Friday, September 27, 2013

Medicine is not Euvoluntary: Open-Form Single Payer Edition

The ACA is doomed. It's incentive-incompatible, politically poisonous, brimming with bureaucratic jackanapery, choked with rent distribution, and at its worst is a national-scale medical database sitting smack dab in the middle of a country that has resurrected the Star Chamber. I'd give 10:1 odds that it won't be around by the time my daughter (who isn't even two yet) is eligible under current rules to obtain her own policy. I'd give even odds that it'll be replaced in the next administration.

But replaced by what?

The combination of far-mode compassion and indirect coercion implies that the free rider problem in medical care is real and that it is here to stay. Individual people care about the collective anthropomorphic "patients" and since state agents have adopted gentler technologies to extract tax revenue, it's much less painful to indulge the care ethic, especially through a political process where voters bear next to no individual accountability for their votes. The probability that a candidate who credibly pledges to transform the medicine delivery industry to a free market condition would obtain high office approaches zero in the limit, even with a tiny electorate.

The old status quo might be politically feasible, but from this distance, even our ol' pal from La Mancha would agree that those are windmills, not dragons. On a generous day, I'd be willing to give a 2% chance (skewed, kurtotic distribution, naturally) that we'll see something like a straight up-and-up repeal. I'd also say that if the Wheel of Morality lands on "you played it for her, you can play it for me. ... If she can stand to listen to it, I can. Play it." (this is the Age of the Internet, there's no excuse for misquoting AFI's #2 movie of all time anymore), the outcomes would be ruinous. Not even the brain damaged cabal of the modern GOP would be willing to guzzle that potion.

What seems more likely is some form of single payer. And in the world of single payer, there are a few models from which to choose. The "bad" version that you hear radio hosts railing against is an NHS-ish model that bars private practice. It may be wise to be skeptical of the sorts of non-price rationing in this model. A better version (by "better" I invoke ordinary welfare economics criteria) can be found in a few of the post-Soviet republics with state provision available for all on the taxpayer's dime with private boutique care available out-of-pocket. The laser eye surgery and vanity rhinoplasty experience here in the states at least hints that this hybrid system is in or near a reasonable choice set.

Maybe. We're looking at a pretty fat inframarginal deep dive though, so who knows if it actually is? Be wary of anyone making strong claims one way or the other. At any rate, medicine is not euvoluntary. As our political institutions navigate us towards a new equilibrium, it's wise to try to remind our political elites that some outcomes are more euvoluntary than others. Look to Latvia, not to Canada.

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Do you have suggestions on where we could find more examples of this phenomenon?