Warrencare

 

Elizabeth Warren recently rolled out her new “Medicare-for-All” plan with the strong claim that “Health Care Is A Basic Human Right.” She then backed up that claim with a story about how, when she was in middle school, her father had a heart attack and their health care expenditures nearly cost her family its home. From those two observations, she has crafted her massive entitlement system which will, when the dust settles, collapse. It will fail as individuals become unable to receive timely health care, and it will exacerbate the dislocations that plagued the Warren family. Why? Because her two points represent the worst way to think about health care, both on the revenue side and on the expenditure side.

On the first point, the stirring claim that health care is a “right” obscures all references to correlative duties. Under classical legal thought, a right to health care referred to the ability of a person to take his own money and spend it on health care with whatever health care providers that he chose. The correlative duties on the rest of the world were not to fund his care but to stand aside and let those contracts go forward as the parties chose. As in all areas of human endeavors, voluntary transactions normally generate gains for both sides. In health care markets, families and individuals are often unsure what contracts to make or why. But their best cure is to hire agents who can fill their knowledge gap, whether as personal advisors, employers, cooperatives, or religious or social groups.

Warren’s radical approach requires the negation of these traditional rights to acquire health care. Her positive right to health care necessarily imposes on someone else the correlative duty to supply that needed health care. But this broad task then faces two insuperable obstacles. First, on whom does the duty of provision apply? The Warren answer in large measure enables a government coterie to coerce employers, large corporations, and a select group of the ultra-rich to discharge that obligation. Once these payors are identified, the state will then set out the terms of coverage by running a planned economy, deciding what bundle of services will be provided, and through which institutions. Friedrich Hayek’s prescient warning about the abuses of centralized power is recklessly thrown to the wind.

Warren’s model also discards private health care insurer’s exhaustive research to determine what kinds of conditions to cover and to what extent. Left to their own devices, these private insurers know that they will not last long if they require customers to make—either directly, or indirectly through health care plans—expenditures that are worth less than they cost. But no such constraint cabins these positive rights when the recipients don’t need to use their own resources to fund the health-care benefits they receive.

Under a positive rights regime, plan recipients no longer seek to conserve resources. They seek instead to take advantage of the system so long as they receive a net gain from treatment, whose cost to them at the time of service is zero. The result is that low priority cases work their way into the health care system, so that under “Medicare-for-All” the total demand for services increases while simultaneously the net benefit from their delivery falls. Health care is not special in this regard; the dangerous overconsumption of positive rights also occurs with housing and education.

Warren’s second mistake is to use personal history as the basis for social policy. All private care plans limit coverage, both in the aggregate and for particular procedures. Those limitations necessarily mean that in some defined class of cases, individuals will come up short after the fact, when with hindsight they would have purchased more coverage earlier. But Warren’s story forms a data set of one case. To get a balanced picture of the insurance market, it is also necessary to take into account the many winners—those individuals who bought limited coverage at lower cost and profited because those policies provided them with all the coverage they needed. Insurance is a large-numbers business, and Warren’s carefully selected anecdote invites going far beyond the already woolly thinking behind the expansive minimum essential benefit plans under the Affordable Care Act, which itself has caused so many dislocations in coverage.

The looming shipwreck should not come as a surprise to any careful student of institutional arrangements who knows that the law of unintended consequences lays waste to such noble dreams as universal health care. This point becomes painfully evident by looking at Warren’s naïve optimism on both funding and expenditures. The initial Warren ploy is to claim that her major redo will result in “not one penny in middle-class tax increases.” Well then, where will this money come from? Even if we could just confiscate the wealth of all of the 400 richest United States citizens, this would generate less than a $3 trillion down-payment on her $52 trillion plan. And of course, this one-time “gain” would be offset by a shrunken capital base in future years, not only from that select few, but also from the countless individuals and firms with whom these financial elites do business.

