In June I proposed to municipalize medicine: Consider letting government take full control of the industry, but at a municipal level. … Some municipalities will find ways to cut overuse, and others will fail, but failures can then emulate successes. …
Sorry, I don't see the forest, either; maybe it was a poor choice of cliche. I think it's important that the price system has been almost totally destroyed in American health care, but I'm not sure how that happened. I'm impressed by Singapore maintaining a price system.
I don’t see a reason why medical professionals should be protected from “unlimited” punitive damages when no other industry is. What makes them different? Why should they not be held responsible for their own actions?A good question. Perhaps punitive damages in all professions should be capped. It's just that I've never heard of someone suing their plumber or their auto mechanic for tens of millions of dollars. Doctors are pretty much the only self-employed people who can be hit with lawsuits in that dollar range. If auto mechanics were regularly hit with million-dollar lawsuits, and all had to take out insurance against that, and the rising cost of auto repair was a major drain on our economy, then I would advocate capping punitive damages against auto mechanics.
Also, perhaps punitive damages should not be capped for class-action suits.
Doctors and drugs are pretty cheap, and thus irrelevant to the dramatic differences between, say, the US and France. The US system is so messed up that any detail causes outrage and most people get stuck on the first detail they look at, usually an easy one to find, like doctors or drugs. Thus it is unlikely that a single line-item is the problem and we should look for more abstract causes.
France spends about the same percentage of its health-care budget on doctors as the US. Sinapore is the only country I know of where doctors are a significant chunk of the medical budget (half, I think), because they spend so little on the rest of medicine.
It's not any easier to get drugs approved in Europe, though maybe they're free-riding on the FDA. Drugs are a much larger portion of the American budget, but still small in absolute terms.
This one’s a no-brainer. Punitive damages should be capped, period. There is no benefit to society from having unlimited punitive damages, and it would be an enormous and direct cost savings to cap them. The only people who benefit from not having a cap are lawyers.
Yeah, I'm going to have to disagree here. First, while punitive damages are not legally capped, they're de facto limited. I don't recall a judgment of $infinity being levied against anyone.
Second, and more importantly, give the increasing economies of scale in medicine, large punitive damages become that much more necessary. The use of punitive damages is warranted when a defendant repeatedly engages in illegal conduct but when no particular case is worth pursuing. No one will bring a suit for being overcharged $5, or other similarly small infractions. To deter such conduct, large punitive damages (absent a class action suit) are necessary whenever someone does pursue the claim.
I don't see a reason why medical professionals should be protected from "unlimited" punitive damages when no other industry is. What makes them different? Why should they not be held responsible for their own actions?
This may be a good idea, but I feel that it's part of a dominant pattern we have, at least in the US, of looking at healthcare in the wrong way. We keep trying to find ways of changing how the money flows, and who pays for it, instead of asking why healthcare is so expensive in the US.
There are two basic reasons I know of why healthcare is so expensive in the US:
1. Doctors charge way too much money. The average surgeon makes over $400,000/yr in the US. Sure, they work hard for their money - or so we're told, though I notice they usually work 6 hours a day, 4 days a week - but so does President Obama, and he makes less than they do.
Doctors make way too much money because the American Medical Association works very hard to ensure that we keep paying more and more money to fewer and fewer doctors. They lobby for legislation requiring the involvement of doctors in anything medical; they lobby to make it hard for doctors from other countries to practice in America; they haze interns to a degree that would be illegal in any other profession. Yet instead of being seen as a shameless self-interested trade union, they are considered respectable, authoritative, and benevolent. We have stricter laws against practicing medicine without a license than for any other profession, except lawyers, who are also experts at lobbying to protect their own incomes. If you say you are an engineer, and you build a bridge, and it falls down and a hundred people die, you won't go to jail for engineering without a license.
Doctors also make way too much money because medical colleges charge a lot of money. I don't know which way causality runs here, but I know that anybody interested in reforming health care cost should look into how to make medical college less expensive. Other countries somehow manage to educate doctors for a tiny fraction of the price. Training to be a doctor does not have especially high costs. Training people to be biotechnology lab technicians is probably much more expensive: Students require experience on a large number of outrageously-expensive machines, costing up to $100,000 each and needing to be replaced every 5 to 10 years; and every day they go through large amounts of expensive, disposable glassware, gloves, and media. Yet it costs about $4000/yr to study to be a lab technician at my local community college, which has excellent facilities. Graduates typically earn about $30,000/yr.
