Results for “singapore best” 97 found
What I’ve been reading
1. C.E. Cubitt, A Life of Friedrich August von Hayek. How come you don’t hear of this book more often? It is an extensive, rambling meditation on Hayek’s last years, full of anecdotes about Hayek’s medical ailments, arguments with his wife, and which groups he did not like. It is also short on any kind of formal documentation. But what could be more of a document than this book itself? Self-published by Hayek’s last private secretary, it seems too detailed and too strange to be entirely made up. You can pull out a random sentence and get something like “He [Hayek] liked women, he told me, providing they were not hirsute and did not offend his sensitive nose, and on one occasion even told me that he was “a little in love” with one of the waitresses in the Colombi Hotel.” Or we read that Hayek was obsessed with euthanasia, and in his last years carried around a razor blade in case it might be needed on short notice. It’s like absorbing a Thomas Bernhardt novel without the literary skill but with real stakes in the history of ideas. Ultimately I found this one unreadable, though it is consistent with my view that intellectual history is first and foremost a matter of biography. And what about the biography of Charlotte Cubitt herself? That is the real mystery here.
2. Jim Baker, Crossroads: A Popular History of Malaysia and Singapore. I loved this book and found every page gripping, it is hard to see how it could be better than it is. One of the best books of last year, it turns out.
The new novels by Orhan Pamuk and David Mitchell appear to be serious efforts, but so far neither one is grabbing me.
Saturday assorted links
1. Liz Lutgendorff is offended by fantasy and science fiction novels.
2. There is no great stagnation, drug delivery edition. And the value of certain and immediate rewards.
3. What do we infer from disclosure?
4. “Superfluids aren’t usually purely super…”
5. More on why fair trade doesn’t work.
6. Greece just got fifty-five billion euros in debt relief.
7. The LKY Musical: Singapore’s history set to song.
8. Oliver Sacks on his cousin Robert Aumann. And other things.
If you could know only one thing about a city’s food scene…
No, it is not knowledge of the city’s best dish, nor is it access to all the Yelp reviews, or even an understanding of how the spices in that cuisine work together.
I have a simple nomination. If you could only know one thing about a city, you would like to know what time the best and most popular restaurants fill up.
If you know that time, you can walk around a restaurant-rich area. Wait for the best places to start filling up, and then make your move and muscle your way through the door. Voila, the wisdom of crowds!
If you come too early, you cannot glean information from watching the customer flow because there isn’t any. If you come too late, the best places are already full, or they have lines which are too long. But if you are there at just the right time, and attentive to the movement of the crowds, what really can go wrong?
In Singapore the best time to start stalking the hawker centres is about 10:30 a.m., certainly no later than 11. Otherwise the lines at the best stalls are simply too long. Just show up at the right time, and assume the Singaporeans know what they are doing. It works. In Paris you must be looking for a good lunch restaurant before 12:30.
It is a common theme in food economics that knowledge of people, or knowledge of social mechanisms, is often more valuable than knowledge of food. Knowing whom to ask and also how to ask is also often more valuable than a detailed knowledge of a cuisine per se.
Jaan, in Sinagpore
Why should you seek out French food in Singapore? Yet I did. I would describe my meal as at the San Sebastian level for quality and presentation, and one of the best I’ve had in the last five years. I also enjoyed the best view of any meal of comparable quality, looking out onto Marina Bay Sands and the Straits.
In fact, Singapore rarely disappoints. There is an all-vegetarian menu as well.
Genetically Engineering Humans Isn’t So Scary (Don’t Fear the CRISPR, Part 2)
Yesterday I outlined why genetically engineered children are not imminent. The Chinese CRISPR gene editing of embryos experiment was lethal to around 20% of embryos, inserted off-target errors into roughly 10% of embryos (with some debate there), and only produced the desired genetic change in around 5% of embryos, and even then only in a subset of cells in those embryos.
Over time, the technology will become more efficient and the combined error and lethality rates will drop, though likely never to zero.
