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By Gerhard Adam | August 3rd 2009 02:41 AM | 25 comments | Print | E-mail | Track Comments
In reading some posts regarding health care reform, someone made a comment that struck me as unusual regarding the pharmaceuticals, namely that they had a right to make a profit too.

What an interesting phrase; "a right to make a profit". Of course, it isn't even remotely true. Companies aren't even guaranteed a right to be in business, let alone make a profit. One could argue that companies are entitled to make whatever profits they may without interference from the government, but then why should a company have a right that isn't available to ordinary citizens? So where does such a phrase come from and what does it mean?

Generally, the only time such a statement is made is when there is an implicit understanding that the company in question isn't really participating in a free market good or service. In short, the first thing that must always be established when examining a company or industry is to determine whether what it does is rightly subject to free market considerations and competition. If not, then whatever else it is, conventional supply and demand models cannot and will not apply.

Therefore the first question that needs to be answered, is whether the company in question is in a free market style industry and what the basis for that is.

Interestingly many people presume that all businesses are automatically free-market based, but in fact there are three types of goods/services in our economic model, each of which has dramatically different ways of interacting within the economy. The three types of goods/services are (1) the conventional free market system whereby people can elect to purchase goods and services from any provider, (2) controlled monopolies where there are companies providing goods or services, but they are not subject to competition and consequently cannot respond to conventional market pressures, and (3) required good and services that cannot respond to supply/demand because there may not be any opportunity to profit at all.

The first case is easily understood and is represented by the companies that we normally engage with to purchase everything ranging from eyeglasses to iPods to groceries. The second example would be filled by companies like utilities, cable companies, where there are no viable
competitors, so the market is essentially a controlled monopoly. The third example consists of services such as law enforcement, fire departments and the military.

Therefore while there may be numerous positive and negative points regarding something like health care reform, the overriding problem is that it currently exists in category 1 and we want it to behave as if it were in category 3. Until this discrepancy is resolved there can be no real solution to the problem.

So what determines the goods/services that belong in category 3? I would argue that those are articulated, at minimum, in the Constitution of the U.S., itself, in the section relating to promoting the general welfare.
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."

Without necessarily rising to the status of law, it seems that one of the primary missions of the government is to provide those goods/services that are necessary to achieve that protection for the general populace. Therefore, it seems that any attempt to privatize such activities is neglecting one of the fundamental reasons for the government's existence.

If we don't think that such a circumstance applies, then let's consider why we don't privatize law enforcement or even the military itself?

If we acknowledge that the market cannot solve every problem and address every circumstance, then questioning the free market status of health care is a reasonable position to take.

While some may choose to disagree, it seems that any services that are pertinent to the protection and general welfare of the population are rightfully under the jurisdiction of the U.S. government and not private industry. However, we should also be clear that the government does not exist separate and apart from the citizens. The question, therefore, isn't whether the government can afford to provide health care to its citizens. If the United States should be threatened by an external power, we would expect all of its citizens to act in its defense.
Shouldn't the citizens of the country also act to provide those same protections to everyone? The question then becomes, can the citizens of the U.S. afford to ignore the welfare of the same people it may well count on for its protection?

In the end, it comes down to the fact that in the absence of true competition in the marketplace there is no point invoking conventional economic models to explain how things should work, because it's the wrong model being applied to the wrong problem.

Comments

Steve Davis's picture
why we don't privatize law enforcement or even the military itself?
Give 'em half a chance Gerhard, and they would.
It may have already begun.

Gerhard Adam's picture
No doubt :)  Actually that might be necessary before people realize that they have a responsibility to produce the government they want, instead of simply letting all the vested interests make the choices for them.

Nicholas Horton's picture
What an interesting phrase; "a right to make a profit". Of course, it
isn't even remotely true. Companies aren't even guaranteed a right to
be in business, let alone make a profit.

