 Well, thank you all for coming, and I appreciate your interest or at least feigned interest in markets and medical care, which has taken on a new dimension in the last few months. People are very interested in how markets can work. Many people think they don't work when it comes to medical care. And of course, this is something that I've had an interest in for some time. I had an article that I wrote with a student, or maybe this student wrote the article with me. She did a lot of the work a number of years ago on third-party payers in medical care, and that article is available in the Journal of American Physicians and Surgeons. I was very pleased a few years ago to have that article cited in the New York Times favorably, which I don't know if that reflects on the quality of the article or not, but I have in the past in this lecture discussed third-party payers to some extent. This year at Mises U, I'm going to do some things that are a little different. Because we need to address some things related to the coronavirus epidemic or pandemic. So let's start off with just a few clarifications of terms here, because we're going to talk a little bit about the government's role in medical care. And there's some confusion on this sometimes about what we mean when we say universal medical care, socialized medicine, things like that. And we toss these terms around quite frequently without being very careful. Socialized medicine is where government actually operates the hospitals and medical staff or government employees. If you think about the VA system, if you think about the National Health Service in the UK or the Spanish system, these are kind of good examples of government actually operating the medical facilities, hiring the doctors and nurses and other staff. Universal coverage means that everyone's got medical insurance. Typically, that would be provided by the government. Hospitals and medical staff might be private, privately owned and operated. The Canadian system might be a better example of something that's close to universal coverage, although even there, you can find some people in Canada that are not covered. Can universal coverage exist in a fully voluntary society? Think about whether maybe if you have a neighborhood, think of that as maybe not just a small subdivision in a suburban community, maybe some larger grouping where people, if they buy into this neighborhood, they are buying in with a package of services which could include medical insurance. There's no particular reason why that couldn't happen. I live in a typical suburban neighborhood. It's got various services and facilities that it provides. There's a swimming pool and a tennis court and a little clubhouse if you want to have an event and some landscaping that is paid for with the dues that are paid annually by everyone who lives in that neighborhood. You could do something like that in a voluntary society as well. I don't think we need to look at universal medical care as necessarily being something that involves government, although certainly that's the association we have with that term today. A single payer system may be found with universal coverage, but universal doesn't need to be single payer. So universal could be a blend of private insurance for people who have employer provided health insurance or you might have some people who have government paid medical insurance. So a single payer and universal coverage and socialized medicine are not interchangeable terms. So that's something to think about. Of course in the last few months we've been very interested in what's going on with the COVID-19 pandemic and it's had a lot of implications economic and medical. But I want to offer a word of caution here as we think about some of these issues. One is that as an economist I'm not an epidemiologist. An epidemiologist is not an economist and sometimes we think that because we've got expertise in one area it qualifies us to speak authoritatively in some other area and we need to be very careful about that. We can quickly get ourselves into some trouble. I saw this morning that Alyssa Milano has suggested that we need to have a national lockdown and UBI Universal Basic Income and we need to have printing of money she says because of the coronavirus epidemic. Now she's an actress. I maybe I will stop speaking about how to act in my economics classes if actresses and actors will agree to stop trying to be authoritative on issues of economics and medical care. Of course they've got a platform and what they say has a lot of impact because of who they are and people listen to Alyssa Milano a lot more than they listen to me. I'm not suggesting that I'm an expert at all on on epidemiology or biology or other things but it's it's important for us to keep in mind you know staying your lane doesn't mean that I can't have an opinion on some of these things but I much prefer to quote someone else who's got some traction who's thought about this more. F. A. Hayek said the hopes they place in planning are the result not of a comprehensive view of society but rather of a very limited view and often the result of a great exaggeration of the importance of the ends they place foremost. It would make the very men who are most anxious to plan society the most dangerous if they were allowed to do so and the most intolerant of the planning of others there could hardly be a more unbearable and much more irrational world than one in which the most imminent specialists in each field were allowed to proceed unchecked with the realization of their ideals and in a similar vein Murray Rothbard wrote it is no crime to be ignorant of economics which is after all a specialized discipline and one that most people consider to be a dismal science but it is totally irresponsible to have a loud and vociferous opinion on economic subjects while remaining in that state of ignorance. Gary Gallis has a great article I've got the link here on why central planning by medical experts will lead to disaster but again I would argue those who are trained in economics those who are trained in related praxeological fields need to be careful before we start trying to speak on say the effectiveness of hydrochloroquine or remdesivir or masks or a lot of other