It is also, of course, possible to raise the corporate tax rate again, a move that technically does not fall on the shareholders. But this maneuver ignores that trillions of dollars in corporate wealth is owned by pension funds whose ordinary beneficiaries would see their annual payouts shrink. Taxes rarely remain where they are levied, and are instead passed forward and backward in a complex array of maneuvers to other parties along the chain of production and consumption. And a rise in corporate tax rates would hurt in yet another fashion. Corporate investments and wages are closely linked, so that as investment lags, wages fall. The recent steady improvement of wages across the income spectrum will quickly become a thing of the past.

Warren’s plan will also divert about 98 percent of the employer cost of health care to the national budget, where it will no longer be devoted exclusively to the employees of the firm but instead be spread among all members of society, representing yet another huge de facto tax on middle class employees, brought to you by the same people who are unable to run the Veteran’s Administration.

The size of these implicit taxes will be compounded by two other features of the Warren plan. First, she hopes to tax the unrealized appreciation of capital assets, an exaction that accrues without any sale of shares. That approach will force shareholders to either sell assets or borrow on them to pay their taxes. Second, taxing unrealized appreciation will present severe challenges of valuation for any financial asset without a readily determined market value. The ensuing administrative nightmare will be compounded if Warren imposes her perverse wealth tax—presently proposed at a rate of 6 percent at the top, double her previous amount. When added to the massive distortions that Warren has planned for labor and international trade, the entire system will quickly collapse under its own weight.

These major disruptions will also be felt on the buyer side of the market as well, where Warren once again attempts the impossible. She first wants to increase the amount of available coverage by offering everyone unlimited health care benefits, when and as they need it. At the same time, she will force tens of millions of people who like their current health care plans into an untested government network set up from scratch. Accordingly, physician salaries will plummet, and all sorts of other medical businesses, from practice groups to niche primary care operations like One Medical and CitiMD, will either close their doors or submit to government control. This creaky Warren edifice rests on the premise that the supply of medical services is wholly inelastic, such that if salaries plummet, the same number of physicians and other health care providers will soldier on as before, even if they can no longer make payments on their home mortgages.

Such passivity is not in the cards. Instead, there will be a rush to the exit. Senior physicians will retire in droves when faced with higher taxes on smaller earnings. Foreign physicians will return home or look for greener pastures elsewhere. Young graduates will bypass medical careers altogether. Toronto and Vancouver will become destination spots for Americans that still have independent means to pay for medical services. And for the rest of the population, the laws of supply and demand will lead to the formation of queues as a wasteful means to ration services. And with queues come gray markets filled with buyers and sellers willing to work outside the system.

Let us hope this fiasco does not come to pass, for if it does, we can be sure that Warren and her inner circle, like the pigs in Orwell’s Animal Farm, will cheerfully exempt themselves from the planned misery they will plan to impose on others.

© 2019 by the Board of Trustees of Leland Stanford Junior University

Published in Elections, Healthcare, Law
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  1. Ralphie Inactive
    Ralphie
    @Ralphie

    Zafar (View Comment):

    Ralphie (View Comment):

    Zafar (View Comment):

    A good point regarding unintended consequences (there always are some) – though (1) how do other economically developed countries (like Australia) manage these for Single payer, and (2) how does the US manage these for its current system?

    They also allow private insurance, something Warren wants to ban. Canada has been returning to private providers to meet the needs of their citizens. England has private insurance/drs as do the Scandanavian countries. It is called two tier medical care, where the rich still get what they need, and for the rest it can be a crap shoot.

    Living in Australia I can tell you public hospitals are not bad (in fact there are no private emergency rooms), and that two systems are pretty intertwined (for eg doctors can work in both systems).

    This Dickensian vision of dregs for the masses is not true here. FWIW.

    You can spend money is a few ways: your money on yourself, your money on someone else, someone elses’ money on you, and someone elses money on someone else. Guess what way is the most efficient and best value?

    The point is spending money together gets us a better bang for our buck per capita. That’s more efficient than any of the options you gave used solo.

    That is only true on paper. This matrix was originally Milt Friedman’s  explaination.  If you can figure out how to cut out fraud and waste, perhaps.  Here is another way of putting it per Walter Williams: If you are going on a business  trip and all expenses are paid by your employer, you will stay at a pretty decent hotel, and eat whatever you want; the price won’t be a big concern. If your employer gives you the money he would have spent and tells you you can keep what you don’t spend, many people would stay at a cheap hotel and eat fast food. If you have to pay for it yourself, you’ll probably argue you don’t need to go.

