not how
much doctors charge per procedure, but how many procedures they perform
and how many patients they see -- a volume of business 60 percent
higher here than elsewhere.

Ooh, those greedy doctors.  They are the problem!  But read carefully, especially the last sentence.  He makes clear doctors in the US are not making more because they charge more, they make more because they see more patients --- ie, they work harder than their European counterparts.  Where have I heard this before?  Again, in every other industry you can name, the fact that our workers work harder than their European counterparts is a good thing, leading to lower costs and higher productivity.  So why is it suddenly bad in medicine?  For this I would instead draw the conclusion that their are perhaps too many procedures (an expected outcome of the screwy incentives in the system) and thus too many doctors.  Doctors, whom Mr. Pearlstein paints as enemy number one in the health care system, are actually its greatest asset, being 60% more productive than their European counterparts, certainly something to build on.

Don't be distracted by arguments that American doctors need to make
more because they have to pay $20 billion a year in malpractice
insurance premiums forced on them by a hostile legal system, or an
equal amount for all the paperwork required by our private insurance
system. The $58 billion in what the study defines as excess physician
income is calculated after those expenses are paid.

Walter Olson, are you listening?  Since Walter is not here, I will say it for him.  Malpractice insurance premiums themselves are only a part of the cost of runaway malpractice.  Defensive medicine, including the overuse of tests, is another big cost.  Malpractice is one big reason doctors prescribe so many more tests and procedures than their European peers.

Proponents of a government-run "single-payer" system will certainly
home in on the $84 billion a year that McKinsey found that Americans
spend to administer the private sector portion of its health system --
a cost that national health plans largely avoid. But as long as
Americans continue to reject a government-run health system, a private
system will require something close to the $30 billion a year in
after-tax profits earned by health insurance companies. What may not be
necessary, McKinsey suggests, is the $32 billion that the industry
spends each year on marketing and figuring out the premium for each
individual or group customer in each state. Insurance-market reform
could eliminate much of that expense.

What freaking planet does this guy live on?  Does he really think administrative costs are going to go down in a single payer system?  That's insane.  I am willing to believe that the number of procedures will go way down, as Congress starts to ration care in favor of building bridges for their constituents  (a savings likely offset as America's world-leading doctor productivity discussed above takes a nosedive).  Does he really think that administrative costs will go down?  Most administrative costs today are for satisfying government paperwork requirements - how is having the government run everything going to reduce these?   I would argue exactly the opposite -- that eliminating government from the equation would reduce private administrative costs substantially.

I won't bore you with any more, but he doesn't miss the chance to blame health care costs on drug and hospital company profits as well.  Just for entertainment value, I urge the reader to look up a few P&L's of some of these companies.  The profit as a percent of sales for Humana is 2.3% of sales.  So if you wiped out all that egregious profit at Humana, you would save all its customers a whopping 2.3% (before, of course, the incentives problems take over and costs bloat for the lack of a profit incentive to manage them). Insurer CIGNA's profit is a bit under 10%.   Merck's profit is a more comfortable 19% of sales, which means that by cutting their profit to zero we could get nearly a 20% discount on drugs.  Of course, new drug development would cease, but the AARP doesn't care about drugs that won't be on the market after their current constituency is dead.

Isn't it more reasonable, as I am sure the McKinsey study actually concludes, that the problem is not in companies making profits or doctors working hard, it is in having a health care system, built the way it is through distortive tax law, that gives neither patient nor doctor any reason to consider costs when deciding on care?  Can you imagine such a screwed up system in any other industry?  How inefficient would retail be in the US, for example, if we all had a "shopping policy" that paid for all our purchases.  Would you give a crap about the price of anything?  Would you hesitate one second buying something you may not need but is covered by your "policy"?

Mr. Pearlstein sortof agrees, but its hard to find this incentives point in the middle of all his blame-it-on-the-profits progressive rhetoric.  Here is our one hint that Mr. Pearlstein understands that the true problem is this mismatch between payer and decision-maker.  Unfortunately (emphasis added) he has a really destructive perspective on the issue:

What we have here is pretty good circumstantial evidence of
Pearlstein's First Law of Health Economics, which holds that if you pay
doctors on the basis of how many procedures they do, and you leave it
to doctors and their insured patients to decide how much health care
they get, consumption of health services will rise to whatever level is
necessary for doctors to earn as much as the lawyers who sue them.

Mr. medico-fascist Pearlstein thinks the big system problem is leaving it to you, the patient, to decide what health care you get.  The solution for him is to have the person spending the money, preferably the US Congress, decide how much health care you get.  I think a much saner solution, and the only one consistent with a free society, is to get back to a system where the same person who gets the care, pays for the care.  If its a good enough system for 9,999 things we purchase each year, its good enough for health care too.

Expect the next Democratic presidential nominee to run strongly on single-payer (ie socialized) medicine.  Vodkapundit reminds us what this is like, with the latest from England:

Hospitals across the country are imposing minimum waiting times -
delaying the treatment of thousands of patients.

After years of Government targets pushing them to cut waiting lists, staff
are now being warned against "over-performing" by treating patients too quickly.
The Sunday Telegraph has learned that at least six trusts have imposed the
minimum times.

In March, Patricia Hewitt, the Secretary of State for Health, offered her
apparent blessing for the minimum waiting times by announcing they would be
"appropriate" in some cases. Amid fears about £1.27 billion of NHS debts, she
expressed concern that some hospitals were so productive "they actually got
ahead of what the NHS could afford".
...

The Sunday Telegraph has learned of five further minimum-waiting-time
directives. In May, Staffordshire Moorlands PCT, which funds services at two
hospitals and is more than £5 million in the red, introduced a 19-week minimum
wait for in-patients and 10 weeks for out-patients. A spokesman said: "These
were the least worst cuts we could make." In March, Eastbourne Downs PCT,
expected to overspend by £7 million this year, ordered a six-month minimum wait
for non-urgent operations. Also in March, it was revealed that Medway PCT, with
a deficit of £12.4 million, brought in a nine-week wait for out-patient
appointments and 20 weeks for non-urgent operations.

Doctors are also resigning. One gynæcologist said that he spent more time
doing sudoku puzzles than treating patients because of the measures. Since
January, West Hertfordshire NHS Trust, with a deficit of £41 million, has used a
10-week minimum wait for routine GP referrals to hospital. Watford and Three
Rivers PCT, £13.2 million in the red, has introduced "demand management": no
in-patient or day case is admitted before five months.

Note that this is not a bug with single-payer systems, it is a feature.  Any 3rd party payer system has to impose some sort of artificial rationing or bankruptcy will ensue.  Would you drive more if your gasoline costs were all covered by a single-payer system, such that you did not pay directly for gas.  Would your choice of cars be affected?

Along the same lines, from Marginal Revolution comes this story of new scholarship showing the enormous spike that occurs in health care demand under third party payer (e.g. insurance) systems.