Sunday, February 5, 2017

The Nirvana Fallacy in Healthcare Economics

by Levi Russell

RegBlog, a great source for regulatory info, published an opinion piece about three weeks ago by Allison Hoffman. a law professor, on the potential for an Obamacare rollback by Republicans. Reading the essay, I recognized several errors of economic logic that I thought I'd point out here. I'm not an expert in this field, but I'm a firm believer that the economic way of thinking properly applied can provide much-needed clarity. As with any other post on FH, I invite others to correct me on any of the following if I miss something important.

The first two-thirds of the post is essentially an exercise in Harold Demsetz's Nirvana Fallacy. Yes, of course people could have more accurate information about treatments and could do a better job choosing good doctors. Does that mean the government should step in? Of course people are generally healthier when they don't pay the marginal cost of care; the cost/benefit calculus is skewed by the fact that the cost is near zero. Of course diseases are caused, to some degree, by things outside of our control. Does that imply the government can control those things or can necessarily make better decisions than we can?

Professor Hoffman then takes on a few individual proposals. She acknowledges that health savings accounts (HSAs) benefit some people, but complains that they are only beneficial for those with "surplus income." Her lack of a concrete example exposes the flaw in her critique. Suppose you are faced with two options for employer-provided healthcare: (1) a traditional "insurance" plan with a premium of $500 monthly and copays for doctor visits or (2) a catastrophic plan with a premium of $200 and an HSA with a contribution match up to $3,000 per year. The HSA allows you to save money for later when your monthly expenditures are lower than what you save. Comparing the two, it's trivial to point out that if I choose (2) I have $300 in "surplus income" to put into the savings account (plus the match!). Certainly some people don't have employer-provided health insurance, but the ACA was quickly making such policies tremendously expensive.

Hoffman later discusses tax credits, tax deductions, and other premium support programs proposed by Republicans. She criticizes one plan that would give a $2,100 tax credit to anyone between the ages of 35 and 50 for medical costs. Her criticism is that this credit would not cover a Bronze ACA plan which costs $4,200 per year. Assuming her figures are correct, this criticism seems empty to me. The credit would probably work well for a lot of people (especially those with low incomes) in scenario 2 above. The fact that it doesn't work with a choice-limiting, 3rd party payer program like the ACA isn't necessarily proof that the tax credit is bad. Perhaps it means choice-limiting 3rd party payer programs are inefficient.

Finally, Professor Hoffman criticizes reform proposals on the basis that the vouchers, credits, or deductions will grow at a rate at or below inflation, which is below historic rates of growth of healthcare costs. Unlike many, many other goods and services (even those produced in "non-contestable" industries), those that are heavily subsidized by the government like education and healthcare increase in cost much more rapidly than inflation. It's possible that reducing the government's role in healthcare will make that industry operate more like other industries, thus lowering costs. I'm sure there are reasons to think otherwise, but federal and state governments have had a lot of control over healthcare markets for at least 7 decades. Perhaps we should try something different.

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