I like that line.  I'm a big believer in the Free Market, but let's face it, there are gambles involved.  Any business venture is a risk, and that goes for drug companies.

regarding privatizing the military/cops, as a guy who's part of a tiny minority of libertarians who is actually FOR government funded universal health care, I am constantly using that example.  We don't have private cop companies for a reason.  Some "businesses", if you want to call police forces that, don't function best in a free market context. 

I like the distinction between private and public goods.  A private good is one that can be divided up and sold to individuals on an as needed basis, like cars, hair driers, shoes, etc.  these goods you can withhold from people who don't pay rather easily, and doing so doesn't undermine the quality of life for the majority of citizens.

A public good on the other hand can't be divided up so easily.  Imagine a military that you had to buy into in order to be protected by.  In the event of a land attack on American soil, just how would the military go about protecting only those that payed their "military bill" last month?! 

Private goods run better in a free market.  Competition keeps the price down, and people get maximum choice. 

But, public goods are actually LESS efficient in a free market.  And they don't serve the purpose they were designed to serve in the first place when in a free market.  Health care is, I contend, a public good.  Depriving health care is something that negatively affects the entire nation.  And in the most extreme cases, hospitals will take people into their emergency rooms and deal with them regardless of payment.  It's a drain on the economy to keep these services private. 

In the interest of a smoothly functioning economy, I think Health Care should be government funded.

Just my 2 or 10 cents.  I think many conservatives, and certainly many right leaning Libertarians are so utopianistic in their views about the magic of the free market, that they honestly think free markets solve all woes.  But, to me that just means they aren't really Libertarians, they're anarcho-capitalists.  Hayek had no problem with the idea of universal health care.  to him, "Libertarian" wasn't synonymous with "Free-market fundamentalism".

Gerhard Adam's picture
I agree.  The problem becomes even more apparent when one considers the business model intrinsic in insurance companies.  It is completely predictable that the only way to leverage premiums against costs is to reduce the risks of a pay-out.  Therefore, the insurance company has an incentive to not insure people that represent a cost.  Their profitability comes from insuring those that don't need it.

Steve Davis's picture
I've been waiting for comments in support of the right to make a profit, but as none are forthcoming I'll put in my 2 cents worth.
The right to make a profit has the same weight as the right to go broke. They are two sides of the one coin.

Gerhard Adam's picture
I'm always cautious when the word "right" comes up because it suggests that there is some external responsibility to ensure that someone is not being prevented from fulfilling that "right".  So what struck me as absurd, was to think about protecting someone's "right" to make a profit when perhaps they were totally incompetent to run a business. 

Besides, such a "right" has all kinds of interesting consequences when one looks at the underground markets of drugs and illegal contraband.  After all, if profiting were a "right" then how does one deal with that aspect?

Steve Davis's picture
This is one of the problems I have with free market theory. If you assert that market forces have a privileged position, you are opening the door for anti-social forms of trade.

Jeff Sherry's picture
   |What an interesting phrase; "a right to make a profit".
Gerhard the Pharmaceutical industry is a highly competitive industry where the R and D can run into the 100s of millions of dollars for each product. Laws are designed to grant a limited time monopoly for the products through patents, so that the companies can recoup their investment. So yes presently the Phamaceutical co.s ( and other comapies in industry) are granted priveleged economic postions in our society.

Gerhard Adam's picture
I understand, if that is the arrangement that people want.  However, it certainly isn't the only one possible.

In addition, recouping investment is not the same as record profits.  Part of my point, is that it is precisely such circumstances where it may make sense to have government controlled (and in some cases directed) efforts because the profitability isn't there.

This is the problem where the pharmaceuticals don't have the incentive to produce drugs that may be necessary, but simply aren't profitable enough.  This goes back to my point about the "free market" being unable to solve every problem, because it may not be a simple supply/demand situation.