Medical lawsuits are another factor. This one's a no-brainer. Punitive damages should be capped, period. There is no benefit to society from having unlimited punitive damages, and it would be an enormous and direct cost savings to cap them. The only people who benefit from not having a cap are lawyers.
2. Getting drugs approved is too expensive. Getting a drug past the FDA costs, on average, over a billion dollars in the US. The pharms then need to make that money back before the patents expire.
Everybody worries about drugs that will kill them because they weren't tested enough. Few people worry about all the people who die because they can't afford the drugs that will save them; or because the drugs that would have saved them, haven't been approved. Once I had a serious knee problem that kept me in a wheelchair for over a year, and a doctor told me, in effect, that he would have several effective options for treating me if I were a horse, but as I was human I was only allowed access to second-rate medical and pharmaceutical technology.
It isn't, but towns can control new development more easily than they can control old development. It's a lot easier to prevent someone from building housing that's attractive to families with children than it is to do something about development that's already there.
Building new housing is often a net money loser for towns, or so I've heard. Taxes on commercial properties tend to end up subsidizing services to residents; shopping malls pay a lot in taxes and don't take up classroom seats.
"Perhaps the economists here could put this in more precise terms, but what seems to me to happen is people who value education tend to collect and create high quality schools, whereas those who don’t, don’t."
Well...yeah. Isn't that a feature? If you value education, you go where people pay for education and pay for it [usually in property taxes.] Why would that not also be true of health care? People who care about fancy health care would go to such places and pay for it. Others who are more willing to settle for bare-bones care go to low-cost/low-service locations.
I think the concern is that "willingness to pay" is obviously constrained by "ability to pay," and most people still exempt health care [and to an extent education] from this basic rule. Willingness to pay for fancy cars is similarly constrained by ability to pay, but most people don't consider that a right or something they'd want everyone to have. Another indicator that most people think of health care as "different" somehow.
One danger is if municipalities are too small. This is the case with public schools, where there is enormous variation in quality depending on municipality. Perhaps the economists here could put this in more precise terms, but what seems to me to happen is people who value education tend to collect and create high quality schools, whereas those who don't, don't. The correlation between valuing education and making lots of money exaggerates the effect, because level of funding affects school performance. And in the end you get two undesirable phenomena. First is, only relatively wealthy people have access to quality public education, because demand is high to live in the corresponding municipalities and they are the only ones who can afford it. Second is, there is a sort of injustice in which the opportunities a person faces depend largely on where his/her parents live.
I would guess these would not be issues if, however, health care were managed state by state.
One thing that would worry me, though, would be inefficiency, due to the 50x redundancy. One would hope, with so many different nations already running public health care programs, there would be little need to try to emulate a market in this way, since we can simply study those nations, try to figure out what would work best here, and proceed trial and error from there.
I am trying to find fault with this idea but the more I try the more I like it.I am attracted the idea of my vote having some actual signifigance on this issue. I like the idea of voting with my feet. I prefer state and local politicians deciding what to do with my taxes, this is the reason I live in Texas and not California.
I don't see exclusion being an issue. Certainly the flight of high earners from some regions will occur, but in my book this a feature. It will force bad policy reform. It seems the ideal place for this kind of system is the US for that very reason. Props for the good idea, Robin.
It's interesting that you mention education and federal guidelines. Here in Michigan, schools are funded on a per-student basis by the state (instead of being funded locally), so I can't speak to your point about discouraging people to move to a municipality based on the cost of students because it's encouraged under this arrangement. However, the extra 7% of federal funds directed at our schools for NCLB compliance create little incentive to retain students who are liabilities. Special needs students and those with behavior issues are liabilities to schools trying to meet annual yearly progress and are often shuffled around as a result (particularly behavior cases).
I wonder if this aspect of public education has any bearing on municipal healthcare, especially since the only way federal municipal health care guidelines could be enforced would be through congressional purse strings.
