Yesterday, I lamented that market critics simultaneously (1) argue that information asymmetries mean that patients are too ignorant to control their health care dollars and decisions, and (2) argue for policies that keep patients ignorant.
As if on cue, Ezra Klein pounced on the same hook I used: a column by David Wessel that cited a study showing that elderly patients are often highly satisfied with their care even when the technical quality is sub-par. Klein argues the study is proof that "consumer-directed health care is a silly idea."
Or, perhaps, those findings show that the policies Klein supports (e.g., government-provided coverage) are keeping patients ignorant.
Klein writes, "patients have no capability to separate good medicine from bad...for all their good intentions, [they] are easily fooled by a firm handshake, a pleasant nurse, and a well-decorated waiting room." Klein continues, "If doctors need watchdogs, then we need to empower institutions or individuals with the education and ability to actually watch over them."
Presumably, Klein thinks a free market would not do so. But if that means the government should monitor quality, how would Klein insulate that effort from the political influence of providers, whose incomes would depend on what the watchdogs decide? Are politicians never fooled by a ($2,000) handshake? Which is easier: to fool all of the people all of the time, or to fool 535 people at any given time?
Yesterday, the DEA announced that it would allow doctors to write multiple, post-dated painkiller prescriptions for chronic pain patients. This is good news. The prior restrictions were odious, and heartlessly required people suffering from chronic pain to make multiple trips to doctors and pharmacists to get their medication.
This problem is worse than it sounds. Because the DEA's witchhunt has scared physicians away from palliative therapy, many of these patients have to drive several hours to find a doctor who is willing to treat them. Doctors willing to administer the most promising chronic pain treatment — high-dose opioid therapy — are even harder to find.
But yesterday's decision doesn't go nearly far enough. And the DEA seems to be trying to use this one concession to show its "reasonableness," thus heading off criticism over the larger, more important issue — it's overly aggressive pursuit of doctors.
Here's what won't change: The agency will continue to substitute its own judgment for the medical opinions of doctors. It will continue to define some high-dose treatments as off-limits, and it will continue to use malpractice standards, meant for civil litigation, in criminal court. The DEA also still refuses to give doctors a set of guidelines they can follow to guarantee they won't be prosecuted, thus giving the agency a great deal of leeway and leaving doctors who engage in the experimental high-dosage treatments in legal ambiguity. The agency will also continue to deny doctors a "good faith" defense to prosecution.
I know, this one's outside my bailiwick, but can you blame me? Apparently New Mexico has forbidden interior designers from calling themselves "interior designers" unless they are officially certified by the government.
What, exactly, is the compelling state interest for such a ban? Are New Mexico legislators fearful that citizens will suffer irreversible harm from bad Feng Shui? "You've lined up your dining room table with your couch?!? Are you mad!?!"
Or have they developed such a keenly felt artisitic sensibility that they must spare New Mexicans from a return to the "Interior Desecrations" of the 1970s?
As a forthcoming Cato Institute paper reveals, state licensure of professionals is a bad idea even in important areas like teaching ("Giving Kids the Chaff: How to Find and Keep the Teachers We Need"). That it is even contemplated in interior design is, at the very least, decidedly tacky.
Hat tip, Jacob Sullum.
I’ve been noodling through a government reform thought experiment, but can’t seem to reach a conclusion. See what you think…
The reform would address that most nefarious dynamic: When the benefits of government spending are concentrated and the costs are dispersed, government will grow and spending will increase.
Mancur Olson described this dynamic more than 40 years ago in The Logic of Collective Action. Steve Slivinski, in his new book Buck Wild, summarizes Olson’s idea as follows:
Olson pointed out that the disparity in incentives between taxpayers and what we now call “special interests” results from an inherent disadvantage of the larger group (i.e., taxpayers) compared to the smaller group (i.e., recipients of public dollars) in its ability to organize to defend its interests. It is this inherent bias in favor of the small special interest groups that provides a very robust explanation of why we still have Big Government, even though many taxpayers would prefer smaller government. “It would be in the best interest of those groups who are organizing to increase their own gains by whatever means possible,” writes Olson. “This would include choosing policies that, though inefficient for the society as a whole, were advantageous for the organized groups because the costs of the policies fell disproportionately on the unorganized.”
To borrow an example from Steve’s book, the National Endowment for the Arts had a 2004 grant budget of $47.4 million — equal to about 0.01% of income taxes. The NEA awarded 1,970 grants that year, so the average grant amount was $24,000. Grant recipients would thus have considerably more financial incentive to lobby for continuing the NEA than individual taxpayers, who on average contribute less than a buck per year to the program, would have to lobby for discontinuing it.
In today's Wall Street Journal, David Wessel writes:
It's fashionable these days, particularly in Washington, to argue that the best way to improve the quality and restrain the cost of health care is to make the market for health care more like the market for everything else.
It's also fashionable for opponents of free-market health care to caricature the case for market-based reform.
I don't know where Wessel comes down in that debate. But he does employ a favorite straw man of those who oppose market-based reforms: that the case for markets "rests on the belief that health care is -- in most respects -- like any other product." In fact, the case for markets does not rest on that assumption.
That assumption is obviously false. As Charles Phelps writes in his leading textbook Health Economics, health care markets face challenges such as extensive government intervention, uncertainty, asymmetries of information, and externalities. Also, health care is scary, involving life-and-death decisions. Of course, each of these dynamics is present in many markets. What makes health care unique is how many of these factors converge in one place.
The case for markets is that markets do the best job of dealing with all those sticky wickets. Take asymmetric information. Critics say that the knowledge gap between doctor and patient is so great that consumers cannot be assured of quality. But information asymmetries occur everywhere; every day, I am positively besieged by them. I don't know how to sew, much less build a car or a computer. But those information asymmetries between me and a seamstress or Subaru or IBM do not prevent me from driving to work fully clothed and blogging about health policy. Markets thrive on informational asymmetries, which are an essential part of specialization.
For the moment, the Democrats are expected to win control of one or both houses of Congress in the congressional election this fall. That may have two strongly beneficial effects on the Republican Party:
- More congressional Republicans will rediscover their commitment to fiscal responsibility when most of the proposals for increased spending originate in a house of Congress controlled by the Democrats. For the past five years, in contrast, congressional Republicans approved almost all proposals for increased spending by the Republican president or their party colleagues.
- More social conservatives will rediscover their commitment to federalism in order to protect the authority to address value issues by state governments when it becomes clear that there is no political opportunity for federal decisions on these issues. With the first unified Republican federal government in 50 years, in contrast, social conservatives have been motivated to propose federal political decisions on these issues for which there is no national consensus.
The combination of a long unnecessary war, the fiscal excesses disguised as compassionate conservatism, and an intolerant social agenda has almost destroyed the traditional Republican political coalition, leaving many of us without any enthusiasm for the candidates and policies of either party. The first step to restoring the Republican Party, ironically, may be a Democratic victory in the congressional election this fall.
Several years in the political wilderness may do much to clear the mind.
According to Kaisernetwork.org:
Reps. Tom Price (R-Ga.) and Tammy Baldwin (D-Wis.) on Wednesday at a joint event by the Brookings Institution and Heritage Foundation encouraged lawmakers to back a bill (HR 5864) that would "allow states to act as laboratories where lawmakers could test methods to reduce the number of uninsured Americans," CQ HealthBeat reports.
In an online debate with Stuart Butler of the Heritage Foundation (here, here, and here), I argued that this approach would favor government-expanding health care proposals.
Those in search of a free-market health care agenda should look elsewhere.