Warren's space

Someone sees hope that we might actually have a rational
debate about fixing/improving our health care system. I hope so. We can’t afford
to pay more so we had better find ways to get more for what we pay.  See Steven Pearlstein, "Behold,
a National and Rational Conversation on Health Care" The Washington Post, August 12, 2009,
Page A14. 

My March 19 and 23 blogs on AIG Bonuses hit many nerves. It is a difficult and sensitive topic. Today’s Washington Post has two excellent follow up articles on the subject that I highly recommend to anyone interested in that topic. Just click on the titles.

Brady Dennis and Tomoeh Murakami Tse,  “Pay Czar Quietly Meets With Rescued Companies”, The Washington Post, Sunday, August 9, 2009, Page A01.

Amity Shlaes, “A Better Umpire for Corporate Pay” The Washington Post, Sunday, August 9, 2009, Page A17.

My debate in Las Vegas whether to abolish the Fed: 

http://www.c-spanarchives.org/library/index.php?main_page=product_video_info&products_id=287860-1

 

I would like to share two quick thoughts with you that fall
under the heading of Unintended Consequences.

 

Sectarian strife in
Iraq: Late Monday I attended a presentation at the New America Foundation
by Wadah Khanfar, the director general of the Al Jazeera Network (the Arab TV
news network headquartered in Qatar, now with an English language channel). He
is a very interesting and impressive guy. His first observation was to totally
refute the nonsense that Muslims, Arabs or Arab Muslims dislike American values
of liberty, respect for the individual, religious freedom, etc. (it’s the
policies stupid).

 

Mr. Khanfar was the Al Jazeera bureau chief in Baghdad
during America’s invasion of Iraq. At Monday’s presentation he was asked if Al
Jazeera had a Sunni or Shia bias in its Iraq reporting. He replied that Al
Jazeera has strict, professional reporting standards and does its best to
adhere to them. He noted that in 2003 he and his fellow reporters did not even
know whether public figures in Iraq were Sunni, Shia, Christian, Jewish or
something else. Only when the U.S. designed elections requiring a balance of
religious group representation on slates of candidates did these officials need
to state their religious affiliations, thus bringing that issue into public
focus—the opposite of the intended purpose. You can see his entire presentation
here: http://www.youtube.com/watch?v=thg0owasbLw

 

Executive pay and
corporate governance: A cornerstone of capitalism is the belief that the
desire for profit by owners will maximize the prospects over time of capital
being allocated to the uses most wanted by consumers. Long-run profit
maximization is a good thing. Venture capitalists deliberately take large risks
for potentially big gains knowing that they will often fail, but it is their
money they are risking. Owners (shareholders) of established companies are
generally interested in the long-run survival and profitability of the firms
they own and are thus less interested in short-run gains that jeopardize the
long run profits of these firms. If paying high prices for the best talent
contributes to the prospects of greater profits over time, owners will want to
do so.

 

This characterization of capitalism is hard to reconcile
with the rules of corporate governance we now have in the U.S. “New York
Attorney General Andrew M. Cuomo reported that the nation’s nine largest banks
handed out $32.6 billion in bonuses last year even as they ran up more than $81
billion in losses and accepted tens of billions of dollars in emergency federal
aid.”[1]
Do such bonus rules reflect the judgment of owners of how to maximize profits
or the exploitation by management of short-term rents at the expense of
owners?  It may shock you, as it
did me, to learn how little owners can control the remuneration of those who
manage the firms they own.

 

“’Under this bill, the question of compensation amounts will
now be in the hands of shareholders and the question of systemic risk will be in
the hands of the government,’ said Rep. Barney Frank (D-Mass.), who leads the
House Financial Services Committee and who authored the bill.”[2]
Among other things the “bill also gives shareholders the right to reject a pay
package, but their vote would be
advisory.”[3] I always
thought that they had the full authority to approve pay packages. This is
shocking. Corporate governance rules need to be strengthened more than Barney Frank’s timid bill to put owners in
charge of managers.

 Like most things, the use of medical services must be
rationed. But who should do the rationing?

All things that are desired and cannot be provided without
cost (as we used to say about air) must be rationed. This is exactly what
markets do by discovering the price at which buyers are not willing to pay more
for more and producers/sellers are not willing to provide more at that price.
This market-clearing price has the interesting property of maximizing the value
(utility) of each person’s income because a reallocation of that person’s
spending would result in having more of things less valued and less of things
more valued. If you spend more on one thing you will have less income with
which to buy other things (what economists call the budget constraint). Each
person’s tastes and choices are different but each person can satisfy this
utility maximization goal in a free market by tailoring the mix of her
purchases to her own tastes. In short, the market-clearing (equilibrium) price
maximizes the value of each person’s income for each person. Why in the world
do they call this the dismal science?