The truth is that many drugs would be unaffordable without the insurance companies, so there is no "free market" pressure to determine what the price will be, because there is an intermediary between the product and the consumer that is willing to pay the price.  We also have to consider that if research is too expensive to produce the drugs we need, then we have to accept that it isn't a viable profit-motivated business model. 

My concern with most of the health industry is that the business need to produce a profit, by definition, requires that one operate at the lowest cost (eliminating as much risk as possible), for the highest price (exploiting a captive audience).

I don't want to sound like businesses profiting are evil or bad, but they can certainly become so when they are placed in untenable businesses that are not suitable for such pressures.  This is my primary objection to this model for health-care.  We would experience the same thing if law-enforcement were privatized in such a fashion.  It wouldn't be shocking to see that the police were patrolling the richest neighborhoods while those with the lowest revenue potential were overrun with crime.

We have to begin recognizing that much of the behavior we think is bad, is brought about by the business models we have created, so it is important to ensure that we create workable models so that people can achieve their objectives and advance our society in a direction we can all agree with.

Becky Jungbauer's picture
What I still don't understand is why health care is a for-profit enterprise.

Hank's picture
Without it being for profit you tend not to get the best people doing it.  I was in the Army, for example, and we have the best in the world, but I couldn't accept getting paid the same as people who weren't very good officers.   When the government gets involved in managing health care, inevitably the focus will be on access for people regardless of quality and fairness to federal union employees, including quota baggage ... and excellence will be nowhere in either of those equations..

Gerhard Adam's picture
Hank, I have to disagree with you.  There isn't any job I can think of that can arbitrarily set its own salaries.
...  but I couldn't accept getting paid the same as people who weren't very good officers.

While I can appreciate the sentiment, I don't see how that's any different in private industry.  Every company has hundreds of employees that could make the same argument regarding management and regardless of how good they are, they will be subject to the pay scale adopted by corporate standards.  There are few people that would voluntarily say that they are being paid exactly what they are worth. 

In the end, it doesn't come to down to what you want to earn, but rather what the market will bear.  There is no job that can claim entitlement to a particular salary, and once that price is set, then people will do it (and do it well), if that's the job they want.  It doesn't mean a reduction in quality, because that would suggest that the same doctor determines the quality of his care solely on the salary you pay him.  While I'm sure there are many motivated in that fashion, I find very few people that intentionally perform poor quality work because of their wages.

In health care we have this notion that somehow if we reduce prices that the doctors are going to all leave for some mythical kingdom where they can continue to charge their prevailing rates.  In truth, the only reason doctors can charge the prices they do, is because of the insurance companies acting as an intermediary.  If doctors had to collect from their patients directly, they would have to come up with a different model regardless of how worthy they felt they were.

All you have to do is look at the quality of the people you have writing on this site, and ask yourself if you really think they would behave differently based on how they were paid.  I'm sure that higher pay would result in a greater sense of duty or obligation to produce something, but I seriously doubt it would affect the fundamental sense of quality each person produces.

Hank's picture
You make two excellent points!
 It doesn't mean a reduction in quality, because that would suggest that the same doctor determines the quality of his care solely on the salary you pay him. 

No, but the subset of people who will no longer go into medicine when they find they have government paperwork and salaries will be lessened, just like in the Army - yes, some will stay because they care about more than money, but not enough to offset the increase in people using the services.  

If you have been to a VA hospital, you know people care - but no one thinks a VA hospital is what they want health care to be like, yet no one has a plan to prevent it.
All you have to do is look at the quality of the people you have writing on this site, and ask yourself if you really think they would behave differently based on how they were paid. I'm sure that higher pay would result in a greater sense of duty or obligation to produce something, but I seriously doubt it would affect the fundamental sense of quality each person produces.

Science writing here is a different animal than health care because people already have jobs and this is supposed to be for outreach and/or fun.  Likewise there are doctors who jet off to third world countries because they care about outreach.   There just aren't enough of them.

