Ramesh Ponnuru is not a health-care economist

"How am I supposed to take your magazine seriously when silliness like that gets printed?"

Difficult as it is to agree with anyone from the National Review, I too wonder why TIME wants to climb into bed with the National Review.

How can one take TIME seriously as it lurches into the neo-con camp? This is indeed silliness.

Apologies. That quote was apparently Chuck referring to the National Review. Agreed, Chuck, it's tricky to understand why anyone takes the National Review seriously.

So why are the editors and management of TIME adding yet another NR writer to their editorial stable? Why is TIME getting into bed with the National Review? This is silliness.

Ponnuru is definitely very conservative, although I don't think he'd consider himself a neocon. The other opinion columnist we've added lately is Samantha Power, who is a little hard to define politically but certainly isn't any kind of right winger. As for the true neocons, Charles Krauthammer hasn't had a piece in the magazine since March and William Kristol's column seems to make it in only once a month or less. The people who dominate the columnist slots are Joe Klein, who is on staff and is generally expected to be in there every week, and to a lesser extent Michael Kinsley. I would agree that this constitutes clear evidence of a bias in favor of people whose last name begins with "K." But I wouldn't really call it lurching into the neocon camp. (Maybe the neokon kamp.) The only other person with National Review ties writing for Time (that I know of) is Richard Brookhiser, who writes occasional history columns that are marked by a notable lack of tendentiousness.

The other opinion columnist we've added lately is Samantha Power, who is a little hard to define politically but certainly isn't any kind of right winger....I would agree that this constitutes clear evidence of a bias in favor of people whose last name begins with "K."

so Mark "Drudge-Rules-Our-World" Halperin isn't expected to contribute anything to the dead tree edition of Time?

The thing about Time columnists is that your supposed "liberals" are always criticizing the left (more than the right, it seems).... and your conservative columnists never seem to criticise the right. Both Kinsley and Klein apparently take great pride in their supposed iconoclasm and apostasy -- when all they are really doing is kowtowing to the conventional wisdom of the denizens of The Village.

Meanwhile, Kristol, Krautheimer and now Ponnuru are out there consistently promoting a far-right agenda. I mean, when was the last time your magazine took the question of single-payer health care seriously? Yet here Time is giving space to one of the most idiotic proposals imaginable.

And "imaginable" is the right word. While single-payer has been proven a highly cost-effective means of delivering health care services in tons of countries, Ponnuru's proposal is pure fantasy. Or maybe not -- there is a reason for "employer based" health insurance, and the existence of Medicare...the abject failure of "the market" to provide affordable health care to individuals.

In other words, Time publishes a whole lot of faux liberal opinion.... and tons of right wing opinion that no thinking person should take seriously. That is bias.

Look, I would agree that Time has no columnist nearly as left-wing as Ponnuru and Kristol are right-wing. I'm just saying that they show up only intermittently in the magazine, while the "faux liberals" are there all the time. So it's consistent conservatives appearing inconsistently vs. inconsistent liberals appearing consistently. Which is sorta symmetrical, no?

As for Halperin, he writes for the dead tree magazine too. He's just not one of the opinion columnists. He's also not really a conservative, as best I can tell. He just has a habit of saying things that drive bloggers and blog commenters nuts.

I find it preposterous that people actually expect for the government to provide health care for them and their families. It would be nice, but it isn't realistic. Even if the government gave free heatlth care, people would do no better of a job taking care of their health. Many would continue to eat bad foods, drink alcohol in excess, smoke cigarettes, use drugs, and have unprotected sex. The government has no obligation in protecting people from their own stupidity.

Even if there was health care for every citizen, those who are illegal immigrants, legal residents, permanent residents, or those who came over to go to Disneyland would expect free health care if something happened. People have no idea how much employers spend on health care. They have no idea how much health care costs. All they want is for the doctor to fix them.

If health care was free, there would still be complaints. Those who believed that they did not get the biggest and best treatment would cause trouble for the system. Patients would still try to sue in cases where they or a loved one was injured or died from a medical procedure. The rich would still receive better treatment because they have more money and can go to see doctors and specialists that the government would not pay for.

Modern medicine is not the cure for suffering and death. It is easier to let some people live in pain and even die. I wish for everyone to live a healthy life, but this is not going to happen. We have to be realistic here and stop pretending that every life is precious and must be protectted at all costs. No one else wants to pay the price for others' troubles.

"And makes me wonder whether we just haven't figured out the right way to structure a true market for health care. But it can't really be denied."

I'm a little bothered by this statement. A marketplace requires that there be choices available to a consumer. However, I think we can all agree that when you're in need of emergency care (i.e., a heart attack or life-threatening injury) you don't have time to engage in market practices and, quite frankly, be unable to make an informed choice (i.e., you're unconscious).