Human genome editing should be regulated. But it should be regulated primarily to assure safety and informed consent, rather than being banned as it is most developed countries (see figure 3). It’s implausible that human genome editing will lead to a Gattaca scenario, as I’ll show below. And bans only make the societal outcomes worse.
1. Enhancing Human Traits is Hard (And Gattaca is Science Fiction)
The primary fear of human germline engineering, beyond safety, appears to be a Gattaca-like scenario, where the rich are able to enhance the intelligence, looks, and other traits of their children, and the poor aren’t.
But boosting desirable traits such as intelligence and height to any significant degree is implausible, even with a very low error rate.
The largest ever survey of genes associated with IQ found 69 separate genes, which together accounted for less than 8% of the variance in IQ scores, implying that at least hundreds of genes, if not thousands, involved in IQ. (See paper, here.) As Nature reported, even the three genes with the largest individual impact added up to less than two points of IQ:
The three variants the researchers identified were each responsible for an average of 0.3 points on an IQ test. … That means that a person with two copies of each variant would score 1.8 points higher on an intelligence test than a person with none of them.
Height is similarly controlled by hundreds of gene. 697 genes together account for just one fifth of the heritability of adult height. (Paper at Nature Genetics here).
For major personality traits, identified genes account for less than 2% of variation, and it’s likely that hundreds or thousands of genes are involved.
Manipulating IQ, height, or personality is thus likely to involve making a very large number of genetic changes. Even then, genetic changes are likely to produce a moderate rather than overwhelming impact.
Conversely, for those unlucky enough to be conceived with the wrong genes, a single genetic change could prevent Cystic Fibrosis, or dramatically reduce the odds of Alzheimer’s disease, breast cancer or ovarian cancer, or cut the risk of heart disease by 30-40%.
Reducing disease is orders of magnitude easier and safer than augmenting abilities.
2. Parents are risk averse
We already trust parents to make hundreds of impactful decisions on behalf of their children: Schooling, diet and nutrition, neighborhood, screen time, media exposure, and religious upbringing are just a few. Each of these has a larger impact on the average child – positive or negative – than one is likely to see from a realistic gene editing scenario any time in the next few decades.
And in general, parents are risk averse when their children are involved. Using gene editing to reduce the risk of disease is quite different than taking on new risks in an effort to boost a trait like height or IQ. That’s even more true when it takes dozens or hundreds of genetic tweaks to make even a relatively small change in those traits – and when every genetic tweak adds to the risk of an error.
(Parents could go for a more radical approach: Inserting extra copies of human genes, or transgenic variants not found in humans at all. It seems likely that parents will be even more averse to venturing into such uncharted waters with their children.)
If a trait like IQ could be safely increased to a marked degree, that would constitute a benefit to both the child and society. And while it would pose issues for inequality, the best solution might be to try to rectify inequality of access, rather than ban the technique. (Consider that IVF is subsidized in places as different as Singapore and Sweden.) But significant enhancements don’t appear to be likely any time on the horizon.
Razib Khan points out one other thing we trust parents to do, which has a larger impact on the genes of a child than any plausible technology of the next few decades:
“the best bet for having a smart child is picking a spouse with a deviated phenotype. Look for smart people to marry.”
3. Bans make safety and inequality worse
A ban on human germline gene editing would cut off medical applications that could reduce the risk of disease in an effort to control the far less likely and far less impactful enhancement and parental control scenarios.
A ban is also unlikely to be global. Attitudes towards genetic engineering vary substantially by country. In the US, surveys find 4% to 14% of the population supports genetic engineering for enhancement purposes. Only around 40% support its use to prevent disease. Yet, As David Macer pointed out, as early as 1994:
in India and Thailand, more than 50% of the 900+ respondents in each country supported enhancement of physical characters, intelligence, or making people more ethical.
While most of Europe has banned genetic engineering, and the US looks likely to follow suit, it’s likely to go forward in at least some parts of Asia. (That is, indeed, one of the premises of Nexus and its sequels.)
If the US and Europe do ban the technology, while other countries don’t, then genetic engineering will be accessible to a smaller set of people: Those who can afford to travel overseas and pay for it out-of-pocket. Access will become more unequal. And, in all likelihood, genetic engineering in Thailand, India, or China is likely to be less well regulated for safety than it would be in the US or Europe, increasing the risk of mishap.