things. Now we have some statistical tools that we we learn about and we can sometimes apply that toolbox to things that relate to human action and the response of an individual or a population to a medical intervention does depend to some extent on that human action. So it's not that economists can't have a word to say but we need to be very careful about this. All right so I've got a list here of some approaches that we might suggest as economists to situations like the one that we're in right now cases where there are pandemics or maybe more localized health problems and really you could apply some of this to other kinds of crises as well. So the first one I'll suggest is to allow price gouging. Now price gouging is a term that's very loosely applied to increases in prices that we don't like. I have students that frequently in writing a paper or a response to an essay question will say something about how we need to stop price gouging. This is a role for government to stop price gouging. They think oh Dr. Terror will like this because of course who could be in favor of price gouging? What a horrible thing. Price gouging and so I'd suggest that actually increases in prices when there's a crisis can be a very good thing. One it keeps if you try to impose a limit on prices with a price ceiling or in this case we're talking about price ceilings but other kinds of interventions like price floors would have other negative effects but if you keep a price below the equilibrium price then you're going to tend to create a shortage and that reduces the incentives for people to come up with innovative solutions to various problems. What kinds of therapies might be helpful in dealing with a pandemic? Low prices mean that those who could make do with less won't so goods run out for those with great need. Now my household we usually keep a we have a full pantry most of the time. We run out of catch up. We don't have to run to the store to buy more. Catch up right away because there's another full bottle in the pantry and we tended to do the same thing with a lot of things. Cleaning supplies, toilet paper and a number of other items that are normal household use. Now does that mean that when I went to the store and I saw after this coronavirus pandemic broke out in the United States and I saw a package of toilet paper on the shelf that I would refrain from buying it because I knew that I had already a package at home. It would probably last me for another couple of weeks. No if I see it and the price is low then I might take it anyway and so many people would behave in this way and think well I don't know when I'm going to be able to get this again and I've got another package at home but I'm going to go ahead and take this while I know I can get it. People will do this. Now if the price goes up then people who already have some at home don't have as urgent a need necessarily and they will say well I'll wait. I'm okay for now. Price controls discourage people from making those kinds of decisions to forgo buying an extra package when they already have some. Third the expectation that prices will be capped by government discourages stockpiling for emergencies. So if you have a retail store and use some part of what you sell to the public might be something that is scarce when there's a disaster. I live in South Carolina we get run over by hurricanes every so often and the building supply stores the lows the home depot and so forth they keep things like chainsaws and generators and plywood and other things that people would like to have after a hurricane strikes the area. Now typically after a hurricane we'll see price controls put into place and stores like Lowe's or Home Depot are told you can't increase your price substantially over what you would normally charge for these kinds of items. So what incentive does Lowe's or Home Depot have to stash a warehouse full of things that might be particularly useful after a natural disaster and in the knowledge that they could then charge a 20 or 30 or 50 percent 100 percent premium on those things after the disaster. Well they don't have much of an incentive if the government controls prices and if it's well known that this is to be expected after a natural disaster. So why would people stockpile hand sanitizer masks or ventilators or any other thing if they don't believe that they'll be able to charge a price that is higher when the need is higher. Furthermore if you have a policy of allowing prices to rise to market levels that doesn't that doesn't mean that you can't have charity just because I'm in favor of markets doesn't mean that I'm against transactions or gifts that might take place without a price being charged and we sometimes forget that. I like markets I think they work pretty well I think they have a lot of benefits but you know I give things away too without expecting things in return. You've seen if you've taken a basic microeconomics class this diagram's supply and demand and you see the equilibrium price there on the vertical axis the price axis and what happens when there is a crisis when there is an epidemic that produces increased demand for certain services doctor services nurses services and other hospital workers and first responders what happens when the demand for a particular kind of medication goes through the roof what happens when ventilator demand goes up what happens when the at the same time the difficulty of getting some of these things may may may increase so it may become may become more difficult to manufacture some of these things for some of the same some of the same reasons if you have a an epidemic and maybe this is this has infected some people who work in the hospital the supply of doctors and nurses and other workers may go down as well so we get something like this where we see the supply curve shifting to the left we see the demand curve shifting to the right the equilibrium price goes up maybe goes up a lot but if we have a policy that says no no no you can't raise your prices you've got to keep the price at the same level that it was before then you're imposing a price ceiling at the old price which is no longer relevant here and we get a shortage we get a huge increase in the quantity demanded a decrease in the quantity