Moreover, a market implies a profit motivation. I think it's fairly clear now that companies running for-profit health insurance or for-profit healthcare organizations do not hold the best interests of their patients to heart. Rather, it is their shareholders (as for-profit companies should--any for-profit company that doesn't needs to have its management team fired and replaced).

Suffice to say, I think it's clear that conceptualizing healthcare into a for-profit market model is inappropriate at best and mindboggling stupid at worst. Clearly, non-profit insurance and providers would be the best (because they are not beholden to shareholders as a profit scheme would be). However, if we remove the profit motive where does that leave us?

Without a profit motive, there is no competition anyways. Wouldn't a rational healthcare plan then involve a single-payer system of some form?

Does that mean I have no chance of becoming a Time kolumnist under the kurrent bias?

No kans, as they say in Holland.

Corey, you are conflating emergency care with insurance. Obviously in an emergency your ability to make market choices is limited. But one of the points of insurance is that the buyer can make market choices about health care before an emergency, when one is freer to explore all the choices the market has to offer.

One of the problems that Ramesh points out is that tying insurance to where you are employed actually limits market choice in health care. The choice is often either to accept whatever health insurance your employer offers, or to switch jobs. A government-managed single-payer system would do little to change this problem.

Not to be a credentialist jerk, Justin, but are you a health-care economist?

The information-asymmetry argument applies also to mechanics, lawyers, accountants, and members of a number of other professions offering services based on highly technical training. Do we need more government regulation of those too?

And Corey, you're conflating markets and profit motive -- there's no ruling out private not-for-profit insurers, of which there are some; and you're falling into the trap of assuming that because markets don't take consumers' best interests to heart, a non-market allocation mechanism would. That doesn't follow logically. Nonmarket allocations have problems with both information (see Social Choice Theory) and motivation (see Public Choice Theory).

Mike,

Not quite. I'm pointing out that a capitalistic market model is an inappropriate model to use for healthcare delivery and insurance. Also...why would single payor [payor rather than payer is the proper term] need to be government-managed? I could easily see a private, non-profit insurance company(ies) be awarded concessions either nationally or regionally.

DrSteve,

You'll note that I was very careful to call out only for-profit delivery points and insurers in my post because I am very aware of the existence of non-profits. Moreover, the best way to delivery healthcare (on an organizational level, not the touchpoints) is to solely be concerned with the welfare of the patient. In a for-profit company, responsible corporate management requires a balance between shareholder concerns and patient concerns (i.e., patient care is by necessity compromised). Not-for-profits don't have shareholder concerns(neither does government for that matter).

Dr. Steve,

Please spell out your nonmarket allocation problems as I don't follow your logic. I will note however, that I don't think healthcare delivery falls under the purview of economics when you frame it in terms of human economic behavior (c.f., Prospect Theory).

Corey, pardon me for being a methodological imperialist, but I think very nearly every aspect of human behavior falls under economics. Part of the problem with being an economist, I suppose.

I don't have any intention of hijacking the thread, so suffice it to say I provided all the information you need by referencing Social Choice Theory and Public Choice Theory. If we don't use markets to allocate resources, we encounter other, entirely different, sets of problems: Preference falsification, poor preference mappings, and the politico-economic dynamic of "concentrated benefits and dispersed costs" among others.

Even if "markets deficient therefore non-markets not" weren't fallacious reasoning (and it is), it's unsupportable theoretically and empirically. So maybe trying to put health care outside of economics' normal efficiency concerns is your way of sidestepping this problem?

DrSteve,

I take a different tack...all human behavior falls under psychology--probably because I'm a psychologist.

Here's my thing. Most human behavior is nonrational--from a processing perspective we lack the cognitive resources and motivation to do so in every situation. Moreover, we don't maximize our utilities--we engage in satisficing, getting to a point where we're happy enough. We use heuristics and processing shortcuts to get us through our lives, conserving resources until needed (e.g., writing a post).

I'll point out two things: 1) I never make the arguments "market deficient, therefore nonmarket not"--I specifically say a for-profit market model may be inappropriate for healthcare delivery and insurance--you keep creating a strawman by implying I say something else (i.e., markets in general); and 2), I don't think SCT and PCT apply in this situation--therefore I'd like to spell out your concerns. The reason I don't think they apply is because neither seems to be able to handle subjective valuations (i.e., the value I place on things in my own mind; c.f. Prospect Theory).

To fully spell out the second point, let's take a fairly obvious example with the following assumptions: a rational for-profit market model would likely require cost-benefit tradeoff for delivery providers and insurance providers (i.e., shareholders and patients must compromise); at a macro level in a fully rational system the benefits of providing healthcare need to outweigh the costs; and, healthcare resources are finite. Back to the example. A child is born with Down's Syndrome. Clearly the cost of caring for this child is going to be greater than the benefits derived from doing so. If we were to use a fully rational system, then healthcare would likely be denied to this child. However, in most ethical systems that is also clearly the "wrong" choice.

