David R. Henderson  

Proposed Questions for Oberlin Debate

PRINT
Francis A. Walker... George Soros, speculator and p...

I announced back in February that I will be debating Yale University's Ted Marmor on health care, with emphasis on the Affordable Care Act, aka Obamacare. I asked you for proposed questions because the debate isn't structured as a traditional debate. Rather, the moderator will ask questions that we will each answer. Each of us can propose questions. The debate will be on the evening of Wednesday, March 19. The public is welcome.

Many of you were very helpful. I've taken the best of the questions you proposed and tweaked some of them. I've also added a few of my own. I plan to send my list tomorrow and so am asking for comments on these. Many of you will recognize your own questions in the list. Here it is:

1. A large part of the Affordable Care Act is based on the idea that health insurance is the best way to finance health care. Do you think that requiring health insurance to cover routine, expected or elective health care expenditures will increase or decrease the cost of such services? Explain.

2. Is there a tension between the public-sector health care trend of "Comparative Effectiveness Research" and the private-sector medical science trend of "Personalized Genetic Medicine?" Does this imply a tension between cutting-edge medical science and cutting-edge health care delivery systems?

3. When the government has a great deal of control over both health insurance and health care, as it does under the Affordable Care Act, will change in line with new technologies be easier or more difficult than when government has less control? [This is a more general version of #2 above.]

4. When the government wants to make it easier for poor and low-income people to buy food, it provides food stamps so that people can buy their own food in line with their own preferences. If the government wants more health care for people, why not provide subsidies for people to buy either health care or health insurance, so that people can choose their own? Why regulate in detail the structure and coverages of health insurance, not just for poor people, but also for everyone?

5. The price of medical care has been rising faster than inflation at the same time 3rd party payments (private insurance, Medicare, Medicaid) have been increasing. Health care expenditures that do not generally accept third party payments (Lasik, plastic surgery) have at the same time been decreasing in price and increasing in quality. Do you believe there is a causal link between these factors?

6. Of the many attributes of the US health system (before ACA) that led to its high costs and inefficiencies, which ones were improved by ACA, which ones made worse, and which ones were left relatively untouched?

7. Is the ACA affordable? If so, why are businesses cutting hours and employees to hedge against the rising costs of the ACA and why are unions asking for and getting exemptions to the ACA?

8. What is the difference between health care and health care insurance, and why are those terms so often confused in health care discussions?

9. What, in your view, would a completely free market in health care look like? Be specific about coverages, cost, competition, etc.


Comments and Sharing





COMMENTS (13 to date)
Michael Byrnes writes:

David Henderson wrote:

"2. Is there a tension between the public-sector health care trend of "Comparative Effectiveness Research" and the private-sector medical science trend of "Personalized Genetic Medicine?" Does this imply a tension between cutting-edge medical science and cutting-edge health care delivery systems?"

As a private sector consultant in the health care field, I find the characterisation of "Comparative Effectiveness Research" as "public" and Personalized Genetic Medicine as "private" to be ridiculous.

A *lot* of comparative effectiveness research is done privately, 1) for marketing purposes (companies spend a lot of money to produce evidence that their drug is better than their competitor's drug!) and 2) for the purpose of convincing third party payers to pay for it. By contrast, an FDA approval requires only that a drug is shown to be safe and effective.

There is certainly a tension between comparative effectiveness research and personalized genetic medicine, but painting this as state vs. free market is absurd.

Also, this is loaded:

"7. Is the ACA affordable? If so, [b]why are businesses cutting hours and employees to hedge against the rising costs of the ACA[/b] and why are unions asking for and getting exemptions to the ACA?"

If you are planning to first present evidence that these cuts are actually happening and are actually attributable to ACA, then this question is fine. (If not, you should also throw in the classic "Have you stopped beating your wife?")

All of the other questions look good.

Daniel Kuehn writes:

Comparative effectiveness research isn't really "public sector" is it? There are lots of private stakeholders in that and it's been spearheaded by researchers at Dartmouth, not the within the government.

It's still an interesting question. There doesn't have to be tension but I suppose there could be.

sieben writes:

Number 4 is no good I think. It is very easy for your opposition to spin a plausible tale about medicine being too complex for the general public to support an efficient marketplace.

I mean, you can counter back that the same public who cannot make informed decisions as consumers will also fail to make informed decisions as voters, but this is going rather deep. If you could convince the opposition that market failure was a good reason to predict democratic failure, I think you could win pretty much any debate :)

Overall I think you run a significant risk of the opposition running the following narrative: "Yes, David, ACA is not as good as we hoped and we didn't anticipate many of these downsides. However, we still think it is better than what it replaced because of XYZ and we expect it to get better in the future as the administration has time to reform the program in an iterative fashion".