supplied and people who want to need this product or service very desperately may be unable to get it at all at any price a second suggestion for dealing with a pandemic from a market perspective is to eliminate occupational licensure and occupational licensure is the practice that applies not only to medical occupations but many others where the government says if you want to engage in this providing the service to the public then you have to pass a test maybe you have to take a certain number of hours of education you know if you were getting an occupational license in the 1950s or 60s you might find that you had to declare yourself not a communist if you wanted to be a veterinarian or something so there's all kinds of requirements that may not be particularly relevant to your competency we think of these things unfortunately as being kind of protective of the public but what happens instead with occupational licensures that it tends to limit competition it tends to ossify the status quo we pretend that this is about protecting patients but what what are we protecting patients from other practitioners that might have a different idea about how to practice medicine we we uh we say this is about protecting patients but this may be more about protecting the mainstream and protecting those who are already in that profession against those who have other ideas under pandemic conditions those who are skilled but maybe they let their licensure lapse maybe they decided to retire they retired maybe very recently their skills are still still fairly current could be very useful but they can't get back into providing that service uh skilled people who are able to perform a function that is legally restricted to another group can't cross over to alleviate a labor shortage in that other group there may be things that nurses do that uh or can do that are limited to doctors and in a crisis of course you'd prefer to have someone with more expertise in a certain area but in a crisis maybe it makes sense to have a person outside legally outside that that the scope of that license to be able to step in and provide that service maybe they're only 80 percent as effective but 80 percent effectiveness is better than nothing at all uh not quite finished students maybe you're just you know going to graduate medical school next week or something you're you're uh capable of doing a lot but without a license you're prohibited from engaging in that activity i'd like to say a couple of words about licensure um more more generally but um i'll note here that even the OECD has stated that this might be a good idea uh they say crisis situations like the coronavirus epidemic can provide opportunities to change the traditional roles of different health care providers and expand the roles of some providers like nurses and pharmacists so that they can take on some of the tasks from doctors and allow the doctors to spend their time more effectively in more complex cases an older article that appeared in the journal libertarian studies which by the way we just resurrected last year we are um we we've got a great series of articles coming out in the next couple of issues um very healthy pipeline for that journal and and if you've um i got a paper that you'd like to to have us consider i'd welcome a submission to the to the journal libertarian studies but ronald hamaway way back uh in the 70s wrote an article on the history of licensure which i think is still very interesting and relevant for us today and he said that in fact uh the the uh the 19th century situation where people could practice medicine without having a license produced some important advances in medical treatment so he says anybody who was unlicensed and had the inclination to set himself up as a physician could do so the market alone determined who would prove successful in the field and who not competition oh sorry uh medical schools abounded in the great bulk of which were privately owned and operated and the prospective student could gain admission to even the best of them without great difficulty with free entry into the profession possible and education in medical uh medicine cheap and readily available large numbers of men entered practice competition resulted not only in a proliferation of medical personnel but in the growth of heterodox theories arising in opposition to standard medical therapeutics now that's a great thing if you know anything about what medical therapy was like in the early 1800s you're bleeding people because they thought that would help people uh get better uh he mentions bloodletting arsenic which is poison uh actually many medicines we have today are poisoned anything is poisonous and sufficiently large doses but arsenic is probably not a good idea for medical treatment and yet this is what people were doing and so uh this was the mainstream and so an alternative school of thought emerged called eclectic eclecticism which said maybe we shouldn't be doing that maybe we should try something different now if we had medical licensure at the time you can imagine the mainstream says well these quacks that don't want to bleed people and don't want to administer arsenic i mean why do we want this i mean we want to you know we're going to lose our jobs and people are going to lose their lives because people aren't taking arsenic so medical licensure as i said before ossified the practice or would have ossified the practice had it existed at that at that time in the late 1800s the u.s had the highest number of physicians per capita in the world some of these were probably not very good physicians others were probably great but the market test of whether you were effective tended to weed out people who were not helping their patients in 1904 the american medical association began a concerted effort to reduce the number of medical students claiming this would increase medical quality it's all for the patient you see not about protecting us from competition not about limiting the number of doctors so that our fees can rise this is about protecting the patient that's what they would argue and so in 1910 a ram flexner published a report for the carnage foundation on us and canadian medical education which suggested the closure of most medical