Consumer Driven Health Care Plans

For about the last 10 years the United States has been experimenting with consumer driven health care plans.  CDH plans typically combine a high-deductible insurance policy with a health savings account or health reimbursement account.  CDH plans now cover well over 8 million individuals, up considerably from 4.5 million in 2007 and these types of plans continue to grow rapidly.  So what have been the results?

The American Academy of Actuaries has recently produced a review of high quality research on these plans.  Here are their conclusions:

The primary indications are that properly designed CDH plans can produce significant (even substantial) savings without adversely affecting member health status.  To the knowledge of the work group, no data-based study has emerged that presents a contrary view.

Cost-savings in the first year of instituting a CDH plan relative to a traditional plan ranged from 12% to 21%, remarkably large figures.  Moreover, costs appear to grow more slowly under CDH plans than under traditional plans.  

The knock on CDH plans has always been that they could cause people to avoid preventative case.  Not only does this appear to be false it’s the opposite of the truth:

Generally, all of the studies indicated that cost savings did not result from avoidance of inappropriate care and that necessary care was received in equal or greater degree relative to traditional plans.  All of the studies reported a signficant increase in preventative services for CDH participants.

Especially interesting is that some of the studies found that CDH plans resulted in better compliance with evidence-based care.

Note that these results come from CDH plans instituted within the current system.  One would expect that the general equilibrium effects of consumer driven health plans would be even larger than the partial equilibrium effects, see Singapore for evidence (but consider Tyler’s remarks). 

The American Academy of Actuaries is a credible organization but I would like to see more of the underlying data.  All of the studies the AAA reviewed used credible methodologies, controlled for selection and were based on substantial data but the major studies so far have been industry funded.

It’s remarkable that in the current debate over how to control health care costs so little attention is being given to the important results of our 10-year experiment with consumer driven health plans.

Charter Cities

Paul Romer's TED talk on charter cities is up and Romer is now writing more about the idea at his Charter Cities Blog.  In the TED talk and on the blog Romer gives a "fanciful" example of how a charter city might work:

Imagine
that the United States and Cuba agree to disengage by closing the
military base and transferring local administrative control to Canada…

To
help the city flourish, the Canadians encourage immigration. It is a
place with Canadian judges and Mounties that happily accepts millions
of immigrants. Some of the new residents could be Cuban émigrés who
return from North America. Others might be Haitians who come work in
garment factories that firms no longer feel safe bringing into Haiti…

Initially,
the government of Cuba lets some of its citizens participate by
migrating to the new city. Over time, it encourages citizens to move
instead to a new city that it creates in a special economic zone
located right outside the charter city, just as the Mainland Chinese
let its citizens move into Shenzhen next to Hong Kong.

With
clear rules spelled out in the charter and enforced by the Canadian
judicial system, all the infrastructure for the new city is financed by
private investment. The Canadians pay for the government services they
provide (the legal, judicial, and regulatory systems, education, basic
health care) out of the gains in the value of the land in the
administrative zone. This, of course, creates the right incentives to
invest in education and health. Growth in human capital makes income
grow very rapidly, which makes the land in the zone even more valuable. 

It's interesting to compare charter cities to Patri Friedman's concept of seasteading (Alex, Tyler). 
Both charter cities and seasteading are motivated by the desire to
break out of conventional political arrangements and create a system
with much greater scope for innovation in rules.

Romer wants
charter cities built on uninhabited land (of which there is plenty),
seasteading is cities built on the sea (even more plentiful).  Aside
from the obvious advantage of building on land, charter cities allow
current elites to buy-in and gain from the charter city (ala Shenzhen and in other ways)
and thus probably have a better chance of getting "on the ground." 
Charter cities also address a key question about seasteading – will
governments regulate or takeover a successful seastead?  A charter city
is an agreement between governments – Cuba agrees to let Canada
import Canadian rules onto a small portion of Cuban property.  Cuba
could renege on the deal but it's going to be much harder for Cuba to
renege on Canada than for the U.S. government to regulate or otherwise
control seasteading.

By the way, the fact that Romer wants charter cities built on uninhabitated land with plenty of immigration from the charter nation goes some way to reducing the problem of nationalism that concerns Tyler and also the problem of transplanting legal institutions that concerns Arnold Kling.