The fry cook analogy is an accurate one.   If a politician promises everyone a chef for their house, you may think you will get the chef at your favorite restaurant but you will instead basically get a kid who would otherwise work at McDonald's - a limited menu of limited quality food but with a high government cost.

Gerhard Adam's picture
If you have been to a VA hospital, you know people care - but no one
thinks a VA hospital is what they want health care to be like, yet no
one has a plan to prevent it.

You have a good point, but I know from my own military experience that the doctors and dentists I dealt with were top-notch Navy doctors/dentists.  To this day (several decades later), I still have dentists commenting on the quality work they see on my teeth.

I think it's important to consider that part of what the military does is to provide an opportunity for qualified students to become doctors in exchange for several years of service in the military.  I could easily see similar programs working to expand the number of doctors and to provide fundamental care.  I suspect that the average medical day is spent diagnosing and dealing with the mundane (which could probably be handled by a nurse or physician's assistant) , but instead we engage our most qualified people to do these jobs.

This is the opposite of your example, where we simply want to get a fast-food burger, but we have to bring in Wolfgang Puck to cook it.  Obviously there are all kinds of discrepancies we can introduce in all these models.

In the end, a major issue is that doctor's have no competitors and their prices are already set and dictated by insurance companies.  So there are plenty of instances where doctors already have to deal with having their options limited by what they will be paid.  The difference is that insurance is motivated by profit and not quality care (or even prevention), so the economics is considerably different than if the doctors dealt with patients directly.

Similarly with hospitals, since there is no competition, and while I can see your point regarding the quality of individuals, it would be hard to argue with hospitals purchasing multi-million dollar equipment that only has specialized need.  It is ironic that it would be cheaper to hire a private nurse and stay in a luxury hotel than to stay in most hospital rooms.  It is precisely this kind of poor planning and utilization of resources that drives prices up, but hospitals have no incentive to address it, because there is a symbiotic relationship between hospitals and insurers that guarantee the smooth flow of revenue and that's what no one wants to upset.

Becky Jungbauer's picture
But money shouldn't be the motivating factor here - the wellness of the patient should be. And the Dartmouth Atlas has shown that more money does not necessarily equal better care.

Jeff Sherry's picture
Becky, presently the medical industry is a specialized service we pay for. You are right more money does not equal better care. Money is the reward factor for a medical practitioner that has spent 8 plus years learning his profession or trade.

My nephew just got his MCAT results back, based on his University grades and test score he is eligible for Harvard Med. Financial Aid, loans and his parents will be paying for his continued education. These aren't freebies.

Gerhard Adam's picture
I'm not completely convinced that the costs are the result of doctors.  In far too many instances, it is hospitals and the extravagant equipment expenses that get in the way.  As I've mentioned elsewhere, you have to wonder why a hospital room is more expensive than a luxury hotel room.  I can understand if a patient is critically ill, but often they are only there for observation or a non-eventful recovery. 

Jeff Sherry's picture

I didn't mean to give the impression that doctors are the primary reason for medical costs.

I hate answering a post wiith a question Gerhard, but how much of the hospital room cost is inflated by unpaid bills to the hospital by previous patients, malpractice insurance or possibly insurance inflation?



Gerhard Adam's picture
I'm sure you're right that those are all factors.  What I'm curious about is why there isn't better control over some of the equipment manufacturers and the outrageous prices they charge for some of the equipment.

I've seen some pretty ordinary wheelchairs that are exorbinantly priced (of course I've also seen some rather fancy ones), but I have to wonder why such a high expense?  After all, they aren't sports cars so why are they billed as if they were?

Jeff Sherry's picture
On wheelchairs I have no idea. I did google and found 5 manufacturers with price ranges from $400 (manual) to $14,000 for an all terrain model. I've never been involved in the manufacture of wheelchairs and have no idea of what materials and labor costs are involved. But the sites I visited all had ways of little or no payment to the consumer through medicare, wheelchair insurance and health insurance.