schools homogenization of education in the remaining medical schools approval of any new medical school by the state government and additional state licensure regulation which created a number of bottlenecks that exist to this day for getting into the medical fields you want to be a doctor you've got to go to a particular medical school that has been approved by the state otherwise they won't license you which means you can't practice medicine so the AMA controls medical schools state by state through an accreditation body called the liaison committee on medical education licenses are only granted to graduates of those schools so as you might expect with a shift of the supply curve to the left you saw fees increasing for doctors and others schools of alternative medicine were almost all closed and those changes to the medical schools resulted in fewer women and fewer african americans in medical education this situation has had a radical impact on the american medical profession and it is a pattern that has been copied in many other many other countries so if you want medical care and all of a sudden there's a pandemic and there's a huge increase in demand licensure prevents a rapid adjustment of the number of doctors and nurses and other care providers to that new situation third suggestion is that we dismantle FDA barriers to innovation the food and drug administration has been around for a little over a hundred years in the united states was a product of some of the progressive era political moves which Patrick Newman's book on progressive era is is great on this the one he edited that discusses some of these things Murray Rothbard's work on the progress progressive era is very enlightening and one of the outcomes of this is this one of the first consumer product regulatory agencies and the FDA essentially is in the business of creating barriers to entry we think of it as protecting patients against bad drugs the lidamide for example which is a drug that was created for morning sickness for pregnant women and turned out to create very serious side effects and form of birth defects for children and the FDA has has been saying ever since you know we see we protected you against the lidamide if it hadn't been for us we would have seen this this problem much more widespread in the united states so what the FDA is doing is it's it's reducing competition for existing treatments once you are past all the hurdles that the FDA has created for getting a new drug onto the market then the FDA is now protecting you against competition there are enormous costs and delays the delays are not as bad as they once were it used to be eight to ten years to get FDA approval now that has been substantially shortened but there are still enormous costs hundreds of millions and even topping a billion dollars to get a drug to the market and a lot of this cost has to do with the FDA requirements now I have students frequently tell me well if we didn't have the FDA then no no new drugs would be tested and we would all be susceptible to the latest in a rat poison or whatever it is that people decided to bottle up and sell it's not as though there would be no testing drug companies tend to not want to get a reputation of administering or selling things to kill people that damages their stock value even if they didn't have any other you know moral compunction about it they do care about their stock value certainly and then they would not want to see that damaged I mean what happened to you know pick your latest botulism case at some fast food restaurant what happens to their stock price when they have a handful of cases of botulism I think this happened to Chipotle a while back and Taco Bell a while back and what happens of course they're their stock value drops and and it's not the state department of health or whoever examines restaurants that's really guaranteeing your safety they may have a certificate on the wall with a letter on it gives you a grade but how many of you look at that grade before you make your order so what's happening and a lot of times by the way that what they're grading is not that relevant to the quality of the product what's foremost in the minds of people who own restaurants is I want to keep my customers coming back which means I need to not make them sick so costs can discourage new drugs we call that drug loss which can cost lives drugs that might have been able to save somebody but we don't have them in the market because the FDA created such high barriers to entry drug lag is another problem where we can lose lives because people are waiting for approval and that period of time has been extended beyond what might be optimal for admitting new drugs onto the market one example of this is Sceptra this was an antibiotic there was a five-year delay imposed by the FDA in getting this onto the U.S. market and an estimate by a Nobel laureate George Hitchings was that this delay cost 80,000 lives in the United States beta blockers there was a lag in the FDA approval there that may have cost 250,000 lives in the United States we get drug suppression Mary Ruart has argued that at least half of pharmaceutical innovations get shelved because the cost to take a drug through the regulatory testing process makes those drugs uneconomic for drug developers to pursue doesn't make any sense if you're going to have to spend a few extra hundreds of billion of millions of dollars to get a new drug onto the market even with very conservative assumptions Ruart found the years of life lost due to the FDA clinical demands numbered in the millions Diego Morris was diagnosed at age 11 with a rare bone cancer there was a drug mefertamide which had been developed and was available in Europe but the FDA required an exceedingly expensive clinical trial which required a large enough number of patients that given the rarity of the disease was very difficult to to arrange and so Diego's parents could not obtain this drug in the United States so they moved to London to get treatment where their bureaucracy had allowed the drug onto the market and he ended up becoming a spokesman for right to trial legislation which was signed into law in 2018 this is at least a step in the right direction so we've seen some some progress