The fear of genetic engineering is based on unrealistic views of the genome, the technology, and how parents would use it. If we let that fear drive us towards a ban on genetic engineering – rather than legalization and regulation – we’ll reduce safety and create more inequality of access.
I’ll give the penultimate word to Jennifer Doudna, the inventor of the technique (this is taken from a truly interesting set of responses to Nature Biotechnology’s questions, which they posed to a large number of leaders in the field):
Doudna, Carroll, Martin & Botchan: We don’t think an international ban would be effective by itself; it is likely some people would ignore it. Regulation is essential to ensure that dangerous, trivial or cosmetic uses are not pursued.
Legalize and regulate genetic engineering. That’s the way to boost safety and equality, and to guide the science and ethics.
To where should you vote with your feet?
If voting with your feet was your preferred method, what would be the best country to immigrate to from the United States for: A) Progressives B) Social Conservatives C) Libertarians
As a follow up, a common expression in the US among adults as I was growing up was “its a free country”. That expressed both disdain of the expressed course of action and a willingness to let the fool do what he wanted. Tom Sawyer and Huck Finn are literary representatives of that, what should I call it, frontier freedom? Are there countries that even if the official line is restrictive, the feeling of liberty might be much greater? Am I nuts to feel that in many ways the US is less free than it was a couple of generations ago?
For Progressives I’ll pick Denmark. They have high taxes and ultimately they are not too friendly toward immigration, instead preferring to keep their social policy comprehensive and expensive. Sweden may not quite manage the same, although they are still a fairly high pick on this list. Another direction to look would be Australia, where government spending is most likely to actually be redistributive.
For Social Conservatives, I say Singapore. They are tough on drugs and the citizens are expected to work and required to save. Parents are treated with respect, at least relative to the West, and when it comes to births at the very least they are trying hard with subsidies and ads on buses. An underrated pick here would be France, by the way.
For Libertarians, I say the United States. For all of the statist intervention in this country, it remains the place where markets are capable of exercising the most power for the better. And it is no accident that such a huge chunk of the world’s libertarians are also Americans, or at least heavily American-influenced. Singapore is in the running for this designation, with its government at eighteen percent of gdp, but so many things there are planned so comprehensively and the attitude of the country is more technocratic than free market per se. Hong Kong is no longer such a free economy, having come under increasing Chinese influence not to mention law-enforced cartelization, and that is on top of their government-supplied housing stock and single payer health care system.
As for the last part of this question, the relatively peaceful parts of Mexico, in my view, very often feel freer than the United States. But I am never sure how much that is worth.
Assorted links
1. An impressive display of, um…Big Data (pdf), addressing how suppliers discriminate against customers in Singapore. There is also an NBER version, but I don’t see it on their site at this moment.
2. The religion that is Iceland.
3. “…the greatest work of journalism from the nineteenth century.”
4. The Hospital is no Place for a Heart Attack. And few from the EU side like the Greek debt swap idea.
5. Best films of the decade? Winter Sleep should be added to the list immediately, it is Ceylan’s masterpiece. That, along with Uncle Boonmee, should be very close to the top.
7. Timothy Taylor on the new corporate income tax proposals.
How much economic potential does Cuba have?
I’m not one of those who thinks Cuba is the next Singapore or even the next Puerto Rico. Why not?
I’m willing to assume that the end of the American embargo will mean some kind of economic liberalization over the next ten years. But how much good will that bring?
We could start by looking for relevant comparisons. We could ask how well have non-British-ruled, non-Dutch-ruled, non-American-ruled Spanish-speaking Caribbean islands done? There is a fairly clear example of such a country with some ethnic, cultural, historic, and linguistic similarities to Cuba, namely the Dominican Republic. For non-PPP-adjusted gdp per capita, the D.R. clocks in at about $5800 per year. And that is about where I think Cuba will end up, after a good bit of turmoil.