Sorry, I don't see the forest, either; maybe it was a poor choice of cliche. I think it's important that the price system has been almost totally destroyed in American health care, but I'm not sure how that happened. I'm impressed by Singapore maintaining a price system.
I don’t see a reason why medical professionals should be protected from “unlimited” punitive damages when no other industry is. What makes them different? Why should they not be held responsible for their own actions?A good question. Perhaps punitive damages in all professions should be capped. It's just that I've never heard of someone suing their plumber or their auto mechanic for tens of millions of dollars. Doctors are pretty much the only self-employed people who can be hit with lawsuits in that dollar range. If auto mechanics were regularly hit with million-dollar lawsuits, and all had to take out insurance against that, and the rising cost of auto repair was a major drain on our economy, then I would advocate capping punitive damages against auto mechanics.
Also, perhaps punitive damages should not be capped for class-action suits.
So what is the forest? You spent a comment saying what it isn't.
I think you're missing the forest for the trees.
Doctors and drugs are pretty cheap, and thus irrelevant to the dramatic differences between, say, the US and France. The US system is so messed up that any detail causes outrage and most people get stuck on the first detail they look at, usually an easy one to find, like doctors or drugs. Thus it is unlikely that a single line-item is the problem and we should look for more abstract causes.
France spends about the same percentage of its health-care budget on doctors as the US. Sinapore is the only country I know of where doctors are a significant chunk of the medical budget (half, I think), because they spend so little on the rest of medicine.
It's not any easier to get drugs approved in Europe, though maybe they're free-riding on the FDA. Drugs are a much larger portion of the American budget, but still small in absolute terms.
This one’s a no-brainer. Punitive damages should be capped, period. There is no benefit to society from having unlimited punitive damages, and it would be an enormous and direct cost savings to cap them. The only people who benefit from not having a cap are lawyers.
Yeah, I'm going to have to disagree here. First, while punitive damages are not legally capped, they're de facto limited. I don't recall a judgment of $infinity being levied against anyone.
Second, and more importantly, give the increasing economies of scale in medicine, large punitive damages become that much more necessary. The use of punitive damages is warranted when a defendant repeatedly engages in illegal conduct but when no particular case is worth pursuing. No one will bring a suit for being overcharged $5, or other similarly small infractions. To deter such conduct, large punitive damages (absent a class action suit) are necessary whenever someone does pursue the claim.
I don't see a reason why medical professionals should be protected from "unlimited" punitive damages when no other industry is. What makes them different? Why should they not be held responsible for their own actions?
This may be a good idea, but I feel that it's part of a dominant pattern we have, at least in the US, of looking at healthcare in the wrong way. We keep trying to find ways of changing how the money flows, and who pays for it, instead of asking why healthcare is so expensive in the US.
There are two basic reasons I know of why healthcare is so expensive in the US:
1. Doctors charge way too much money. The average surgeon makes over $400,000/yr in the US. Sure, they work hard for their money - or so we're told, though I notice they usually work 6 hours a day, 4 days a week - but so does President Obama, and he makes less than they do.
Doctors make way too much money because the American Medical Association works very hard to ensure that we keep paying more and more money to fewer and fewer doctors. They lobby for legislation requiring the involvement of doctors in anything medical; they lobby to make it hard for doctors from other countries to practice in America; they haze interns to a degree that would be illegal in any other profession. Yet instead of being seen as a shameless self-interested trade union, they are considered respectable, authoritative, and benevolent. We have stricter laws against practicing medicine without a license than for any other profession, except lawyers, who are also experts at lobbying to protect their own incomes. If you say you are an engineer, and you build a bridge, and it falls down and a hundred people die, you won't go to jail for engineering without a license.
Doctors also make way too much money because medical colleges charge a lot of money. I don't know which way causality runs here, but I know that anybody interested in reforming health care cost should look into how to make medical college less expensive. Other countries somehow manage to educate doctors for a tiny fraction of the price. Training to be a doctor does not have especially high costs. Training people to be biotechnology lab technicians is probably much more expensive: Students require experience on a large number of outrageously-expensive machines, costing up to $100,000 each and needing to be replaced every 5 to 10 years; and every day they go through large amounts of expensive, disposable glassware, gloves, and media. Yet it costs about $4000/yr to study to be a lab technician at my local community college, which has excellent facilities. Graduates typically earn about $30,000/yr.