you can't even advertise a an already approved drug for a new use without getting the FDA approval for that new use some companies won't find it worthwhile to revisit the approval process to get that new use approved and so people may not know about that new use Tom DeLorenzo has mentioned that that this may have been a problem with aspirin that aspirin can be useful in preventing heart attacks apparently not a doctor not suggesting that but that's that's what I'm told so if you if you make aspirin and you can't advertise that that aspirin is useful for this new purpose then if that's correct and this this could actually prevent heart attacks how many more heart attacks do we have because they were not allowed to speak about that in their advertising also folic acid was was another case of this um very useful apparently in preventing birth defects and yet folic acid manufacturers were not permitted uh early on to advertise their product as being helpful in this back to COVID-19 I'm not going to get into the whole question of hydrochloroquine or remdesivir or other therapies or preventive treatment preventive approaches to to COVID-19 but it does appear that even here with a lot of political capital being expended to to try to to address this this pandemic quickly we still have the FDA standing in the way so Charles Silver and David Hyman in a in an article from April of this year said scientists are now studying whether remdesivir might be effective in fighting SARS-CoV-2 the virus that causes COVID-19 remdesivir was developed six years ago to combat various viruses including Deng fever the West Nile virus Zika MERS SARS and Ebola but it was never approved for use apparently because Gilead Sciences the patent holder maybe we'll talk about patents in a minute saw too little financial gain to warrant the cost of the FDA's approval process the result is that we are effectively starting from scratch in the search for a COVID-19 treatment the federal government also botched the process for creating and administering coronavirus tests because SARS-CoV-2 is a new variant a new test was needed to track its spread German researchers had developed one in mid-January but the CDC decided that the Centers for Disease Control decided not to use it instead pressing ahead with the development of a separate test when that test was released in late January it proved faulty and the FDA prevented private laboratories from developing tests of their own the CDC also distributed its few test kits equally to labs across the country without regard to size of local populations resulting in a dramatic shortage of valid tests in populous areas which create created the false impression that the number of cases in the US was low in early March facilities in the US had administered 3099 tests by comparison South Korea a much smaller country whose epidemic had started the same day as ours had had administered 188,000 now I don't have time in this short talk to cover some of the issues related to the kind of the externality in public goods arguments for dealing with pandemics and the arguments are essentially that if you get if you take steps to prevent yourself from getting a disease you're also conferring a benefit on other people because you're making it harder for them to also get the disease they if you can't get if you don't get it then they can't get it from you at least and so you'll hear this kind of argument kind of argument that that people may be taking too few steps to prevent a disease because they don't directly get any benefit from a stranger not getting the disease so I this is beyond the nine minutes I've got left here but I will point you to an article very recent article in fact is still forthcoming but you can find this on SSRN paper by Byron Carson at Hampton Sydney privately preventing malaria in the United States 1900 to 1925 malaria is a disease that we hardly ever see in the United States anymore but used to be very common especially in the southeast and can is the private sector completely helpless when it comes to these diseases that are what what can we what can we say about something that appears to many economists to be a pure public good preventing diseases like malaria where mosquitoes breed on one person's property fly over to somebody else and transmit the disease I suggest that you take a look at at Dr. Carson's paper number four though moving along we should put patients not government in charge of patient care and I have written on on third party payers and I can send you a link to that later if you like but third party payers whether that's government or insurance companies tend to create a moral hazard problem which leads to regulation and and rationing what about universal medical care we've seen this trotted out again as another supposed cure for pandemics that if we had universal medical care then we would we see people getting earlier treatment and early earlier diagnosis earlier testing and and all of this this is no real solution for one thing if we have nationalized or healthcare where everybody is maybe not nationalized maybe just universal medical care switching my own terms around a little bit but if we have a a system by which people don't pay the marginal cost of their own medical care that's going to increase the quantity of medical care that people tend to want which means that we're going to have to have some means of rationing that medical care there are not enough tests to go around then the test may end up going to people who are simply more anxious about their situation not necessarily people who are more exposed not necessarily people who have a greater chance of actually having the disease we're testing for furthermore government does not do a particularly good job of containing costs so the argument that having government involvement lowers costs efficiently that people have more access to medical care and can get earlier treatment and diagnosis and so forth if you look at where markets are dominant for medical services such as cosmetic services which government won't pay for generally the cost increases in that sector have been substantially lower over time than medical care in general which has increased at rapid rates relative to general price increases i