Paul Krugman jumped further in to the health care reform debate today just as the CBO announced that the Obama Plan, billed as a cost-saver, continues to be anything but cost saving. Krugman rightly points out that in a land of third party payers, you are not going to find a free market solution. This is simply true by definition so why is there so much confusion?
Krugman borrows heavily from an earlier treatise by Kenneth Arrow, one of the early pioneers of modern economics in a 1963 treatise called Uncertainty and the Welfare economics of health Care. (Note: The link on Krugman’s blog is bad so use mine.) Let me just mention here that Welfare in economics means you’re looking for allocative efficiency within an economy given that economy’s income distribution. Since so few folks in this country have the majority of income and resources, for example, the U.S. is a considered about average on allocative efficiency. Our resources are not distributed based on the aggregate welfare of society. We have a system where there are winners and losers because most of our goods are distributed by ability to pay and most of that ability to pay comes from accident of birth.
So, Krugman updates the Arrow treatise and argues that healthcare is not what you would refer to as a standard market that would thrive under free market conditions. He points to two very distinct characteristics that takes it out of contention for a completely free market solution which borrow heavily from Arrow.
There are two strongly distinctive aspects of health care. One is that you don’t know when or whether you’ll need care — but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor’s office; and very, very few people can afford to pay major medical costs out of pocket.
The second thing about health care is that it’s complicated, and you can’t rely on experience or comparison shopping. (”I hear they’ve got a real deal on stents over at St. Mary’s!”) That’s why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.
If you’ve followed any of my blogging carefully, you will recognize two underlying themes that we’ve frequently talked about throughout Krugman’s assessment. That would be that the health care market has the two nasty frictions of moral hazard and information asymmetry. Insurance companies, theoretically, should provide cost effective remedies to both. However, there are things unique to health insurance and the underlying risk of getting catastrophic illnesses that make huge risk pools the most cost effective. This is the primary economic argument for universal healthcare. Putting every one (the healthy and the unhealthy) into one HUGE risk pool, minimizes the cost to everyone, thereby maximizing allocative efficiency and economic welfare. Insurance companies that cherry pick, and healthy folks that self opt-out of risk pools, violate these principles and make it more expensive and less efficient for every one.