#9 opens a huge can of worms for them to make all the nastiest fearmongering arguments they can muster. I don't think you should let them channel their energy in such an unfavorable way.

You want to be playing offense. The easiest way to do that is to show that the government could have adopted much better policies, but didn't for whatever reasons.

[broken html fixed--Econlib Ed.]

Mark V Anderson writes:

In your first sentence, I presume you mean you are debating "at" Yale, not debating the entire university?

I really like #9. Although many libertarians have emphasized that that the pre-ACA state was nowhere near a free market, I think your average person hasn't heard it. And those that have heard it often think it's a bogus issue. So it is important to emphasize how different our health care would be if it was truly a free market system, even if welfare spending on medical care for the poor was included.

Of course some audience members would be scared by such patient freedom, others would be enticed by the thought. I think it is a good argument that such freedom is quintessentially American.

David R. Henderson writes:

@Mark V. Anderson,
No, I meant that I’m debating all of Yale. :-) Good catch. No, it’s a Yale professor. It will be at Oberlin.

Jim Glass writes:

"3. When the government has a great deal of control over both health insurance and health care, as it does under the Affordable Care Act, will change in line with new technologies be easier or more difficult...?"

Possibly relevant...
~~~~~~~~

Inside the Making of Obamacare, Ezekiel J. Emanuel
...
To control costs and improve quality in health care, the White House economic team believed that we had to change the way physicians are paid.

About 85% of payments to physicians are fees for individual services—which gives doctors incentives to order more tests and interventions. Fee-for-service puts volume above value; it rewards treating sickness rather than promoting health.

"Bundled payments" are widely recognized as a promising new approach to paying doctors. If fee-for-service payment is like ordering a la carte, bundled payment is like a prix fixe menu: It puts all the costs for an episode of care together for one price ... Since the doctors are paid one fee for the entire episode of care, regardless of how many tests and scans and drugs they order, they no longer have an incentive to provide unnecessary care for a few extra bucks. When implemented in hospital settings, bundled payments have been shown to encourage providers to improve efficiency and eliminate unnecessary procedures without stinting on care.

We presented the idea of phasing in bundled payments, especially for chronic conditions, to the rest of the White House reform team, where we found some strong support.

But then we hit a brick wall. Many of our colleagues who worked for Medicare feared that creating the bundles would be too hard and warned that Medicare didn't have the computer infrastructure to handle it.

The arguments went back and forth, but the Medicare bureaucracy wouldn't budge....

Brandon Berg writes:

5. Are medical prices actually increasing faster than inflation when it comes to the price needed to achieve a particular outcome given a particular condition? It's not clear to me that this is a valid comparison. It may well be, but perhaps the question should be made a bit more precise to clarify that?

Larry writes:

- what is the most important "mend" that could be done for ACA?
- is ACA sustainable in its current form?

George writes:

I'm not too keen on the healthcare debate but, I do have a basic understanding of supply and demand. So I guess my question would be: "Would increasing the current number of doctors in this country increase, decrease or have no impact on the cost of healthcare? Would the ACA increase, decrease, or have no impact on the number of doctors in this country?"

Does the ACA have any provisions on increasing the number of doctors in the U.S.? I'm just curious.

David Friedman writes:

Under the ACA, young people pay more than the actuarial cost of their insurance in order to permit older people to pay less—that is why the enrollment of a sufficient number of young people is considered crucial for the success of the program. Is there any good reason for income distribution from young to old?

Politics Debunked writes:

A comment above disputed the idea of raising the issue in "4. When the government wants to make it easier for poor and low-income people to buy food, it provides food stamps". I think that is a crucial issue, Obamacare wouldn't have been passed if they hadn't used that excuse. Government uses the poor as an excuse to micromanage many areas of our economy, it is an important issue to attack.

I think the other crucial issue to harp on is to emphasize that despite that excuse, most healthcare regulation (including ACA) winds up being "crony capitalism", full of regulatory capture examples. Many liberals fear corporate influence over government but don't realize it is likely the major factor leading healthcare costs to rise.

This page:
http://www.politicsdebunked.com/article-list/healthcare
touches on both the issue of #4 and crony capitalism in healthcare with myriad links to sources for details about how competition has been undermined by government leading costs to rise.

Mr. Econotarian writes:

Why should an employer be responsible for someone's health care, outside of WWII era wage control policies?

RPLong writes:

re: question #2, I guess it's open to interpretation, but I don't consider it a "public vs. private" question so much as a "top-down vs. bottom-up question."

Yes, there is an implication that public health delivery systems are heavily weighted toward "top-down." But assuming the debate covers more than just "public vs. private" it would be interesting to hear the debaters' take on how to move things forward. Plan managers (public or private) tend to favor CER, while health care practitioners tend to favor personalized medicine.

Comments for this entry have been closed
Return to top