Medical lawsuits are another factor. This one's a no-brainer. Punitive damages should be capped, period. There is no benefit to society from having unlimited punitive damages, and it would be an enormous and direct cost savings to cap them. The only people who benefit from not having a cap are lawyers.
2. Getting drugs approved is too expensive. Getting a drug past the FDA costs, on average, over a billion dollars in the US. The pharms then need to make that money back before the patents expire.
Everybody worries about drugs that will kill them because they weren't tested enough. Few people worry about all the people who die because they can't afford the drugs that will save them; or because the drugs that would have saved them, haven't been approved. Once I had a serious knee problem that kept me in a wheelchair for over a year, and a doctor told me, in effect, that he would have several effective options for treating me if I were a horse, but as I was human I was only allowed access to second-rate medical and pharmaceutical technology.
It isn't, but towns can control new development more easily than they can control old development. It's a lot easier to prevent someone from building housing that's attractive to families with children than it is to do something about development that's already there.
Building new housing is often a net money loser for towns, or so I've heard. Taxes on commercial properties tend to end up subsidizing services to residents; shopping malls pay a lot in taxes and don't take up classroom seats.
"Perhaps the economists here could put this in more precise terms, but what seems to me to happen is people who value education tend to collect and create high quality schools, whereas those who don’t, don’t."
Well...yeah. Isn't that a feature? If you value education, you go where people pay for education and pay for it [usually in property taxes.] Why would that not also be true of health care? People who care about fancy health care would go to such places and pay for it. Others who are more willing to settle for bare-bones care go to low-cost/low-service locations.
I think the concern is that "willingness to pay" is obviously constrained by "ability to pay," and most people still exempt health care [and to an extent education] from this basic rule. Willingness to pay for fancy cars is similarly constrained by ability to pay, but most people don't consider that a right or something they'd want everyone to have. Another indicator that most people think of health care as "different" somehow.
More people using parks means more people to maintain them.
Thanks for the tip! I just added to the post on it.
One danger is if municipalities are too small. This is the case with public schools, where there is enormous variation in quality depending on municipality. Perhaps the economists here could put this in more precise terms, but what seems to me to happen is people who value education tend to collect and create high quality schools, whereas those who don't, don't. The correlation between valuing education and making lots of money exaggerates the effect, because level of funding affects school performance. And in the end you get two undesirable phenomena. First is, only relatively wealthy people have access to quality public education, because demand is high to live in the corresponding municipalities and they are the only ones who can afford it. Second is, there is a sort of injustice in which the opportunities a person faces depend largely on where his/her parents live.
I would guess these would not be issues if, however, health care were managed state by state.
One thing that would worry me, though, would be inefficiency, due to the 50x redundancy. One would hope, with so many different nations already running public health care programs, there would be little need to try to emulate a market in this way, since we can simply study those nations, try to figure out what would work best here, and proceed trial and error from there.
I am trying to find fault with this idea but the more I try the more I like it.I am attracted the idea of my vote having some actual signifigance on this issue. I like the idea of voting with my feet. I prefer state and local politicians deciding what to do with my taxes, this is the reason I live in Texas and not California.
I don't see exclusion being an issue. Certainly the flight of high earners from some regions will occur, but in my book this a feature. It will force bad policy reform. It seems the ideal place for this kind of system is the US for that very reason. Props for the good idea, Robin.
It's interesting that you mention education and federal guidelines. Here in Michigan, schools are funded on a per-student basis by the state (instead of being funded locally), so I can't speak to your point about discouraging people to move to a municipality based on the cost of students because it's encouraged under this arrangement. However, the extra 7% of federal funds directed at our schools for NCLB compliance create little incentive to retain students who are liabilities. Special needs students and those with behavior issues are liabilities to schools trying to meet annual yearly progress and are often shuffled around as a result (particularly behavior cases).
I wonder if this aspect of public education has any bearing on municipal healthcare, especially since the only way federal municipal health care guidelines could be enforced would be through congressional purse strings.
Finland has municipal healthcare.
Why is new development much more likely to have kids than old?
The second to last paragraph should be a blockquote. Sorry.