Now various official sources put Cuban per capita gdp (again, non-PPP-adjusted) at about that same level. That is highly misleading, and yes I have been to both countries. (Other countries at that level don’t have so many hungry people or so many women selling their bodies to tourists.) In any case I expect Cuban reforms, along with a good bit of additional deindustrialization from U.S. competition, to bring a short-run gdp dip, with an eventual climb into a D.R.-like economy, albeit with big bumps along the way.
Here are a few additional points:
1. The Caribbean in general has done very poorly since the economic crisis of 2008. Most of it does not show signs of bouncing back.
2. The short-run trends for foodstuffs are not so great. The major agricultural exports are sugar, citrus, fish, cigars, and coffee. Sugar is by far the most important of those, and right now the sugar price is well below half of its 2011 level.
3. Cuban industrial production is below half of its 1989 level (pdf, p.8).
4. National savings and investment rates are at about ten percent, well below Latin American averages (pdf, p.8).
5. I don’t in general buy “brain drain” arguments, but they do sometimes apply to islands and for historical reasons they are especially likely to apply to Cuba. Many of the most talented Cubans were encouraged to leave, or managed to leave, and staying in Miami will be better than going back for a long time to come.
6. Cuba has some of the best beaches in the Caribbean, but I expect most of those returns to accrue to land and capital, not labor.
7. Cuba already imports 30% of its food from America. Note that sum has been falling lately, as Cuba seeks cheaper alternatives, such as food from Vietnam. Post-liberalization, trade with America will go up a good deal but we are not starting from zero under the status quo.
8. Cuba is inheriting some very serious problems with institutions, and that is assuming they manage to move away from communism. In my admittedly limited experience, a fair number of Cubans still believe in communism, while also thinking the revolution somehow went astray. Emmanuel Todd has argued that Cuban family structures make the country susceptible to authoritarian rule. I consider that speculative, but still communism has had a long shelf life there, well past the fall of the Soviet Union, so let’s not dismiss it out of hand. The country also had a notable history of instability well before the Castro revolution. It is hard to be optimistic on this front.
9. Cuba seems to depend a good deal upon…Venezuela. Is that an asset you wish to hold in your portfolio?
10. Foreign investors can hire Cuban labor only through a state employment agency, and no this has not led to a form of efficient offsetting power, rather it has kept productivity low. More generally, this long Brookings study of FDI in Cuba (pdf) shows how difficult the environment is for foreign capital.
11. Costa Rica has far, far better institutions than Cuba and still it is relying on agriculture and tourism.
On the bright side:
12. The island has significant reserves of nickel and cobalt, top five in the world for nickel by many estimates.
13. Literacy is high, probably higher than in the United States, and there is a functioning social health infrastructure which reaches a high percentage of Cubans.
14. Circa 1959, the book value of U.S. capital in Cuba was three times higher than in the rest of Latin America combined (pdf).
15. The Cuban diaspora may nonetheless kick in as a source of talent and investment.
I’m not a super pessimist on Cuba, I just think they will need a long time to get to the point the Dominican Republic is at today. Being “the next Costa Rica” seems for them impossibly far off.
Assorted links
1. Will it work for Norway to pay Liberia to stop deforestation? Does the Coase theorem hold?
2. New York City food menus from one hundred years ago.
3. What does this Singaporean road sign mean? Duh.
4. Those 538 guys missed what is actually the best taco (economies of scope).
5. How to best survive a black bear attack.
6. Videotape of Solow, DeLong, myself and Russ Roberts on Piketty.
A libertarian case for expanding Medicaid
Currently health care is very expensive in the United States, especially if you have to buy hospital care without formal insurance. Under ideal institutions, it would be much cheaper, maybe a third of the current price or lower yet (not for everything, though). For instance in Singapore health care expenditures are about four percent of gdp. A libertarian may think that laissez-faire or near laissez-faire is the way to go, while others might favor single payer with price controls, and so on. In any case, in the meantime we are stuck with expensive health care, and for reasons related to bad and coercive government policy.