We don't have many examples of charter cities in action but Hong Kong is a promising example.  Despite nationalism, the agreement with Britain was accepted for over 100 years and it worked.  Contra Tyler, we shouldn't think of what happened in 1997 as China
taking over Hong Kong but rather as the final element of Hong Kong taking
over China.

Seasteading does have one big advantage over charter
cities.  Seasteading is more radical but it is more open, less
tied to elites, and more flexible so, if it works, it is a better design for what Romer
calls innovation in rules formation.

Felix Salmon on Short Sellers

What happens when companies engage in fraudulent activity? Short-sellers get wind of it, and, by selling the stock of the company in question, depress the share price and save uninformed investors some of the loss they would otherwise have suffered had they bought in at an undepressed level. How much is that worth? According to Xiaoxia Lou and Jonathan Karpoff, somewhere between 0.2% and 1.5% of the firm’s market cap.

But what if the short sellers have it wrong, and the company in question is not engaged in fraud? Well, in that case the uninformed investors have just been given the opportunity to buy into that question at a discount, thanks to the shorts. They win again!

Is there any downside to short-selling? Not really: the authors say that “there is no evidence that short selling exacerbates a downward price spiral when the misconduct is publicly revealed”.

So thank you, short-sellers, for saving us from buying in to fraudulent firms at inflated prices, and from giving us a nice discount on the share price of non-fraudulent firms. You rock!

That's Felix Salmon.  We need to make short selling easier not harder.  Wouldn't it be great if someone like Jim Cramer routinely recommend shorting a stock?

Markets in Everything: Iraqi Mixed Marriages

Muhanad Talib, a Sunni Muslim, married his Shiite bride because she was a "suitable woman" for him. It also didn't hurt that their vows made them eligible for a $2,000 payout from the government.

Talib and his wife are among more than 1,700 newlywed couples who have accepted cash from a government program that encourages Sunnis and Shiites to tie the knot.

It's encouraging that according to the AP story such marriages are on the rise and the money seems to be treated more like a bonus than a compensating differential for risk.

Hat tip to Daniel Lippman.

Pharmaceutical R&D

In an over-the-top post Megan McArdle goes all Xena warrior princess on Ezra Klein and Jerry Avorn.  I especially liked this bit: Here's Avorn on why we need not worry that regulating drug prices will reduce innovation:

There are a couple reasons that this is a specious argument. One is that according to their filings with the SEC, the drug companies only spend about 15 cents of every dollar on research and development. That's compared to more than 30 cents in administration and marketing and more than 20 cents on shareholder equity. As an investment in R&D, I think any venture capitalist would say a company spending 15 percent on research is not a robust innovation engine.

and here is McArdle swinging the sword of truth:

This makes about as much sense as saying that Dr. Jerry Avorn cannot be that smart because his brain only weighs about three pounds. Presumably, you can't be really smart–really innovative–unless your brain is at least 30 percent of your body weight!

This is obviously ludicrous–so why would Dr. Avorn say it about an R&D department? Like your brain, the R&D department is part of a complex system that does a lot of important stuff. You can argue that the R&D department is the most important part of a company, not least because it couldn't survive long without it. I think the same thing about my brain–but I'd still be just as dead without my liver. You certainly can't prove anything about my effectiveness as a journalist by pointing out that [my brain] weighs less than my bones. So how big should a "brain" be? Hard to say. But let's look at some companies that are generally recognized as pretty innovative, and their R&D as a percentage of revenue:

Apple:  three cents out of every dollar

Google:  ten cents out of every dollar

Intel:  fifteen cents out of every dollar

Genzyme (innovative biotech startup!):  sixteen cents of every dollar

US Government:  three cents out of every dollar

I can assure Dr. Avorn that any venture capitalist would be happy to invest in these hidebound laggards who haven't had a new idea in centuries. The first few, anyway.

By the way, I liked Jerry Avorn's book Powerful Medicines (see also here) but I thought it was weak on economics, a fact which really shows in this interview (he does make a few good points about comparative effectiveness research). 