Medical equipment isn't part of high end for manufacturing of consumer goods. It isn't as if every home will end up with an MRI unit in the garage.

Gerhard Adam's picture
I agree completely and I apologize if I sound a little off, because it's pretty late here and I'm fairly tired.  Here's where the problem with hospitals, equipment, and insurance comes into play.  They are obviously using some super-dimensional form of math that isn't normally used in our universe.

I got some of these figures from Google.

Consider an MRI machine costs about $3M, while an MRI scan costs about $400 - $2000.  Let's use the small number.  That means that 7500 MRI scans would pay for the machine (at least in our universe).  Now unless these machines are exceptionally delicate, I wouldn't think they need to be replaced every three years, so that would be plenty of time to recover the costs of the machine (and ancillary costs too).

However, since it can take up to 90 minutes (from Google) for an MRI session, then if we use that number then three times as much time is being used than the scan actually requires (20-30 min.).  If MRI scans are being prescribed unnecessarily (such as is considered in breast cancers), then the cost is being incurred because the time is being spent making the machine unavailable, creating pressure to buy more than one machine.

I'm sure I haven't considered all the nuances of this, but it isn't difficult to see that there is little consideration for the efficient use of equipment, since everyone is so casual about the fact that "someone" will presumably pay for it.

Jeff Sherry's picture
I enjoy reading your posts and thoughts Gerhard, no need for apologies. With the costs of MRI scans, I wonder how many referral and consulting fees are tagged onto each. I'm guessing that there are software updates done periodically which isn't cheap because of the specialization.

I did a quick research on MRIs and did not realize how complicated they are, some are delicate due to the use of Permanent magnets or superconducting electro-magnets. Presently I live in the Ohio Valley, the hospitals in this area share a travelling MRI that does a circuit around 6 to ten hospitals, a semi-trailer is used to move the equipment. Basically the hospitals rely on a corporation to administer MRIs, but I don't know how much it lowers the costs or increases  them. I can't get an MRI, because I have metallic flakes in my eyefluid.

Jeff Sherry's picture
Gerhard I think you have been bringing up pointed questions that have been ignored for decades about the medical industry.

Can the present arrangement be improved for us the consumer? Of course it can be, but will it be improved or watered down? If I were to get a similar cancer as Ted Kennedy under the future insurance system, will I receive similar top notch treatments?

Presently I don't see that we are having an overhaul of the medical industry. What I see is a change in medical insurance by extending coverage to all Americans and who pays for it.  

Do you think insurance helps to raise the overall cost of medications and treatments?

Sorry that I have generated more questions than answers to your statements.

   

Gerhard Adam's picture
Great questions!

I think the answer to your first set of questions is precisely what represents the unknown and everyone is highly suspicious that it will be adequate for all involved.  In the interest of trying to keep the insurers and health industry happy, it appears that it may become too watered down to truly be effective.
Do you think insurance helps to raise the overall cost medications and treatments?

Insurance hurts in this case.  Health insurance is a non-viable business model since there is no cap to the costs that need to be covered, so the means by which an insurer acquires revenue is lost to them.  The net effect, is that the only way they can ensure a steady revenue stream is by eliminating as many risks as possible, which for their business means the people that really need it.

In addition, the insurers play the role of the consumer, and therefore are not representative of a real economic interaction.  If doctors had to be paid directly by their patients, you can bet we'd have to come up with a different method, because most would either lose their patients or be spending all their time in collections.  From this, I can only conclude that it is the insurance companies that are propping up this failing infrastructure by enabling doctors and hospitals to charge these rates because they're still able to get the money for treatment from the insurers.




An Alternative to Capitalism?

The following link, takes you to a "utopian" article, entitled "Home of the Brave?" which I wrote and appeared in the Athenaeum Library of Philosophy:

http://evans-experientialism.freewebspace.com/steinsvold.htm

John Steinsvold

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