Now, would a libertarian think that we should cut health care services in prisons, simply because tax dollars are in play? No, the prisoners — many of whom are morally innocent — have nowhere else to go for treatment. When it comes to health care, many potential Medicaid recipients are in essence prisoners, locked into a policy-deficient environment and so they cannot buy quality care at affordable prices. So if we favor health care expenditures for prisoners we might also favor Medicaid expansions.
That said, expanding the current version of Medicaid is unlikely to be a first-best solution, no matter what your broader political stance.
Addendum: Jacob Levy offers comment.
*Massacre in Malaya*
The author is Christopher Hale and the subtitle is the rather misleading Exposing Britain’s My Lai.
The first fifth of this book is in fact the best short early economic history of Malaysia and Singapore I know, even though the focus of the book as a whole is on one colonial event, namely the 1948 Batang Kali massacre during the post-war Malayan Emergency. The next section is a superb treatment of the Japanese occupation and the political issues leading up to that occupation. This book reflects a common principle, namely that often, to learn a topic, you should read a book on an adjacent but related topic, rather than pursue your preferred topic directly. The book on the adjacent topic often will take less background knowledge for granted and explain the context more clearly for what you actually wish to learn, while getting you interested in other topics along the way.
Just about every page of this book has useful and interesting information, here is one new word I learned:
The history of the ‘Malay World’ in the centuries before the momentous fall of Malacca to the Portuguese in 1511 is predominantly a convoluted narrative of maritime statelets, technically thalassocracies.
This one will make my best non-fiction of the year list.
More thoughts on which countries will be having the next financial crises
Many loyal MR readers have been asking me, since my post from yesterday, whether all those countries listed are likely to have financial crises in the next few years.
I say that most of these countries are quite unlikely to have major financial crises anytime soon. Let us return to the distinction between a recession and a financial crisis. When the U.S. real estate bubble burst in the late 1980s, there was a downturn in output and employment but no financial crisis. No capital markets froze up for instance and risk premia never deviated much from normal in the first place. And if that late 1980s-like path is what someone is predicting for the Nordics, Canada, or Singapore, well maybe so. I’m not predicting it myself but I certainly can see that within the realm of the plausible. (In any case, here is the Singaporean defense of their own economic prospects.)
Why then was the American carnage of 2007-2009 so much worse? Well, for at least two reasons. First, after the relative prosperity and stability of most of the 1990s, so many people thought “the great moderation” had arrived, so investors were much more overextended that time around.
More importantly, the bursting of the real estate bubble overlapped with previously unrecognized, massive systemic risk in the shadow banking system. All of a sudden people realized that U.S. financial institutions, far from being the world’s finest, were in some serious trouble. Risk premia shot up and in some ways they have stayed stubbornly high. Our whole theory of the financial system behind the world’s premier “riskless” asset required a radical and rapid revision.
There were other differences too, but those will suffice for now.
Now let us ask, do any comparable phenomena — in terms of very significant and deeply frightening systemic risk at the global level — exist when it comes to Singapore, Canada, and the Nordics? I don’t see it, so I think if those economies have troubles they will be a relatively moderate set of recessions, a bit like America in the late 1980s. You could make the “China is going to blow and take everyone else down with it” argument. I still see a very good chance of that blow-up happening, but not as soon as 2014, and furthermore its fallout would take a while to travel too. Note also that event probably would not devastate the Nordics, though it would hurt Singapore and Canada more.
You also could try the “the taper will kill us all and reveal the emerging economies to have been bigger bubbles than we thought” line of reasoning. Maybe so, but again that won’t crush Singapore, Canada, or the Nordics. Furthermore the taper already is expected, already has done some of its damage, and the emerging economies already have begun to adjust. Or not.
I do see the global implications of the taper as a real issue. I also see current account deficits for badly run indebted governments as a real issue. I see political instability as a real issue, in part because it may prevent economies from adjusting to the taper and loss of liquidity as they ought to. And when you put those pieces together, you come to the view that Turkey and Thailand and Indonesia are the most vulnerable potential victims for the financial crises to come.
I don’t in general believe that countries with bad institutions are always the best picks for pending financial crises, but I see the current constellation of forces — namely a lot of advance time to adjust and prepare, on the heels of a global great recession and a well-signaled taper– as pushing us toward that view right now.