    • #31
  2. The Reticulator Member
    The Reticulator
    @TheReticulator

    Zafar (View Comment):

    The Reticulator (View Comment):

    The Reticulator (View Comment):

    Zafar (View Comment):
    The point is spending money together gets us a better bang for our buck per capita. That’s more efficient than any of the options you gave used solo.

    More efficient from a state-centric point of view. Maybe not from a people-centric perspective.

    From a what I pay for my healthcare (directly or through taxes) point of view. I pay less than I would otherwise for a very similar personal healthcare product.

    I do understand the mistrust of Government, sort of, but I am not sure that it doesn’t make people refuse to look at facts that do not align with ideology when it comes to this. Iow it’s moved into the realm of belief, where it sits with religion.

    (I’m sure you could say the same of the mistrust of Corporations, in many cases.)

    This is what it looks like to me, but I could be missing the facts based arguments wrt outcomes and costs.

    Thoughts?

    There is no such thing as fact-based arguments. Facts are used to test arguments.  

    And I am not talking about mistrust of government. I am talking about the inherit conflicts of interest between governments (and especially the managers of government) and people.   But yes, there are a lot of similarities between government corporations and private corporations in this regard.   

    • #32
  3. The Reticulator Member
    The Reticulator
    @TheReticulator

    MISTER BITCOIN (View Comment):

    Zafar (View Comment):

    Are citizens entitled to police services?

    Are citizens entitled to any Government services?

    yes to police

    no to ‘any government service’

     

    Tell that to Andy Ngo.   

    • #33
  4. Zafar Member
    Zafar
    @Zafar

    @ralphie – waste and fraud are issues in private and public organizations.

    But just noting: every time one talks about the relative costs and advantages of (for eg) public vs private insurance schemes the conservative response is a brief exposition on why private systems should be more efficient – usually using a theoretical and non-medical example.  

    Are there no actual medical examples that come easily to mind? Are there any such when comparing (for example) the US system (18% of gdp spent on healthcare) and Australia ((10%)? I haven’t heard any yet. 

    @thereticulator – those percentages are the facts which support my argument that a mixed public private insurance stem with single payer is more efficient than a system without single payer.  

    • #34
  5. The Reticulator Member
    The Reticulator
    @TheReticulator

    Zafar (View Comment):

    @ralphie – waste and fraud are issues in private and public organizations.

    But just noting: every time one talks about the relative costs and advantages of (for eg) public vs private insurance schemes the conservative response is a brief exposition on why private systems should be more efficient – usually using a theoretical and non-medical example.

    Are there no actual medical examples that come easily to mind? Are there any such when comparing (for example) the US system (18% of gdp spent on healthcare) and Australia ((10%)? I haven’t heard any yet.

    @thereticulator – those percentages are the facts which support my argument that a mixed public private insurance stem with single payer is more efficient than a system without single payer.

    A national system can certainly be more efficient at herd management, assuming a certain amount of culling.   It’s less likely to be more efficient in treating humans as humans. 

    • #35
  6. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Zafar (View Comment):

    MISTER BITCOIN (View Comment):

    Zafar (View Comment):

    Ralphie (View Comment):

    Zafar (View Comment):

    A good point regarding unintended consequences (there always are some) – though (1) how do other economically developed countries (like Australia) manage these for Single payer, and (2) how does the US manage these for its current system?

    They also allow private insurance, something Warren wants to ban. Canada has been returning to private providers to meet the needs of their citizens. England has private insurance/drs as do the Scandanavian countries. It is called two tier medical care, where the rich still get what they need, and for the rest it can be a crap shoot.

    Living in Australia I can tell you public hospitals are not bad (in fact there are no private emergency rooms), and that two systems are pretty intertwined (for eg doctors can work in both systems).

    This Dickensian vision of dregs for the masses is not true here. FWIW.

