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FiveThirtyEight

Politics

George Will’s latest:

The puzzle is: Why does the president, who says that were America “starting from scratch” he would favor a “single-payer” — government-run — system, insist that health care reform include a government insurance plan that competes with private insurers? [...]

Assurances that the government plan would play by the rules that private insurers play by are implausible. Government is incapable of behaving like market-disciplined private insurers. Competition from the public option must be unfair because government does not need to make a profit and has enormous pricing and negotiating powers. Besides, unless the point of a government plan is to be cheaper, it is pointless: If the public option conforms to the imperatives that regulations and competition impose on private insurers, there is no reason for it.

Emphasis in original. Will’s argument is apparently this: The government does not need to make a profit and will have greater leverage with providers; therefore it will deliver the same service for less money. That’s unfair!

Is this really the best argument that one of the most prominent intellectual conservatives can mount against the public option?

I’m a big believer in the profit motive in 99 percent of all cases. If the government decided to open a non-profit hamburger stand, I doubt that it would compete successfully against Five Guys. If it tried to open a non-profit airline, I doubt that it could offer the same value as JetBlue. Insert joke about General Motors and/or the Post Office here. The point is, I think the profit motive is generally well worth it in terms of the incentives it creates to cut costs, develop new products, improve customer service, and so forth.

But health insurance is not like those things.

Insurance exists because of the decreasing marginal utility of income: most people would rather have a 100% chance of paying $300 a month than a 1% chance of paying $30,000 a month. In fact, our hypothetical customer — let’s call him Frederick, after George F. Will’s middle name — might very well accept a 100% chance of paying $400 a month rather than take 1% chance of having to pay $30,000, which he might not be able to afford. This is true even though Frederick will lose $100 on this deal in an average month.

There’s nothing wrong with this arrangement — the customer has improved his marginal utility and the insurance company has made $100. It’s a win-win.

The thing is, though, that the insurer hasn’t had to work particularly hard for his $100. He hasn’t had to figure out how to cook up tastier fries or save you a few bucks off the cost of your next flight to Orlando. All he has to do is to have a bunch of money pooled together, such that he has a different marginal utility curve than you do. He has the luxury to accept the risk of unlikely outcomes, particularly if he can hedge his position by making the same deal with other customers, most of whom won’t wind up requiring an angioplasty or cataract surgery, even if Frederick does.

Now, what’s supposed to happen in the free market is that another company will come in and offer Frederick a better deal: they’ll offer him the same coverage for $350 a month, accepting a smaller profit, and Frederick will happily take the deal. There are at least a couple of reasons, however, why this may not be happening in the insurance industry. The first is that Frederick might not realize he’s paying $400 every month for insurance. That’s because if he’s like the majority of Americans, he’s getting his insurance through his work, and except when the HR lady gave him a shiny brochure on his first day at the office, he’s probably never thought very much about what this insurance is costing him in terms of foregone salary. This is particularly so because health insurance benefits, unlike other types of income, aren’t taxed, and so Fredrick is less cognizant of them if show up on his paycheck at all. Not only, then, is the free market maxim of perfect information violated, but it’s violated in such a way that creates artificial profits for the insurance industry: the government is effectively subsidizing every dollar that Frederick’s company is willing to spend on his insurance benefit.

The profits the insurance industry is making, of course — profits artificially boosted by an enormous backdoor tax subsidy — don’t seem to be buying the customer much of anything in terms of improved service or cost savings. On the contrary, health care costs are rising by as much as 9-10 percent per year, without any concomitant increase in the level of service. If JetBlue were raising the cost of its fares by 10 percent per year, they’d be out of business.

The reason the insurers are staying in business, though, is because barriers to entry in the health insurance industry are in practice quite high. Insurers benefit from pooling risk. The larger the pool, the better in terms of the insurer’s ability to hedge its risk and build negotiating leverage with its providers. That makes it very difficult for a Five Guys or a JetBlue type of start-up to compete: they’ll have trouble getting together enough customers to pool their risk adequately, and even if they do, they won’t have as much negotiating leverage as the big guys. Health care providers may demand a better deal or refuse to accept them. As such, they’ll never get off the ground.

Insurance, in other words, is a volume business, the main requirements for which are that (1) you have a lot of money pooled together and that (2) you’ve been around for awhile.

CIGNA and Aetna have a lot of money pooled together and they’ve been around for awhile — but they don’t have as much money, nor have they been around as long, as the federal government. It’s possible, certainly, that the profit motive in the insurance industry has driven more innovation than we’re giving it credit for. But that isn’t my bet, and it isn’t George Will’s: There’s no obvious reason that the government couldn’t provide more for less. And if we are wrong, we would find out soon enough: if the public option can’t deliver more bang for the buck than private insurers, it wouldn’t gain much market share from them, and Will will have nothing to worry about.

What Will’s position reflects instead is ideology: who cares that the federal government could build a better mousetrap? They’re the government and that’s bad. His argument is really no more sophisticated than that. If a libertarian conservative wants to make this argument, more power to them, but they absolutely should not be turning around and suggesting that a public option would raise health care costs. They’re saying, rather, that they’re morally opposed to the cost savings that would ensue.

If you’ve been reading me for a while, you’ll know that, as compared with most self-described liberals, I’m unusually sympathetic toward the notion of the profit motive and private industry; I’ve defended Wall Street bankers and the AIG bonuses at various points during the financial crisis, among other things. It’s my belief that private industry is usually able to deliver more efficient outcomes to the consumer than the government could.

But usually isn’t always. And health insurance, as Will seems to admit, is one of those exceptions.

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