Or so I think today.
Automation, inequality and geopolitics
Joss Delage wrote me with a question, here is part of it:
Here’s what I’m curious about: assuming things turn out as described in your book, what do you think are the geopolitical ramifications? More specifically, do you envision some countries specializing to attract the top earners, and if so which and how?
I don’t cover geopolitical questions in Average is Over, but here are a few observations:
1. I see elites, working in a coalition with elderly voters, as able to control the political agenda enough to prevent most developed economies from flipping into purely destructive economic policies. So I expect the leading wealthy nations to maintain relatively strong positions in the world. (The book by the way does explicitly predict that U.S. government will get bigger and that social welfare spending will rise, contrary to what some reviewers have suggested.) This will be hardest, however, for the relatively pure democracies, such as the Westminster systems.
2. Some small nations, most notably Monaco and Luxembourg and Singapore, have the option of “specializing” in the higher earners and keeping in only a minimum of stagnant wage earners. A mix of immigration policies and land prices will enforce this choice. Commuting will rise in importance, where possible. But such outcomes will not describe a very large share of the world.
3. One class of vulnerable nations will be current exporters who rely on low wages to be competitive. Automation in the wealthy nations will disrupt their business models. The current Indian model of “doing most things internally” — which is by no means ideal — will be relied on increasingly. Export-led surpluses will not be available to drive growth, as the wealthier nations become the export leaders by increasingly wide margins. Given the rise of smart software and robots too, labor costs will not hold them back.
4. African nations and other poor nations, such as those in southeast Asia, also will not have the option of “last generation” export-led growth, pockets of resource wealth aside. Many of these nations will specialize in lower middle class earners. Free-riding upon global technologies will be important, as with cell phones today. Many more technologies will spread in this fashion, with the aid of price discrimination. We might see billionaires adopting particular regions or groups and transferring technologies to them at relatively low cost. “Wealth without wealth generation” will describe many locales.
5. One key question is whether software-led growth will lower or raise the relative price of most natural resources. There will be much more production! One possible scenario is that manufacturing growth will rise more rapidly than natural resource production will be eased. Countries with the higher-priced natural resources will then be geopolitical winners. And in that case high energy prices become quite a burden on lower middle income earners, who switch out of cars and into bicycles, mass transit, and the like. Yet it remains possible that smart software will do more for energy production, or for copper production, than it will for manufacturing production.
6. In talks (but not in the book) I have suggested that food production is the best candidate for “what will be most difficult to augment” in an age of smart software. Food production seems harder to “wall off” and it seems more embedded in local culture (for better or worse, usually for worse) than factory production. See our MRU video on conditional convergence, which considers the work of Dani Rodrik in this regard. It would mean that the price run-up for Midwestern farm land in the United States may not be a bubble.
Let’s say smart software, robots, and artificial intelligence really do pay off. What other geopolitical predictions would this imply?
*Affordable Excellence*
The author is William A. Haseltine, the subtitle is The Singapore Health System, and the Kindle edition is itself an…affordable excellence at $0.00.
This book is a clear first choice on the Singapore health system and everyone interested in health care economics, or Singapore, should read it. It is short, clear, and to the point. And anyone interested in public policy or fiscal policy must, these days, be interested in health care economics.
Singaporeans have some of the best health care outcomes in the world and yet the system consumes only four (!) percent of gdp. Here is one short bit:
Private expenditure in Singapore amounted to around 65 percent of the total national expense (2008). Note that this includes payments out of the government-run MediShield scheme and related insurance schemes, MediSave accounts, and other private insurance schemes or employer-provided medical benefits. The figure for the United States is 52 percent, 17 percent for the United Kingdom, and 18 percent Japan. Singapore’s relatively high private expenditure is a direct result of the government’s efforts to shift more of the cost burden to consumers than do most other countries.
Before you pure libertarians get too happy, however, note that public sector hospitals account for about 80% of all patient hours and there is a single payer system for catastrophic expenditures.
Definitely recommended, at this price or even the paperback for $20.00.
