Putting a price on health

Kevin Drum is healthcare blogging:

Ezra Klein attended a healthcare presentation this morning by Alan Enthoven ("the godfather of managed competition") where Enthoven laid out the pros and cons of a single-payer system. Here's his list of cons:

1. Locks in fee-for-service medicine. Hard to change once implemented. Medicare's coverage of preventive services has been poor.

2. We need a lot of innovation in payment and delivery services, and single-payer blocks that.

3. Too much entanglement with politics. Think of how the earmarks will work

4. Government can't set every price correctly. There are too many of them!

5. Tax burden probably too high for the US.

6. Government isn't really designed for efficient program management.

7. There's little accountability for poorly run public programs.

8. There's poor customer service.

9. Legislators don't want efficiency.

10. Medicare's low administration isn't merely efficiency, it's also undermanagement.

Anybody else see the real con at work here? By my count, 7 out of 10 of these bullets (3-4 and 6-10) are essentially the same: government is inefficient and can't administer public programs well. But saying it seven times doesn't make it so. I suppose it's possible that American government is uniquely inefficient, but what makes Enthoven believe that? Other countries manage to operate national healthcare plans of varying degrees of centralization in a more efficient way than our weird public/private/corporate hybrid, so why couldn't we?

For obvious reasons, I'm skeptical of any argument against national healthcare that boils down to "government doesn't work." That's ideology, not argument, and this list is heavily padded to make the problems with single-payer look a lot worse than they are. I don't think you'd need to do that if you were making an honest case.

Obviously, I differ, but I'm not going to start up a debate right now on government efficiency. I do want to focus on one item, number four, and make a fairly uncontroversial point: 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.