DrSteve,

I know the above posts has holes in the logic, but I lack time to find them and address them. However, you still haven't addressed the central part of my thesis regarding the inappropriateness of for-profit healthcare markets-the required balanced between shareholder and patient interests. All responsible for-profit corporate governance requires that the shareholder interests be maximized. In the healthcare business, that means, by necessity, patient interests must be compromised to a certain degree, even inside of ethical for-profits (we'll ignore unethical ones for now). By definition, all for-profit heathcare delivery companies and insurance providers compromise patient interests and care.

"The reason I don't think they apply is because neither seems to be able to handle subjective valuations (i.e., the value I place on things in my own mind; c.f. Prospect Theory)."

Mainstream economics has been based on subjectivism since 1870. Subjective value theory and marginalism are pretty much the hallmarks of modern economic theory. So I'm not sure where that's coming from. What are your specific concerns with SCT and PCT on the issue of subjectivism?

There's plenty of work done in economics on Bounded Rationality (although it's a menagerie of ad-hoc specifications and nothing you could generalize or base policy on), and there are mainstream schools that depart from the man-as-economic-calculator framework (Austrian Economics, for example, just requires that people act purposefully).

I sincerely apologize for attacking a straw man, but a great deal of your argument above seemed to swing on problems with the profit motive (and as you consistently linked it, with "markets" -- please reread your posts) in allocating resources in health care. My question is, what's your alternative for saying how resources get distributed? You seem unwilling to put much meat on those bones, or to consider the possibility that allocation through fiat or political mechanisms (what are the other alternatives?) each present problems of their own.

Since you persist, and since you haven't specified how you want to proceed (maybe single-payer?), it's hard to formulate a specific critique. But let me say this -- SCT and PCT are both relevant if we're going to use political processes rather than markets to decide how big the global health budget is and who gets care.

Finally, for what it's worth, competitive but nonprofit insurance providers embedded within a market system providing information about the value of alternative uses of resources might not be a bad way to go.

As to the point you wanted me to address, every system that's going to limit the volume of resources allocated to patient care will require that patients compromise. With shareholders, with non-health programs in the budget, with whatever. Government health programs (be they socialized insurance or socialized medicine) do say "no." They do de-list conditions and therapies. Take a look at what had to happen to get Fabry Disease treated in Canada. Or to gain funding for specific autism treatments.

As for your Down's example, isn't that undermined by every person currently with Down's who is, in fact, receiving care in the U.S. now?

DrSteve,

This persistence is based on a really boring secondary research project I'm working on.

I'm specifically referring to some obtuse wikipedia articles when referring to SCT and PCT--the way I've read them it looks like both have difficulties with individual differences-and both seem to specify maximization of utilities rather than satisficing and Prospect Theory.

The concern I have with the profit motive only extends to insurance and delivery organizations as a whole (not allocation of care). Individuals (i.e., physicians and company employees) as well as suppliers (e.g., pharmaceutical companies, medical technology) can use a profit motive. Only when do you get down to deciding who and what to cover do I become concerned. Moreover I'm well aware that healthcare resources are finite and that not everyone can receive the same care. My thought is that everyone should receive the same level of basic care (which doesn't happen now due to the way we allocate healthcare resources currently).

Personally, my opinion is that if we were to set up single-payer from the goverment and let it compete in the market, it would win because it provides the best patient care as it doesn't have to compromise like for-profits do. However, non-profits would likely do well too. I'll note that this is John Edwards's plan.

"Personally, my opinion is that if we were to set up single-payer from the goverment and let it compete in the market, it would win because it provides the best patient care as it doesn't have to compromise like for-profits do."

Depends on what you mean by "let it compete in the market." The political reality is that it would likely get cross-subsidized (the urge among supporters would be irresistible) and "win" in the market through inefficient substitution -- there's even a name for this phenomenon: Fabian Socialism. Bellamy actually prescribed this for a socialist takeover of the economy.

I'm not sure it does provide the best patient care. Ask the parents of an autistic child in Manitoba sometime, or a kid with thalassemia in Ontario.

"SCT and PCT--the way I've read them it looks like both have difficulties with individual differences-and both seem to specify maximization of utilities rather than satisficing and Prospect Theory"

Both do involve maximization, but show me a coherent theory of social planning that doesn't. As for "difficulties with individual differences," this is precisely the point of the SCT critique of voting allocations -- voting distorts the aggregation of individual preference orderings, leading to intransitivity in the social welfare function the social planner is assumed to be trying to maximize.

I'd recommend the original Arrow monograph on Social Choice Theory (Cowles Foundation, I think) rather than a wiki. It has the benefit of being very short! And Tullock for PCT.

Corey and DrSteve are the same person. I can tell from the similarities in the writing styles of the posts. Whoever you are, you are one crazy dude!