By the way, here are some changes they likely will be making to the Singaporean health care system, moving it closer to traditional welfare state policies (for better or worse).
Options for health care coverage reform
This topic has been reconsidered much as of late, so I thought I would do a summary post on some of the possible options. I suspect I have covered all or most of this ground in 2009 or so, but here goes:
1. Universal health insurance vouchers on exchanges, with means-tested subsidies and also a mandate. The logic of this can work just fine, but it is quite expensive as it would exist in the United States and we end up spending too much on health care. Over time it would be accompanied by say a five percent VAT.
2. Single payer systems. I don’t want to repeat the usual debates, but perhaps we can agree single payer won’t come anytime soon in the United States. I also think they work least well in the land of medical innovation, and best in small countries such as New Zealand, but that consideration doesn’t even rise to the fore here.
3. The Singapore system, involving single payer for catastrophic expenses and health savings accounts for smaller expenditures. To varying degrees you can combine this with forced savings for the HSAs and price controls on service provision, both of which you will find in Singapore. Where “catastrophic” starts can vary as well. This is my first choice, although if you wish to dismiss it as “utopian” for the United States you have a point. I’ll get back to that.
4. One particular path for how ACA could evolve into a (relatively inefficient) form of a Singapore system. Imagine that the mandate becomes fairly narrow with time, while at the catastrophic end insurance companies evolve into (inefficient) public utilities. Health savings accounts are reintroduced through new legislation, perhaps under a Republican administration, and can be supplemented with cash transfers when desired. Here is one discussion of that path.
5. The mandate and subsidized exchanges under Obamacare prove unworkable and eventually they are abandoned either partially or in full, or in some states but not others. Their place is taken by a Medicaid expansion. Coverage is not universal, though it is higher than pre-ACA, and of course coverage under the status quo is not going to be universal either.
6. The status quo of Obamacare.
7. More managed care. We should remove the legal restrictions and barriers which penalized managed care in the first place, as it is a feasible and desirable means of bending the health care cost curve. You will note that this option is not a strictly rival alternative to 1-6, but rather can be combined with them in varying degrees. Still, it seems appropriate to list it as an option.
Now, if I am allowed to be utopian, I favor #3 over the status quo. If I am asked to be less utopian, I see #4, #5, and #7 as some of the better versions of what ACA could evolve into. I would not predict that those options come to pass, nor would I say those options are better than the rather unrealistic version of ACA as envisioned by its proponents, but I think they follow from the dictates of reality as the better options on the table, #3 aside of course. And I do not feel I am being utopian in holding them as alternatives to the status quo. They are not so far away from the status quo in the policy space.
I don’t think ACA in its current form is stable. Too many moving parts, too many margins of danger, too many jerry-rigged incentives, too many “it worked OK in Massachusetts so it has to work at the national level even if it doesn’t appear to be maximizing” requirements, and too little recognition that the whole system is poorly geared for a world of stagnant median wages and rising inequality. The higher is inequality and the lower are lower-tier wages, the harder it is to guarantee near-equal consumption of health care through employment institutions. The greatest single danger to ACA is eventual massive employer-shedding of health care obligations, penalties or no, which at best evolves us into #1, which I do not favor. On top of that there is state shedding of Medicaid obligations, which again pushes us into #1. Most generally, the national health care systems which work are much more consolidated in nature than is the U.S. status quo.
It is a Denkfehler when people write “you don’t have an alternative to ACA” or “the Republicans don’t have a health care plan,” and so on. You can take such pronouncements as leading indicators that ACA is not going well. #3 aside, you can take the relevant alternatives as a mix of #4, #5, and #7. Those are not so much alternatives “given by the Republicans (or whoever else),” as much as they are given by reality. I don’t see “ACA as envisioned by its propnents” as on the table either, so in this sense it is also the Democrats who don’t have an actual health care plan.
I view the real choice before us as #1 vs. some mix of #4, #5, and #7. And in that setting I do not favor #1 and I still can dream of and advocate #3.
Addendum: Here is my earlier post on how to debate health care policy. Let’s see how many of its strictures you all violate.