High speed trading swimming

Next year the innovative swimming suits that are causing world records to fall at rapid pace will be banned.  Michael Mandel wonders if this is the beginning of the counterrevolution against technological progress and Tyler argues “essentially on innovation we’re seeing a flipping of the burden of proof and I don’t think it is possible to easily fine-tune that flipping in a way to capture good innovations and rule out bad ones.”  Believe it or not, Mandel really was talking about swimsuits.   Tyler, however, was talking about high speed trading but is there much difference between the two?  I don’t think so.

High-tech swimming suits and trading systems are primarily about distribution not efficiency.  A small increase in speed over one’s rivals has a large effect on who wins the race but no effect on whether the race is won and only a small effect on how quickly the race is won.  We get too much investment in innovations with big influences on distribution and small (or even negative) improvements in efficiency and not enough investment in innovations that improve efficiency without much influencing distribution (i.e. innovations in goods with big positive externalities).

One difference between swimsuits and trading systems is that the former are regulated by FINA, the federation that administers international competition in aquatic sports.  We have some hope that a group like FINA can internalize the major externalities both because it encompasses the primary players in the market and because externalities outside of the market are likely to be small (swimming rules are unlikely to cause non-swimmers many problems.)  Thus, FINAs rules on swimsuits have some claim to efficiency.  Note that we see similar “anti-innovation” rules in many other sports such as car racing.  NASCAR, for example, does not allow stock cars to use fuel injectors even though this innovation is now standard on production cars.

NASDAQ (and the other exchanges) are the logical equivalent to NASCAR and FINA in that they can internalize the externalities among the primary players.  Thus, if the exchanges were to regulate various high-speed trading strategies I wouldn’t have any problems with that.

But would exchange regulation go far enough?  Unfortunately we have learned that the exchanges don’t internalize systemic risk.  Trading rules can cause non-traders many problems.  As a result, I think there is a case to be made for greater regulation than the exchanges would provide.  There is good reason to be skeptical about regulation in general but since this product, “financial innovation,” is primarily about distribution I’m less worried about regulation in finance than in fields where innovation is more closely tied to efficiency.

It’s official

Don Boudreaux, chair of the GMU econ department, comments on this sign of the times:

…Uncle Sam is on the verge of paying the City of Los Angeles $30 million to subsidize a ten-year run of Cirque du Soleil. 

So it's finally come to pass – America has embarked on the same road down which ancient Rome marched to its ruin: Uncle Sam not only subsidizes bread (by subsidizing wheat production) but now also circuses.

Gelman’s Good Advice

Andrew Gelman offers some good advice on writing up your results for a research paper: 

1. Start with the conclusions. Write a couple pages on what you've found and what you recommend. In writing these conclusions, you should also be writing some of the introduction, in that you'll need to give enough background so that general readers can understand what you're talking about and why they should care. But you want to start with the conclusions, because that will determine what sort of background information you'll need to give. 

2. Now step back. What is the principal evidence for your conclusions? Make some graphs and pull out some key numbers that represent your research findings which back up your claims. 

3. Back one more step, now. What are the methods and data you used to obtain your research findings.

4. Now go back and write the literature review and the introduction.

5. Moving forward one last time: go to your results and conclusions and give alternative explanations. Why might you be wrong? What are the limits of applicability of your findings? What future research would be appropriate to follow up on these loose ends?

6. Write the abstract. An easy way to start is to take the first sentence from each of the first five paragraphs of the article. This probably won't be quite right, but I bet it will be close to what you need.

7. Give the article to a friend, ask him or her to spend 15 minutes looking at it, then ask what they think your message was, and what evidence you have for it. Your friend should read the article as a potential consumer, not as a critic. You can find typos on your own time, but you need somebody else's eyes to get a sense of the message you're sending.

Bottom line?  Readers are "potential consumers," make it easy for them to buy.  And don't think that marketing is below you.  It isn't.  Marketing can expand the market for what is profound and deep as well as for what is fun.  

Coincidence? I think not.

From a very good piece in the NYTimes on lobbying:

One of the largest sources of campaign contributions to Senate Democrats during this year’s health care debate is a physician-owned hospital in one of the country’s poorest regions that has sought to soften measures that could choke its rapid growth.

According to the Times, the hospital has been quite successful in its efforts.  And where is this powerful hospital with all the lobbying money located?  Why in the metropolitan area of McAllen, Texas.  McAllen, Texas?   Hmmm…now where I have heard that name before? 

