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发帖数: 3150 | 1 【 以下文字转载自 USANews 讨论区 】
发信人: lqm1989 (Jeremy Lin), 信区: USANews
标 题: The Myth of Health Care's Free Market By David Cay Johnston
发信站: BBS 未名空间站 (Mon Jan 6 00:33:29 2014, 美东)
The Myth of Health Care's Free Market
By David Cay Johnston / January 03 2014 1:05 PM
Ever wonder why an appendectomy costs $8,000 in one place and $29,000
elsewhere? REUTERS/Jim Bourg
Has it ever occurred to you to negotiate with the pilot of the plane you
just boarded about her pay?
Assuming the pilot was willing to take bids for her services, would you have
any idea of how to evaluate the worth of that particular pilot compared to
anyone else who might be at the controls? How long would it delay the flight
while you and other passengers haggled over that fee?
And what of the risks in having a pilot focused on whether she negotiated
good deals with her passengers, rather than getting everyone safely to their
destination?
While haggling with pilots is absurd, the idea that individual Americans
should negotiate the prices each pays for health care is getting a lot of
serious discussion right now. The reason is the Affordable Care Act, a.k.a.
Obamacare, which critics are desperate to find some way to stop.
For weeks, politicians and writers in the opinion pages of The Wall Street
Journal and other critical outlets have declared Obamacare a failure with
plenty of victims. Those are silly assertions because the law only took
effect this week, on the first day of 2014.
These critics are all outrage with no detailed alternatives, except the
mantra that competition will magically bring down health-care costs. The
libertarians at the Cato Institute argue “we need market competition more
than ever. Not the mealymouthed substitutes bandied about by most health
policy wonks. We need something that none of us has ever seen – real
competition in a free health-care market.”
No. We need something easier, simpler, and already proven to cut costs.
For starters, markets can push prices up as well as down. The electricity
market rules, initially written by Enron (at the urging of former Vice
President Dick Cheney, who was pals with the company’s late founder), can
raise prices to 90 percent of what an unfettered monopolist could charge, as
I showed in my book Free Lunch, citing research by Professor Sarosh
Talukdar of Carnegie-Mellon University that no one has challenged.
Then there’s the knowledge component of markets. When one side knows and
the other side is ignorant, you get price-gouging. Under current policies,
prices for medical services are generally confidential. You could call
hospitals and your health insurer to ask the cost of a standard medical
procedure, say cataract or gall-bladder surgery. I tried that, and was told
at every turn that prices were proprietary information – none of my
business, until I got a bill.
More than four decades ago the Supreme Court defined a fair market as the “
price at which the property would change hands between a willing buyer and a
willing seller, neither being under any compulsion to buy or to sell and
both having reasonable knowledge of relevant facts.” How many of us have “
reasonable knowledge” of medical procedures, costs, or even the difference
between a neurologist and a nephrologist?
Is an accident victim writhing in pain, life’s blood flowing out of his
body, free of compulsion?
And how many of us know the assortment of facts needed to price an MRI, an
angiogram or just a dozen stitches? Or, for that matter, whether any of
those procedures is the best alternative, or even necessary?
We don’t have a free market for health-care services. If we did, we would
see a narrow range of prices for the same service. After all, a Ford F-150
pickup with the same options costs about the same in Washington, West
Virginia, or Wyoming. Not so hospital and medical costs, a fact brought home
in the 2012 Pricing Report of the International Federation of Health Plans,
a trade association for health insurance companies.
While the average U.S. hospital stay is just under $4,300 per day, one in
four patients are charged $1,514 or less and one in 20 pay $12,537 or more.
The total cost for an appendectomy ranges from $8,156 for a fourth of these
procedures to more than $29,426 for the most expensive 5 percent. The
average cost is $13,851.
Economists learn before they get their undergraduate degrees that such huge
variations are signs of inefficient markets or even faux markets. Such wide
price variations may even indicate collusion among some providers to jack up
prices, which is generally illegal.
But even if we ignore these huge price variations, the trade industry report
illustrates another problem: American health-care costs are completely out
of line with the rest of the modern world.
In France the average daily cost of a hospital stay is $853; in the U.S., it
’s $4,287.
An MRI costs on average $335 in Britain and $363 in France, but $1,121 in
the U.S.
Routine and normal childbirth costs, on average: $2,641 in Britain and $3,
541 in France but in the U.S. averages $9,775. Caesarean section delivery
runs $4,435 in Britain, $6,441 in France; $15,041 in the U.S.
This pattern holds for all 21 procedures examined in the report.
Excessive health-care costs drain both the public purse and private purses,
make manufacturing uncompetitive and force employers to divert attention
from running their firms to dealing with health insurers.
Our universal single-payer health-care plan for older Americans, Medicare,
has lower costs and lower overhead than the system serving those under age
65. If everyone in the U.S. was on Medicare, the savings would move the
federal budget from deficit to surplus.
Of the 34 modern economies, the U.S. has by far the costliest health care
system. For each dollar per capita that the other 33 economies spend on
health care the U.S. spends $2.64, my analysis of Organization for Economic
Cooperation and Development data shows.
Canada, Germany, and France each spend about 11.5 percent of their economy
on health care, compared to 17.6 percent in the U.S.
We could have eliminated the income tax in 2010 had we adopted the Canadian,
German, or French health-care systems.
Look at your pay stub and how much goes to federal income taxes, then think
about the unnecessary economic pain American health care causes you.
LINEBREAK
One important distinction between other modern countries and the United
States is that they all provide universal health care, while 48 million
Americans had no health insurance in 2012 and another 30 million had
coverage for only part of the year. Millions have coverage riddled with
loopholes and exceptions, not paying for such vital services as an ambulance
, even when the patient is unconscious. And all private health insurers try
to avoid paying claims in various ways, from requiring onerous paperwork to
denying a procedure was necessary.
On top of all this are restraints on trade in American medicine, like
limiting the supply of doctors and nurses. The American Medical Association
has acknowledged that it worked to hold down the number of physicians to
push up income for doctors. Under state licensing rules, many of even the
best-trained foreign doctors cannot practice here.
And then there are the drug and other medical patents. Economist Dean Baker
notes that in America, “we grant patents to providers and then let them
charge pretty much whatever they want, while other countries also grant
patents, but then limit the prices charged.”
When a patent expires, American law allows the drug company to pay would-be
makers of generic versions to not produce the drug. That keeps prices, and
profits, high. It ought to be illegal.
Congress expressly forbids Medicare from negotiating wholesale price
discounts for the Medicare Part D program initiated by President George W.
Bush, so Americans pay far more for drugs available in other countries,
which negotiate huge discounts.
Finally, not everything should be judged by price competition. The love and
affection of our families, the loyalty of our diplomats, and the integrity
of jetliner makers and of the airlines that hire pilots are not matters for
market economics.
We could experiment with the kind of price competition that the Cato
Institute proposes. It might even work, though I doubt it. But why? We
already know that universal coverage with a single payer is much cheaper
than what America spends now. And we know that the quality of U.S. health
care is far from the best – 37th in the world, according to the World
Health Organization, which ranks France No. 1.
When opponents of the Affordable Care Act argue for patients negotiating
health-care prices they make as much sense as proposing that passengers
haggle over pay with an airline pilot. |
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