    You can spend money is a few ways: your money on yourself, your money on someone else, someone elses’ money on you, and someone elses money on someone else. Guess what way is the most efficient and best value?

    The point is spending money together gets us a better bang for our buck per capita. That’s more efficient than any of the options you gave used solo.

    can you provide an example of the efficiency of spending money together (while we hold hands)?

    The US spends 18% of its GDP on health care, other industrialised democracies spend about half that %age for very similar results. (Australia spends about 10%.) They spend this in the context of significant Government intervention in health care – either by way of single payer (Australia) or by way or regulating insurance companies wrt what they offer and whether they can be for profit or not.

    That looks like an efficient use of resources for the people of these countries, basically achieved because they pay for healthcare together and that gives them bargaining power.

     

    you’re only looking at cost and not benefits

     

    • #36
  7. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Zafar (View Comment):

    @machogrande – yes, I agree simple arguments for complex issues are not adequate. (Neither is dodgy maths – Australia probably could grumblingly afford to extend health care coverage to 4% of the population for free [if it doesn’t already do so]). That the US is too big for a version of single payer is, imho, one such argument.

    Any scheme can be run better (public or private) but is there significant appetite among US Seniors to get rid of Medicare so that they can just spend the money buying private insurance plans? If not, that’s telling you something.

    Similarly does the majority of the population in any other industrialized country want to exchange their own health care system for something like the US’?

    And – we shouldn’t be too proud to learn from each other. The US has plenty to teach the rest of the world, but that doesn’t mean it doesn’t have anything to learn from the rest of the world as well.

    what medical innovations have come from australia?

    how many australians have won the nobel prize in medicine?

     

    • #37
  8. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Zafar (View Comment):

    @machogrande – yes, I agree simple arguments for complex issues are not adequate. (Neither is dodgy maths – Australia probably could grumblingly afford to extend health care coverage to 4% of the population for free [if it doesn’t already do so]). That the US is too big for a version of single payer is, imho, one such argument.

    Any scheme can be run better (public or private) but is there significant appetite among US Seniors to get rid of Medicare so that they can just spend the money buying private insurance plans? If not, that’s telling you something.

    Similarly does the majority of the population in any other industrialized country want to exchange their own health care system for something like the US’?

    And – we shouldn’t be too proud to learn from each other. The US has plenty to teach the rest of the world, but that doesn’t mean it doesn’t have anything to learn from the rest of the world as well.

    we have 50 states. each state can learn from each other too.

    but not under medicare for all

     

    • #38
  9. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Ralphie (View Comment):

    Zafar (View Comment):

    Ralphie (View Comment):

    Zafar (View Comment):

    A good point regarding unintended consequences (there always are some) – though (1) how do other economically developed countries (like Australia) manage these for Single payer, and (2) how does the US manage these for its current system?

    They also allow private insurance, something Warren wants to ban. Canada has been returning to private providers to meet the needs of their citizens. England has private insurance/drs as do the Scandanavian countries. It is called two tier medical care, where the rich still get what they need, and for the rest it can be a crap shoot.

    Living in Australia I can tell you public hospitals are not bad (in fact there are no private emergency rooms), and that two systems are pretty intertwined (for eg doctors can work in both systems).

    This Dickensian vision of dregs for the masses is not true here. FWIW.

    You can spend money is a few ways: your money on yourself, your money on someone else, someone elses’ money on you, and someone elses money on someone else. Guess what way is the most efficient and best value?

    The point is spending money together gets us a better bang for our buck per capita. That’s more efficient than any of the options you gave used solo.

    That is only true on paper. This matrix was originally Milt Friedman’s explaination. If you can figure out how to cut out fraud and waste, perhaps. Here is another way of putting it per Walter Williams: If you are going on a business trip and all expenses are paid by your employer, you will stay at a pretty decent hotel, and eat whatever you want; the price won’t be a big concern. If your employer gives you the money he would have spent and tells you you can keep what you don’t spend, many people would stay at a cheap hotel and eat fast food. If you have to pay for it yourself, you’ll probably argue you don’t need to go.

    it’s true on paper?

    what paper?

    invisible paper?