While I know very little about the health industry, it is
obvious that the necessary rationing of medical services if we are to get the
best value from our incomes faces some challenges. The share of GDP going to
medical care in the U.S. has reached over 16% and is still climbing. This is at
least twice the level of spending of other developed countries, but the result
is not healthier Americans on average. For example, infant mortality rates in
the U.S. are about 40% higher than those in other high-income OECD countries
(World Bank data).

If medical care is provided to users free of charge (i.e. if
someone else pays the actual cost of producing it), those users will consume
medical services until the marginal value of an additional amount is zero (even
though the actual cost is far from zero).
Such users have no need and thus no incentive to restrict (ration) the
medical services they consume in order to save the income for something else
they value more. If insurance pays the full cost of all medical services, the
consumer, at the margin, is getting them free. This is why co-payments are now
usually required and serve the useful purpose of returning some incentive to
the consumer to ration services more carefully (e.g., should you ask for a
simple blood test or a much more expensive comprehensive one?).

If consumers don’t pay, other mechanisms for rationing are
required if gross over provision of medical services is to be avoided and it is
obvious that the escalating costs of such services (without a commensurate
increase in benefits) arise in part for this reason. Insurance companies
themselves ration by establishing what they will pay for and how much they will
pay for it. Ideally consumers would choose insurance plans that ration in ways
that match their own preferences as closely as possible. However, competition
among insurance providers over such cost/benefit decisions is limited by the
fact that since World War II employers have generally provided health insurance
to their employees (because the government subsidizes employer provided
insurance by exempting that form of employee remuneration from taxation). Thus
the employers rather than the actual consumers of medical services decide which
insurance plans to provide. This restricts competition among insurance
companies to provide the mix desired by consumers. Employer provided health
insurance also makes it harder for workers to change jobs and increases the
hardship of unemployment because it also result results in the loss of
insurance coverage.[1]  A national Insurance Exchange through
which everyone could chose competing insurance programs, as is now being
considered, would also increase competition for insurance plans.[2]

One problem with insurance (including Medicare) deciding how
to ration services is that they often do not know as well as trained and
experienced doctors which services (treatments, medications, and technology)
are most cost effective for each situation. So if consumers have little
incentive to ration, maybe doctors should make such decisions for them. Indeed
they are surely the most knowledgeable for making good judgments about the medical
services that are most appropriate and cost effective and in fact we rely
heavily on their judgments in this area. Unfortunately, doctors have several
strong incentives to over supply expensive services. Most doctors in the United
States are paid on the basis of the tasks performed (fee for service) rather
than on the basis of the services rendered (treating pneumonia, or setting a
broken bone) or the results of their efforts (curing a back pain). The more
they do the more they are paid whether they make the best choices or not. Some
medical practices, such as the Mayo Clinic have obtained good cost containment
with high quality service by making their doctors employees rather than paying
them fees for services. If the Mayo Clinic, or Doctors Inc. charge a fixed fee
for treating a particular ailment, they have an incentive to find the most cost
effective ways of doing so for each patient. But then they might have an
incentive to cut too many corners to save money.  HMO’s are another approach to rationing in an effort to deliver
good service at a reasonable cost. They have been unpopular with many people,
but might be the best choose for some if offered as one of many options.

The oversupply of services by doctors has another cause as
well. American malpractice liability laws encourage lawsuits by offering very
large damages, sometimes in cases of reasonable judgments that proved wrong.
Malpractice insurance, often costing individual doctors several hundred
thousand dollars per year, has added considerably to medical costs directly. But
the threat of such suits has also added considerably to such costs indirectly
(with no real benefit) through the defensive, over use of extensive diagnostic
tests by doctors to ensure that they are protected from nuisance lawsuits. Most
professional practitioners (lawyers, engineers, directors, etc.) are protected
from such suits if they have adhered to established norms (protocols) of
decision making even if in retrospect their decision was wrong or not the best.
Reform of malpractice law for medicine along similar lines is needed.

Individual doctors rely on medical boards to establish
protocols for what is best practice in treating each disease and condition.
President Obama wants to establish professional boards to set such standards
for insurance coverage and to evaluate and propose the most cost effective
treatments. It is clear that individual doctors do not have the time and
resources with which to do so and still practice medicine. The American Medical
Association develops such protocols, but it also restricts medical practice in
ways that limit competition among doctors and techniques (e.g., phone or
internet consultations across state lines). As with other services, progress
comes from competition and experimentation. If doctors can never try new
techniques or technologies because they are dealing with human beings, medicine
would be frozen where it is (or where it was).