mentioned the term moral hazard a minute ago so moral hazard is that risk or hazard that a insured person is going to engage in activities that are undesirable or immoral from the insurer's point of view because they make it more likely that the claims will be larger so if i have a car that's insured against let's say hail damage or or something then if there's a storm that comes along i may not pull the car into the garage or i may not be as as eager to do that because i know that if it is damaged then somebody else is going to pay for it so maybe this is relevant as well to medical care if i'm covered by medical insurance maybe i don't take all the steps that i would otherwise take to seek out early early diagnosis or treatment because somebody else is going to pay the bill if i get sick enough to wind up in needing much more expensive care i might have to skip over some of this here on costs for the sake of time but moving along here with universal medical care i think it's it's important for us to think about these arguments because you're going to see more and more of them the oecd whom i quoted earlier is actually getting something right on occupational licensure i think gets this wrong in the same article they say that the COVID-19 crisis demonstrates the importance of universal health coverage as a key element for the resilience of health systems high levels of out-of-pocket payments may deter people from treating early or seeking earlier diagnosis and treatment etc so let's think about this don't insurance companies want to avoid really high medical expenses that might occur if the person doesn't get treated early i mean insurance companies it seems would have incentive and in fact we see that even before aca affordable care act mandates private insurance some of some of the policies at least offered first dollar coverage for preventive care services why well i mean they they don't want you to get expensively sick they'd rather catch things early will untested people take no steps to avoid contracting a disease or be uninterested in getting tested and treated earlier so that they can avoid their own out-of-pocket costs of treatment of a full-blown disease will a bureaucratized system result in gaming the system such as classifying patients according to the most lucrative diagnosis rather than what is most accurate in um japan one just almost trivial example of this kind of thing um in japan if you want a vaccination at least a while back you the the government specified what the price was going to be for vaccination well that's that's what the doctor could charge per visit it's a per visit cost so what do doctors do well okay hmm patient needs a vaccination that's one visit but what if i made it two visits what if i split the vaccination up into two two separate visits i could charge twice as much so that's what they did how do we know that that there's not going to be that kind of gaming of the system um i will very briefly go with this uh last diagram then we'll stop but uh this is a not a supply and demand diagram precisely this is a a marginal benefit marginal cost diagram and you have the marginal private cost that's the upper sloping curve marginal private cost of getting preventive care that's the cost to you of getting preventive care whether that's seeking out a test or taking steps to avoid transmission or something and the downward sloping curve there is the marginal private benefit that's the benefit to you of getting preventive care now what happens if there's an extra benefit when you get preventive care you're helping somebody else who's not going to get the disease from you so we get an additional benefit we stack on to the private benefit we call that maybe this marginal social benefit that's an external benefit it it doesn't accrue to you it accrues to somebody else and this creates is as traditional microeconomics would would call this a dead weight loss that's that gray triangle where there are gains that are not being realized because the cost of the private individual is higher than the benefit to the private individual so then what about government stepping in here and subsidizing the preventive care or providing the preventive care that's kind of the policy suggestion a lot of people would come into from from looking at this so what happens if the government subsidizes but they oversubsidize we could call this overshoot they're subsidizing more care than is ideal which is certainly possible in that case if they've overestimated the external benefit and they over subsidize as a result we get a loss that right gray triangle that is larger than the loss that the market on its own would have produced so one of the cautions here is don't make government into some kind of cure all for this that's not going to create any problems of its own so too many times we look at cases of like this and we say well you know the market has failed market failure therefore we need government come in and fix it there's government failure too government failure can be worse and can be worse by far it's subject to many other problems not constrained by the search for profits etc so we could add I mean we maybe maybe we get rid of this deadweight loss on the left but we add a deadweight loss that's even worse if the government gets this wrong and there's no way to measure this marginal social benefit value is subjective we know this as Austrian economists but value is subjective we don't know where what that marginal social benefit is we don't the government has no information that is available to it to be able to subsidize correctly not to mention the property rights violations that that incur that that occur here also we get costs added here from waste from political lobbying people who provide preventive care want to sell more of their product they're going to seek through lobbying more more government subsidies i'll close with this even if we could find the efficient quantity of preventive care how can this trump property rights if you force a person to fund the care of a stranger or buy a product like insurance or engage in preventive care you're violating fundamental property rights this is a separate separate argument the one I think should be given voice so thank you very much