     

    • #39
  10. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    The Reticulator (View Comment):

    Zafar (View Comment):

    The Reticulator (View Comment):

    The Reticulator (View Comment):

    Zafar (View Comment):
    The point is spending money together gets us a better bang for our buck per capita. That’s more efficient than any of the options you gave used solo.

    More efficient from a state-centric point of view. Maybe not from a people-centric perspective.

    From a what I pay for my healthcare (directly or through taxes) point of view. I pay less than I would otherwise for a very similar personal healthcare product.

    I do understand the mistrust of Government, sort of, but I am not sure that it doesn’t make people refuse to look at facts that do not align with ideology when it comes to this. Iow it’s moved into the realm of belief, where it sits with religion.

    (I’m sure you could say the same of the mistrust of Corporations, in many cases.)

    This is what it looks like to me, but I could be missing the facts based arguments wrt outcomes and costs.

    Thoughts?

    There is no such thing as fact-based arguments. Facts are used to test arguments.

    And I am not talking about mistrust of government. I am talking about the inherit conflicts of interest between governments (and especially the managers of government) and people. But yes, there are a lot of similarities between government corporations and private corporations in this regard.

    what is a government corporation?

    do they have shareholders?

     

    • #40
  11. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    The Reticulator (View Comment):

    MISTER BITCOIN (View Comment):

    Zafar (View Comment):

    Are citizens entitled to police services?

    Are citizens entitled to any Government services?

    yes to police

    no to ‘any government service’

     

    Tell that to Andy Ngo.

    we pay for government services such as the police.

    who pays the police? taxpayers

     

    • #41
  12. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Zafar (View Comment):

    @ralphie – waste and fraud are issues in private and public organizations.

    But just noting: every time one talks about the relative costs and advantages of (for eg) public vs private insurance schemes the conservative response is a brief exposition on why private systems should be more efficient – usually using a theoretical and non-medical example.

    Are there no actual medical examples that come easily to mind? Are there any such when comparing (for example) the US system (18% of gdp spent on healthcare) and Australia ((10%)? I haven’t heard any yet.

    @thereticulator – those percentages are the facts which support my argument that a mixed public private insurance stem with single payer is more efficient than a system without single payer.

    you’re only looking at cost.

    what about waiting times?

    what about patient satisfaction?

     

    • #42
  13. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Zafar (View Comment):

    @ralphie – waste and fraud are issues in private and public organizations.

    But just noting: every time one talks about the relative costs and advantages of (for eg) public vs private insurance schemes the conservative response is a brief exposition on why private systems should be more efficient – usually using a theoretical and non-medical example.

    Are there no actual medical examples that come easily to mind? Are there any such when comparing (for example) the US system (18% of gdp spent on healthcare) and Australia ((10%)? I haven’t heard any yet.

    @thereticulator – those percentages are the facts which support my argument that a mixed public private insurance stem with single payer is more efficient than a system without single payer.

    if you’re a doctor would you prefer to practice in australia or usa?

    by the way, for complicated medical treatment australians travel to singapore which has an excellent health care system, not single payer

     

    • #43
  14. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    MISTER BITCOIN (View Comment):

    Ralphie (View Comment):

    What if I don’t want what the government is giving me for my personal use? No right to seek my own solution to a problem? The Dems are 1/2 right, we spend too much money, but the reason is wrong. It is because government got involved in the first place. Same with education. Wherever the government gets involved, mandates and pays, they need more money and people to meet the mission.

    it’s quite insidious and stupid.

    democrats limit supply while subsidizing demand then complain about rising health care costs and blame big pharma.

    it’s a two year old argument

     

    i mean it’s an argument made by a two year old

     

    • #44
  15. MISTER BITCOIN Inactive
    MISTER BITCOIN
    @MISTERBITCOIN

    Zafar (View Comment):

    MISTER BITCOIN (View Comment):

    Zafar (View Comment):

    Are citizens entitled to police services?

    Are citizens entitled to any Government services?

    yes to police

    no to ‘any government service’

     

    The police are one Government service.