All of the above reflect failures or weaknesses in
traditional market rationing of medical services. They have contributed to the
high cost of these services in the United States in relation to the quality of
these services. In some cases services are expensive but produce superior
results (new medicines and machines) but in many cases they are wastefully
expensive without providing better results. As in other areas of providing
goods and services, financial and other incentives need to be properly aligned
to provide the best serve at the least cost, which is the level of service and
related cost desired by each consumer from the offered options. And all
services need to be competitively provided (insurance, doctors, labs,
hospitals, etc.). Currently medical services are not being properly rationed. I
wish I knew the answer to the best way forward. Generally the best approaches
result for experimentation and the survival of the best in the market place.
Medical care to too regulated for this traditional approach to work well, but
keeping in mind the importance of getting the incentives right will be part of
improving our system of delivering medical services in the U.S.

I have noted on several occasions (most recently “State Ownership of Businesses) the growing threats to America’s economic productivity of ever greater government involvement in the economy. This productivity is the basis of our high standard of living and of our influence in the world. It is almost impossible for the government to get involved, especially as a shareholder without replacing commercial judgment and considerations with political considerations. Rather than better goods and services at lower prices we get more expensive goods that provide employment or profits for the benefit of a congresswoman’s constituents at tax payer expense. Today’s Washington Post has an article that so clearly illustrates this corrosive danger that I must pass it on: "Time to Click and Drag Car Sales into the 21 Century". The government’s involvement in the economy reduces its productivity but of equal if not greater importance it erodes the integrity of government.

On Friday in Las Vegas I debate whether we should get rid of the Federal Reserve as part of FreedomFest. If interested, you can see it on C-SPAN.

Best wishes,

Warren

Whatever you think about the necessity of the various government bailouts of banks, insurance companies, investment banks and now auto makers, we should all clearly recognize the inevitable consequences of state ownership and thus ultimately control of enterprises. When governments own enterprises, they have an obligation to the tax payers to ensure that their oversight of the companies they finance serves the public interest. History is full of examples of how this has worked out in practice around the world—bloated work forces (how can a caring public official say no to unemployed relatives); thus high cost, uncompetitive outputs; misdirected investments (how can a caring public official say no to constituents in his home town); thus low productivity and losses; thus lower growth and per capital income—but our Congress has wasted no time in demonstrating how it works.

 

This morning’s Washington Post reports that "Lawmakers Chide Automakers Over Dealership Cuts". Surely no one imagines that Congressmen have better judgment about the contribution to the profits and thus the financial viability of GM of its dealer franchise arrangements than GM does itself. Congressmen are responding to the complaints and pressures from GM dealers in their congressional districts. Why would these dealers go to their congressmen to try to pressure bankrupt GM to give them a better deal with tax payers’ money? Well, of course, because the U.S. government and thus Congress now own a significant share of GM and thus have a say in its business decisions. You might hope that your congressman puts the national interest first (the restoration of a viable profitably GM), but you will generally be disappointed (unless you are a GM car dealer). It is our representative’s local congressional district voters who put and keep him/her in office and whose interests must come first. This is the nature of and the way government works and is one of the many reasons it should not own enterprises.

In yesterday’s Post Steven Pearlstein gave one of many specific examples of this behavior: “For sheer hypocrisy, however, you can’t beat Republican Sen. Bob Corker of Tennessee. Last November, Corker took to the Senate floor to denounce the Bush administration’s proposal for bailing out domestic auto manufacturers, saying it didn’t force the companies to do enough to restructure their costs and their operations. Among his big concerns: oversize dealer networks that prevented even the strongest dealerships from making a decent profit.

“Fast forward to today, as Chrysler and GM are finally undergoing the radical downsizing and restructuring that Corker had long demanded. And what does Corker have to say about that? He’s outraged at the way the discontinued dealers have been treated and is pushing legislation to ensure that they get at least six months to wind down their operations and receive full refunds from the automakers for any unsold cars or parts.”[1]

From across the isle Rep John P. Murtha (D-Pa) says it all (in connection with his investigation for favors to and from the “military industrial complex?): "If I’m corrupt, it’s because I take care of my district."[2]

When President Bush first proposed bailing out GM and Chrysler, I argued that if they could not raise the money they needed in the market they should seek the protection of bankruptcy, which provides a well defined and orderly process for restructuring (if warranted) under Chapter XI. A year later both have declared bankruptcy, but the new Obama administration has managed to make mush of the legal bankruptcy process (e.g. treating junior creditors better than senior credits[3]) further politicizing our economy and eroding the rule of clearly defined property rights, which provide the basis on which investors act. I still have confidence that most policy makers of both parties understand the risks of moral hazard and the importance of incentives in guiding behavior, but if they ever get out of hole they dug in crisis mode to start rebuilding a sounder long run, they will have many steps to climb to get out of the policy mess we are in. But for the sake of the country we need to reclarify what should be rendered unto Caesar and what is ours.