Monday, February 9, 2009

Single Payer (ugh)

Single-payer is a tough one for me. For the doctrinaire liberals and libertarians, it's an easy call: ideology allows a side-step of the trickiness. Anyhow, I'm far from edumacated on the matter, but I was reminded of the matter just recently, and Obama's promised action, so might as start working those public policy muscles... Anyway, stream-of-consciousness style:

  • A huge selling point of single-payer is the Wal-Mart effect. When a buyer is a sufficiently high portion of a vendor's business, that buyer can drive prices very low. Although liberals tend to be mixed in their views on Wal-Mart, the things that bug them are labor laws and romanticized boutiques. I don't see liberals worrying about doctors or pharmacies in the same ways.
  • Markets clear best when transaction costs are low and things aren't "sticky." Employer-mediated healthcare makes job transitions trickier, tends to penalize workers who would rather work part-time, etc. For libertarians, anything that can reduce the transaction costs for hiring/firing is, cetrius paribus, a good thing. Liberals probably wouldn't be convinced by this line of reasoning.
  • Health care is a lot of things. It's insurance, in the case that any of us can come down with a strange unknown disease or break a leg in a freak accident. Mostly, though, a health "insurance" plan is more similar to a buyer's club where consumers combine for greater bargaining power. Preventative care comes to mind here. It might be that the insurance and group discount components of health care can or should be separated.
  • One explanation for rising health care costs might be that the job is getting harder. When the life expectancy is 40, you can go a long way just by handling infections and infectious diseases properly. Once you get past 70, you move from accute, narrowly treatable ailments into direct consequences of aging. Beating Alzheimer's, MS, cancer, Parkinson's, and many of the other degenerative diseases will really require a fundamental hack of the body's cellular biology. The research that goes into studies, tests, treatments and drugs will be expensive. Kicking all of those will just open up even hairier problems, possibly leading to an (undoubtedly pricey) assault upon mortality itself.
  • One component of health care costs is labor. Doctors in particular. The opportunity cost of being a doctor is huge: roughly a decade of schooling and tens of thousands in debt. Doctor's salaries remain decent, but the combination of a decade of tuition and a decade of lost earnings is hard to overcome. Obama's plan to make federal tax rates slightly more progressive will have an impact here, on the margin. The rhetoric will point at executives, but it will be professionals (doctors, lawyers, etc) that bear a large part of the burden (SS minimums, for example). Anecdotally, the lost decade, the debt, and taxes were all factors in my decision to not pursue med school.
  • Our military spending is single-payer and I'm suspicious that we might still be overpaying. Will we create a new corporatist healthcare-industrial complex? Or, perhaps more accurately, further stimulate the one that we already have?
  • The stand-by libertarian argument: what happened to the efficient market hypothesis? What makes health care special here? Is it that consumers are making stupid decisions, with negative externalities? If so, what guarantee do we have that the government won't make equally stupid decisions, with equally negative externalities? Why pay billions for e.g., the SEC and FDA when I or some other private actor could have ignored Madoff and salmonella for a tenth of that?
  • There will be economies of scale (aka Wal-Mart effect), and possibly other policies taken to address the supply side, but ultimately, if we're aiming to provide helathcare to more people than currently consume it, and more healthcare to those already consuming it, we're going to end up spending more money. From whence do we draw that money? Taxes? Deficit? Spending cuts elsewhere (hey, it could happen, right? Right?)?
Anyhowz, that's a start. Perhaps more to come. Perhaps not. We'll just have to wait and see.


twifkak said...

1. Also, liberals are worried about sacred burial grounds. And there is some precedent for the "romanticized boutique" aspect in medical - see the WB show Treatwood, or general distrust of HMOs.

2. It's spelled "ceteris paribus".

3. Insurance is not efficient. Companies that produce goods and services can be judged by the quality of those goods and services. We pick the product that has the best bang / buck, regardless of its manufacturing cost. Insurance, however, is money in, money out. In a perfect economy (i.e. total information, zero transaction cost), we pick the company that provides the most money out / money in. This will equalize towards no profit, or perhaps even selling insurance at a loss and making it up elsewhere (e.g. in-network fees). Since insurance companies are profiting from insurance plans (okay, I assume), we must therefore be lacking information about them. QED.

Me said...

1) The same people who distrust HMOs wouldn't be caught dead without them. If they were bad, we would want to replace them. They're not all bad though, so do we replace them or improve them? Perhaps by eliminating the middle man (HR departments that select plans)?

2) Yeah, the Fox is great, but it doesn't spell-check Latin.

3) Wal-Mart is not efficient. They spend money on goods, then charge you more than they spent. Actually, Wal-Mart provides distribution, and bullies vendors into lowering their prices. HMOs basically do the second part of that. Collective bargaining.

They also provide insurance, which is also efficient. I pay for insurance, but haven't been to the doctor in ages. Those who suffer unexpected illness or injury are covered by the hedges of folks like me who (so far) have not.