    Why them and not any others?

    no one is entitled to anything except life liberty and the pursuit of happiness?

     

    • #45
  16. Ralphie Inactive
    Ralphie
    @Ralphie

    MISTER BITCOIN (View Comment):

    Zafar (View Comment):

    @ralphie – waste and fraud are issues in private and public organizations.

    But just noting: every time one talks about the relative costs and advantages of (for eg) public vs private insurance schemes the conservative response is a brief exposition on why private systems should be more efficient – usually using a theoretical and non-medical example.

    Are there no actual medical examples that come easily to mind? Are there any such when comparing (for example) the US system (18% of gdp spent on healthcare) and Australia ((10%)? I haven’t heard any yet.

    @thereticulator – those percentages are the facts which support my argument that a mixed public private insurance stem with single payer is more efficient than a system without single payer.

    you’re only looking at cost.

    what about waiting times?

    what about patient satisfaction?

     

    What about freedom? 

    I do think the health system we have now is a mess. It isn’t in the market, prices are not being paid for the most part by the end user, and should be. There are examples of cheaper health services, like the new braces that are being sold everyday, or eyeglasses that are sold online. Professionals generally protest. There was and may still be a push by pharmacists to provide limited care for patients, like blood pressure (an example from a pharm tech module I took a few years ago.) Drs. don’t like it.  When high imaging could look at artery build up without being invasive, heart drs resisted. Heart drs do a lot of cath procedures and make money from those. (this was told to me by a radiologist, who said patients would rather have a noninvasive, cheaper procedure if given the choice, and I think heart drs may be trying that (imaging) themselves. Drs do compete with each other, and they do make a lot of money. I know I draw a lot of their houses and cottages. And I’ve also seen where they are expanding in other business ventures outside of medicine.)

    I also think you could use the argument for anything we use and depend on, like cars. How about something like the Yugo, or just small, medium and large cars depending on household occupants? No car for you if there is public transportation. Where is the line between efficiency and choice?

    The government has been very involved in paying for health care for decades, and the private sector gold status plans have been subsidizing the goverment cheap pay. 

    Remember it was Vermont that passed single payer, a tiny state, that had to revoke it because they could not make the number work; taxes would have be raised, and drs and hospitals refused to take cuts.

     

    • #46
  17. Zafar Member
    Zafar
    @Zafar

    MISTER BITCOIN (View Comment):

    Zafar (View Comment):

    @ralphie – waste and fraud are issues in private and public organizations.

    But just noting: every time one talks about the relative costs and advantages of (for eg) public vs private insurance schemes the conservative response is a brief exposition on why private systems should be more efficient – usually using a theoretical and non-medical example.

    Are there no actual medical examples that come easily to mind? Are there any such when comparing (for example) the US system (18% of gdp spent on healthcare) and Australia ((10%)? I haven’t heard any yet.

    @thereticulator – those percentages are the facts which support my argument that a mixed public private insurance stem with single payer is more efficient than a system without single payer.

    if you’re a doctor would you prefer to practice in australia or usa?

    by the way, for complicated medical treatment australians travel to singapore which has an excellent health care system, not single payer

    Oh Mister Bitcoin, you disappoint me :-(

    Bolded below for your convenience.

    From (shudder) wiki:

    Healthcare in Singapore is supervised by the Ministry of Health of the Singapore Government. It largely consists of a government-run universal healthcare system with a significant private healthcare sector. In addition, financing of healthcare costs is done through a mixture of direct government subsidies, compulsory savings, national healthcare insurance, and cost sharing.

    Or if you prefer another source:

    Healthcare infrastruture in Singapore consists of both public and private healthcare facilities with both offering high quality of medical care but generally different level of service and comfort. Health plans, insurance, and benefits vary largely and depend typically on your immigration status and the employer. Singapore citizens and permanent residents are entitled to subsidized government healthcare services through compulsory national savings scheme whereas foreigners holding various work passes get the health coverage either through their employer or purchase it privately on their own.

    I suspect I have more respect for anybody who’s reading these comments than you do.

    • #47
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