Keep this in mind when you hear promises of Medicare savings from Washington.

Identifying and Popping Bubbles: Evidence from Experiments

On the way up, bubbles encourage excessive investment in the bubble sector.  On the way down a bursting bubble can create wealth shocks, liquidity shortages, and balance-sheet death-spirals.  For both of these reasons, it would be good to be able to identify and pop bubbles.  Identifying bubbles isn't easy, however, because, especially when interest rates are low, prices can increase rapidly with small, rational changes in investor expectations.  But the difficulty of identifying bubbles is reasonably well known.  What I think may be less appreciated is that bubbles are hard to pop even when you know that they exist.

In the lab we can create artificial assets with known dividend streams and thus known fundamental values.  Since Vernon Smith's classic experiments (JSTOR), we know that even in these cases efficient markets fail and bubbles are common.  Bubbles occur even as uncertainty about the fundamental value diminishes (JSTOR).  We also know that once a bubble starts it's difficult to stop.  Circuit breakers and brokerage fees (transaction taxes), for example, don't do much to stop bubbles (see King, Smith, Williams, and Van Boening 1993, not online.)  Investor education doesn't help (for example telling participants about previous bubbles doesn't help). Even increasing interest rates doesn't do much to stop a bubble already in progress and may increase volatility on net.

Futures markets (JSTOR) and short selling do tend to dampen but not eliminate bubbles, thus, there is a case for expanding futures markets in housing and making short selling easier (not harder!).

Bubbles are also less common with more experienced traders – this is one of the strongest findings.  Don't get too excited about this, however, it's experience with bubbles that counts not just trading experience.  I once asked Vernon, for example, how the lab evidence generalized to the larger economy.  In particular, I asked whether 3 bubble experiences in the lab–the number which seems to be necessary to dampen bubbles–might translate to 3 big bubbles in the real world such as the dot com, commodity and housing bubbles (rather than to experience with your run of the mill bubble in an individual stock).  He thought that this was a reasonable inference from the evidence.  Thus we may not see too many big bubbles during the trading lifetime of current market participants but experience is a very costly teacher.  Can we do better?

The last factor that does seem to make a difference is that bubbles liftoff and reach higher peaks when there's a lot of cash floating around.  In theory, this shouldn't matter, fundamental value is fundamental value. If an asset is worth $10 in expected value then it's worth $10 whether you have $20 in your pocket or $200.  But in practice bubbles are bigger when cash relative to asset value is high.

Note that the latter experiments are consistent with the Fed having a significant role in bubble inflation (a theory I have not pushed).  In other words, rather than identifying and popping bubbles already on the rise, not blowing bubbles in the first place may be easier and more productive.   

The Uninsured: Adverse Selection Problem or Distribution Problem?

In his recent post on health care and insurance Paul Krugman writes:

[Insurance companies] try to avoid covering people who
are actually likely to need care.

If insurance companies do avoid covering people who are
"likely to need care," this suggests that the uninsured are
unhealthy.  But 60% of the uninsured are in excellent health
(Table 10) (In fact, overall the uninsured are only slightly less healthy than the insured).

To be sure, this doesn't mean that being uninsured is not a problem
but, contra Paul, it does mean that insurance companies would be
willing to cover most of the uninsured at the same rates as the insured
if the uninsured could or would pay those rates. In Paul's story there is a market failure, in the latter story health insurance is expensive and some people don't buy it.  The difference matters because the wrong diagnosis will almost surely lead to the wrong treatment.

Addendum: McArdle nicely takes the time to follow the logic.

Akst on Organ Buying and Selling

Daniel Akst has some good questions:

It's illegal in this country to buy or sell organs for transplant. This is an unjust law made and enforced by people who desperately need neither organs nor money. It condemns kidney-disease sufferers to death and potential organ donors to poverty. It's a law that I will unhesitatingly break if one of my children needs a kidney, and I hope you will have the decency to do the same if a member of your family is in a similar situation.

…The unearned piety of those who condemn these transactions strikes me as outrageous. If someone has the right to abort her own fetus, why does she not have the right to sell her own kidney? By what authority does the state tell me I cannot save myself or my family members by paying money I earned to a willing seller of a surplus item?